DEPARTMENT OF THE NAVY
CHIEF OF NAVAL OPERATIONS
2000 NAVY PENTAGON
WASHINGTON, O.C. 20350-2000
5800
Ser 100002
22 Apr 20
From: Chief of Naval Operations
To: Vice Chief of Naval Operations
Subj : PRELIMINARY INQUIRY INVOLVING USS THEODORE ROOSEVELT (CVN 7 1 )
Ref: (a) ADM R. Burke, USN Itr 5 800 Ser N09D/20U1 008 1 8 of 7 Apr 20
(b) ADM R. Burke, USN Itr 5800 Ser N09/20U100519 of 14 Apr 20
1 . I reviewed references (a) and (b), your Preliminary Inquiry report and addendum, and I
approve the report except as noted herein.
2. The Summary ofFindings are modified as follows:
a. Sununary of Finding 4.u. is approved as written, with the following sentence added: “By
29 March, nearly all hotels in Guam had closed due to a drastic decrease in tourism business, not
due to Executive Order. These closures resulted in widespread layoffs of hotel staff.”
b. Summary of Finding 4.v. is approved as written, with the following sentence added:
“Once the decision was made to have the crew occupy off-base hotels, the hotels were only able
to re-hire enough staff to open up about 400-500 rooms per day.”
3. The Conclusions are modified as follows:
a. Conclusion 5.1. is approved as written, with the following sentence added: “The email
trace revealed no evidence that the CO sent his email (enclosure 2) and letter (enclosure 3) to
anyone other than those recipients listed in enclosure 2.”
b. Conclusion 5.o. is omitted and substituted with the following: “The CO was ultimately
responsible for the safety, health, and well-being of the crew and embarked personnel.
Therefore, he was ultimately responsible for the plan to respond to the infectious disease
spreading amongst the crew. All other commanders in the chain should have been in support of
his plan. The CO correctly diagnosed the problem and developed the proper courses of action
(COA). The plan to debark the crew and place them into Guam hotels was the preferred COA
for the CO, CCSG-9 and C7F — and indeed was ultimately the plan that was executed. However,
the CO should have better plaimed for and executed the most likely COA of debarking more of
his crew into on-base accommodations, even if sub-optimal, while waiting for off-base hotels.”
c. Conclusion 5.p. is omitted and substituted with the following: “The SMO, his medical
department, and the medical chain of command were earnest in their effort to provide the CO
and the chain of coiiunand with medical advice about the disease and its spread amongst the
crew. Their work was informed by the available expert-developed information and the proper
Subj : PRELIMINARY INQUIRY INVOLVING USS THEODORE ROOSEVELT (CVN 71 )
collaboration was occurring amongst the medical staffs. Indeed, the plan advocated by the
medical officers was ultimately approved and executed by the chain of command and some of
the medical staff predictions were later borne out by the number of positive COVID-1 9 cases.
However, like the CO, the medical team failed to plan for the most likely COA of utilising on-
ship and on-base accommodations to isolate and quarantine portions of the crew while awaiting
development of the preferred plan. The stated intent of the medical department letter to ‘submit
this letter to the public to demonstrate our concerns’ was inappropriate and improfessional.”
4. I approve recommendations 6.a through 6.e. You are directed to assign appropriate offices or
staffs to complete these tasks and report completion to me. I disapprove recommendations 6.f.
through 6.i.
5. By copy of this memo, I direct Commander, U.S. Pacific Fleet to lead an in-person After
Action Review (AAR) regarding the COVID-1 9 planning and response efforts for the USS
THEODORE ROOSEVELT (CVN 71) crew and embarked personnel. This AAR will include
the in-person participation of Commanding Officer, USS THEODORE ROOSEVELT (CVN
71), Commander, Carrier Strike Group NINE, Commander, Joint Region Marianas, Commander,
U.S. SEVENTH Fleet, and Commander, U.S. Pacific Fleet. It will occur prior to the
THEODORE ROOSEVELT getting underway in May 2020, and result in a report due to me
within 30 days. The report will capture lessons-leamed and provide valuable insights not only
for the U.S. Navy’s response to COVID-19, but it’s applicability to a range of crisis scenarios.
Copy to:
COMUSPACFLT
DEPARTMENT OF THE NAVY
VICE CHIEF OF NAVAL OPERATIONS
2000 NAVY PENTAGON
WASHINGTON DC 20350-2000
5800
Ser N09D/20UI00818
7 Apr 20
From: Vice Chief of Naval Operations
To: Chief of Naval Operations
Subj: PRELIMINARY INQUIRY INVOLVING USS THEODORE ROOSEVELT (CVN 71)
Ref: (a) JAGMAN, Chapter II Section 0203
End: ( I ) CNO WASHINGTON DC Itr 5800 of 2 Apr 20
(2) USS THEODORE ROOSEVELT (CVN 71) e-mail of 29 Mar 20
(3) USS THEOEX)RE ROOSEVELT (CVN 7 1) Itr of 30 Mar 20
(4) USS THEODORE ROOSEVELT (CVN 71) Medical Department Itr of 3 1 Mar 20
(5) Summary of Interviews
(6) Timeline
1. This reports completion of the preliminary inquiry conducted in accordance with reference (a).
2. Personnel contacted:
a. Commander, U.S. Pacific Reet (CPF)
b. Commander, Naval Air Forces (CNAF)
c. Commander, U.S. SEVENTH Reet (C7F)
d. Commander, Carrier Strike Group NINE (CCSG-9)
e. Commander, Joint Region Marianas (CJRM)
f. Commanding Officer. USS THEODORE ROOSEVELT (CVN 71) (CO)
g. Senior Medical Officer, USS THEODORE ROOSEVELT (CVN 7 1 ) (SMO)
h. Reet Surgeon, C7F
i. Fleet Surgeon, CPF
j. Executive Officer, USS THEODORE ROOSEVELT (CVN 7 1 ) (XO)
k. Commander, Carrier Air Wing 11 (CAG 1 1 )
l. Commander, Destroyer Squadron 23 (CDS 23)
m. Chief of Staff, C7F (COS. C7F)
Command Master Chief. USS THEODORE ROOSEVELT (CVN 71) (CMC)
Subj: PRELIMINARY INQUIRY INVOLVING USS THEODORE ROOSEVELT (CVN 7 1 )
3. Materials reviewed: I reviewed enclosures (1) through (5). Enclosure (6) was developed to aid in
understanding the sequence of events.
4. Summary of findings (all times listed in Chamorro Standard Time (GMT +10)):
a. Once positive novel coronavirus (COVED-19) cases became known on THEODORE
ROOSEVELT, the Senior Medical Officer (SMO) began to keep a running prediction of the total number
of THEODORE ROOSEVELT Sailors infected and an estimate of potential THEODORE ROOSEVELT
Sailor fatalities. These projections leveraged observations from the cruise ship Diamond Princess
sequestered in Japan, which had a different demographic population from the THEODORE
ROOSEVELT, and would result in a higher expected fatality rate.
b. Upon arrival in Guam on 27 March, CCSG-9 and THEODORE ROOSEVELT had a plan to
rapidly egress those Sailors confirmed to be infected and key watchstanders who were known to have
avoided contact with any infected Sailors. There was no plan yet developed to rapidly egress the large
number of quarantined people ashore, nor was there a strategy in place for required testing prior to Sailors
going ashore to Naval Base Guam.
c. Prior to arrival in Guam, C7F, CCSG-9, CJRM and THEODORE ROOSEVELT all understood
the requirement for 4,000 beds, with no discussion of the beds being CDC-compliant (i.e., one bed and
one head per room). None of them knew how many such rooms were achievable or where they would be
located. Broadly, there were three courses of actions (COAs) identified:
(1) Obtain 4,000 rooms. This was the preferred COA, as it was the fastest and safest;
(2) Transfer Sailors to Okinawa and Atsugi. This involved coordination with the Government of
Japan and a 9-hour plane ride;
(3) Naval Base Guam accommodations only, using government and temporary makeshift
facilities.
d. C7F established a priority that THEODORE ROOSEVELT needed to remain able to get
underway rapidly for contingency operations. The fastest means to achieve this was to establish a testing
rate of SOO tests per day to match available lab capacity, a rate which was beyond the capacity of the
shipboard equipment. CCSG-9 and THEODORE ROOSEVELT felt continuous pressure from these
requirements, and they felt distracted from egressingthe crew in a timely manner.
e. Prior to arrival in Guam, CCSG-9 issued guidance which established movement of COVID-19
infected Sailors to isolation ashore as the first priority. The next priority was preserving the ability to
rapidly get underway for contingency operations, and accordingly key watchstanders that had been
protected from spread of infection were quarantined next. The CO and Warfare Commanders had initial
expectations that 4,000 CDC-compliant isolation rooms would be available for quarantine of the
THEOEXDRE ROOSEVELT crew in Guam upon arrival. It is unclear that this expectation was
transmitted to C7F. Insufficient efforts were made to think through the triage regarding use of limited test
equipment that would be required to egress those persons under investigation (PUI), which was a majority
of the crew. Regardless, there was no plan, and this contributed to delays in getting potentially non-
infected crewmembers off of the ship.
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Subj : PRELIMINARY INQUIRY INVOLVING USS THEODORE ROOSEVELT (CVN 71)
f. Naval Base Guam, C7F and THEODORE ROOSEVELT agreed to the egress strategy and its
prioritization of categories of Sailors. Dissatisfied with the pace of egress, C7F repeatedly prompted
CCSG-9 for THEODORE ROOSEVELT’ s plan to utilize the additional isolation/quarantine quarters
available via the daily synch VTC and email in the days before arrival in Guam. With no plan in hand
four days after the ship’s arrival, and hundreds of temporary quarantine bunks remaining unused, C7F
issued '‘C7F TASKORD for Recovery of USS THEODORE ROOSEVELT from COVID-19 Infection”
on 1 April, formally requiring development of this plan.
g. Naval Base Guam did not have sufficient contracted food available for the number of Sailors in
isolation and quarantine. As this capacity continued to ramp up, and the number of Sailors ashore
increased, there were quality control and timeliness issues that leadership addressed as quickly as they
could. Sailors expressed their concerns on social media and this was relayed to the CO and XO.
h. The ship’s leaders were concerned about the practicality of the temporary open-bay facilities as
they did not meet CDC guidelines and cots were not initially arranged to enable social distancing.
Although not CDC-compliant, these facilities, with proper physical arrangement, would likely decrease
the probability of infection spread, and the shipboard population would be decompressed. However, the
SMO’s continued insistence on “only CDC-compliant facilities” led to confusion in execution, and
delayed the crew’s egress from the ship into open bay facilities.
i. In reaction to social media posts and out of concern for his Sailors in the isolation/quarantine
facilities, the CO established policy that no Sailors would leave the ship until guarantee of sufficient meal
service was available. Additionally, the CO requested the ability for ship’s company to inspect
isolation/quarantine facilities for suitability prior to moving Sailors (e.g., adequate meal service, heads,
physical separation).
j. The Government of Guam issued a state of public health emergency on 14 March, and as a result.
Naval Station Guam was in Health Protection Condition Level (HPCON) C+, which significantly limited
personnel on and transit within the base. Additionally, the pier area around THEODORE ROOSEVELT
had been designated a Force Health Protection Boundary (FHPB), restricting movement for those Sailors
off of the pier. The Naval Base Guam CO and Commander, Joint Region Marianas (CJRM) denied the
request for any THEODORE ROOSEVELT personnel to leave the immediate FHPB on the basis of their
policy that all THEODORE ROOSEVELT members were potentially infected.
k. C7F did not know why THEODORE ROOSEVELT Sailors were not occupying all available
isolation/quarantine quarters. C7F believed that all facilities were available and fully functional, and that
the CO and CCSG-9 resisted sending the crew to any isolation/quarantine areas that were not fully CDC-
compliant. The CO’s requirement for verification/validation of adequate quality of life services for the
isolation/quarantine areas also contributed to this.
l. As a result of the issues outlined above, hundreds of available isolation/quarantine bunks
remained vacant through 2 April when the CO was relieved.
m. The SMO, on at least two occasions, misunderstood discussions during daily C7F medical
synchronization meetings about additional infection testing, and construed the discussions to levy new
testing requirements, despite no formal direction to do so. This also contributed to the delay of the crew
egressing from the THEODORE ROOSEVELT. The SMO did not consistently attend or send a
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Subj; PRELIMINARY INQUIRY INVOLVING USS THEODORE ROOSEVELT (C VN 7 1 )
representative to the daily C7F nnedical synchronization meetings because the medical staff was heavily
loaded with patient care and testing.
n. During COA development for additional CDC-compliant isolation quarantine areas, the Warfare
Commanders, CO and XO developed an information paper outlining their preferred COA for establishing
additional isolation/quarantine areas. This paper would later fomn the basis of the CO’s letter. The paper
was provided to CCSG-9 on Sunday, 29 March by entail. CCSG-9 concurred with the recommendation
and proposed this COA to C7F that same day, but C7F directed them to continue to focus on Okinawa as
the primary COA. C7F advised that their preferred COA for hotel rooms, while still being pursued, was
not looking likely, as the government of Guam was not currently amenable to potentially infected Sailors
leaving Naval Base Guam. Bringing the THEODORE ROOSEVELT to Naval Base Guam had been
predicated by a guarantee from CPF to the government of Guam that no support would be required from
them.
o. CCSG-9 and THEODORE ROOSEVELT were tasked to develop plans to airlift crew members
to Okinawa on Saturday, 28 March. After hours of work towards this task, the CO called Commander,
Fleet Activities Okinawa (CFAO) to confirm the availability of appropriate and sufficient berthing and
was told there were insufficient bunks available. The CO discussed this with the XO and senior Warfare
Commanders. They believed the C7F staff had wasted their time on a non-viable COA.
p. C7F had arranged for III MEB to evacuate their barracks in Okinawa upon notification that the
airlift plan had been approved. This would have made 5,700 rooms available on the Marine Corps side of
the base in Okinawa, not the Navy side of the base that CFAO had cognizance over. The CO and Warfare
Commanders were unaware of this.
q. On 29 March, with over 1,000 members of the crew on board in quarantine, the CO released 900-
1,000 Sailors in aft quarantine based on the recommendation of the SMO and XO. The SMO based his
recommendation on his belief that preventative isolation was not working as some Sailors in preventative
isolation were becoming symptomatic and tested positive subsequent to being placed in isolation.
Additionally, there were large numbers in quarantine and the spaces to which they were confined were
very crowded.
r. CPF rejected C7F’s plan for movement of the THEODORE ROOSEVELT crew to Okinawa on
Sunday, 29 March, based on the risk of accelerating infection spread on the aircraft during the 9 hour
flight to Okinawa, and complications with the government of Japan.
s. On Sunday, 29 March, there were 1,150 racks available on Guam with 535 racks occupied.
t. On Sunday, 29 March during the daily C7F medical synchronization meeting, the SMO made the
first mention to an off-ship audience of the expectation for 4,000 CDC-compliant rooms as that was the
fastest and safest way to get THEODORE ROOSEVELT back to sea. This appears to be the first time
any organization outside of CCSG-9 or THEODORE ROOSEVELT knew of the ship’s expectation for
CDC-compliant rooms for all crew members who were to be egressed. CCSG-9 proposed this COA to
C7F later that same day. C7F articulated that he did not view the temporary facilities as inadequate as
they were a short-term improvement over shipboard conditions that would provide a bridge to a longer
term solution.
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Subj : PRELIMINARY INQUIRY INVOLVING USS THEODORE ROOSEVELT (C VN 7 1 )
u. CJRM began consulting with the government of Guam on Saturday. 28 March to obtain hotel
rooms, independent of and without any knowledge of the ship’s expectations, as part of C7F’s parallel
plan. The CO and CCSG-9 were not aware of these efforts.
V. CPF contacted the Governor of Guam on the evening of 31 March to finalize the agreement for
an undetermined number of hotel rooms.
w. At this point, the CO, XO and Warfare Commanders were frustrated. This was compounded by
the continued increase in number of COVI[>-I9 positive Sailors and the worst-case narrative of
THEOEXDRE ROOSEVELT fatalities that continued to be discussed among THEODORE ROOSEVELT
leadership. Believing that the C7F staff was not seriously entertaining or working towards obtaining
CDC-compliant hotel rooms in Guam for crew isolation/quarantine, the CO sent an email (enclosure (2))
with an attached letter (enclosure (3)).
X. The CO’s email was sent to 10 people in total, three in the ‘To" line (CPF, CNAF, CCSG-9). and
seven in the “cc” line (Executive Assistants for CPF and CNAF, and fellow 0-6s on the ship). All ‘To”
line addressees were in the CO’s administrative or operational chain of command.
y. The CO stated that he did not release the letter to the media, nor did he intend to do so. He
provided background on his experience as the investigating officer for the line of duty investigations for
Sailors lost on the USS JOHN S MCCAIN (DDG 56) in the 2017 collision. He felt that COs could have
made a difference and that inaction caused problems. He applied that lesson here, and stated that he did
not want to lose a day and potentially lose a Sailor.
z. The XO stated during his interview that he edited the letter (enclosure (3)) and prepared the email
(enclosure (2)) on the unclassified network, but had not thought about the possibility of the letter being
released to the public. When the letter was released to the press, he felt personally responsible. He stated
that, in retrospect, he should have put it on a classified network, but he knew of no intention on anyone’s
part to release the letter to the press.
aa. The SMO, THEODORE ROOSEVELT Surgeon, THEODORE ROOSEVELT Family Physician.
THEODORE ROOSEVELT Physical Therapist and THEODORE ROOSEVELT Flight Surgeon signed a
letter (enclosure (4)) which expressed similar concerns as those in the CO’s letter, but also stated their
intent to release their concerns to the public. The junior Medical Officers drafted and presented the letter
to the SMO, who added his signature and forwarded it to the Navy Surgeon General via email. In his
email to the Navy Surgeon General, the SMO indicated that he would not release the letter to the press,
but that he could not speak for the other signatories.
S. Conclusions:
a. Navy and Fleet Commander COVlD-19 guidance did not address the optimum handling of
significant numbers of potentially infected Sailors seen onboard THEODORE ROOSEVELT. The
SMO's application of contact tracing, while appropriate when numbers were small, rapidly caused the
entire ship to be considered infected. Additionally, guidance did not anticipate the scenario in Guam with
large numbers of Sailors requiring isolation and a lack of adequate CDC-compliant facilities present. To
be fair, the crew was learning in-situ, and their experience will clearly inform revised Navy procedures.
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Subj : PRELIMINARY INQUIRY INVOLVING USS THEODORE ROOSEVELT (CVN 7 1)
b. Communications and actions were uncoordinated between THEODORE ROOSEVELT, CCSG-9,
NB Guam, CJRM and C7F. Significant differences of understanding existed regarding: THEODORE
ROOSEVELT and CCSG-9’ s expectations for quarantine capacity in Guam; testing requirements for
moving Sailors to isolation; testing requirements for and reasons for delaying movement of crew to
temporary facilities; the availability of berthing in Okinawa; and efforts being made to secure Guam
hotels. Contributing to this:
( 1 ) There was no plan for rapid egress of the majority of the crew, and it had not been developed
until after the relief of the CO.
(2) Multiple entities were working towards different objectives, and ‘who owned what’ was not
clearly understood or practiced.
(3) Communications “bottle necks’’ resulted in frequent miscommunication, difficulty confirming
data, and frustration on both sides.
c. A contentious relationship and an “Us vs. Them’’ culture existed between the C7F staff, the CSG-
9 and the THEODORE ROOSEVELT team prior to the COVID-19 outbreak. This pre-existing
environment exacerbated the communications challenges once the outbreak began. Although both staffs
were aware of this environment, no one took action.
d. Based on the projections for individuals of a population similar to the crew, there was a low
probability of fatalities onboard the ship. However, a rapid rise in positive cases, together with worst-
case projections for THEODORE ROOSEVELT Sailor infection rates and fatalities, drove a culture of
fatalism among THEODORE ROOSEVELT and CSG-9 leaders. An increase in numbers should have
been expected, and the continued minor nature of symptoms for those Sailors experiencing the COVID-
19 virus should have helped to put the risks in perspective. The Sailors were displaying only minor
symptoms, as CDC guidelines suggest. No Sailors from the THEODORE ROOSEVELT have been
hospitalized to date. The team should have recognized that actions taken to date had already reduced the
percentage of Sailors infected as compared to the Diamond Princess cruise liner, where no action was
taken.
e. In a very dynamic situation characterized by clear communications challenges, and with each
failure of another organization to meet expectations, the CSG-9 and THEODORE ROOSEVELT staffs
became increasingly untrusting of C7F. They also felt increasingly overwhelmed by requests for
information and planning products while simultaneously trying to test, egress and treat Sailors. This
further aggravated the situation — C7F demanded more information, while CSG-9 and THEODORE
ROOSEVELT staffs resisted. As a result, CSG-9 and THEODORE ROOSEVELT staffs turned their
efforts inward and focused exclusively on their preferred COA (egress to Guam hotels).
f. Actions to release personnel in quarantine on the ship on 29 March may have expedited or
increased the spread of infection on THEODORE ROOSEVELT. This should be examined further.
g. CCSG-9 and THEODORE ROOSEVELT did not adequately plan for crew egress beyond that of
the immediately ill and protected non-infected watchstanders. Although they had the details of available
berthing prior to arrival in Guam, they had expected to remove all remaining crew to waiting CEXT-
compliant hotel rooms. This contributed to delays in crew egress.
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Subj : PRELIMINARY INQUIRY INVOLVING USS THEODORE ROOSEVELT (CVN 7 1 )
h. The SMO consistently recommended actions and drove impractical, unconstrained decisions
towards an ideal triage plan that did not reflect the operational and resource realities. For example, rather
than spread out and thin down the number of cots in an open bay space ashore, the SMO considered the
space to be non CDC-compliant, and in some cases, the cots went unused, leaving Sailors on the ship.
i. The effects of the issues discussed in conclusions a, b, c, e, g and h resulted in many crew
members remaining onboard THEODORE ROOSEVELT for an unnecessarily long period of time.
j. The CO, in the company of the XO, sent a letter (enclosure (2)) requesting assistance to his
embarked CCSG, his Administrative Type Commander (COMNAVAIRFOR), and CPF shortly after
concluding that there were insufficient rooms available in Okinawa and surmising that no hotel rooms in
Guam would be made available. The Warfare Commanders, CO and XO all held this opinion. The CO
did not discuss sending this letter with CCSG-9. The CO’s primary goal was to expedite getting proper
accommodations for his crew. He did not understand the magnitude of effort that was already in
progress. His intent was to operate within the chain of command, bypassing C7F due to his frustration
with that staff, and reaching above C7F, but within his administrative and operational chains of command,
for help. The CO’s stated intent is consistent with clear direction from senior Navy uniformed leaders to
Commanders to reach out if they need help and a shift in mentality from a “must do’’ to a “can do’’
culture.
k. At the time the CO sent the letter, there was low risk of fatalities to THEODORE ROOSEVELT
Sailors. The language he used in the letter conveyed otherwise. Additionally, by this time, the
Department of the Navy had already mobilized significant resources, and was preparing to secure an
agreement with Guam for the hotel rooms, although the CO did not know this. Moreover, due to the
cascading delays in egressing Sailors, many had not yet been able to leave the ship for the available
temporary isolation/quarantine spaces. This ran counter to the narrative of his letter, which suggested
Sailors were not safe on the ship. During his interview, the CO stated that he believed it was unlikely
anyone would die, but exaggerated the impact on Sailors in the letter in order to draw leadership’s
attention — he “wanted to send a red flare.”
l. Although he transmitted the letter on an unclassified email network, there is no indication that the
CO had intent to leak the letter to the press. At my request. Fleet Cyber Command (FCC) has initiated an
email trace to investigate the path of the transmitted email.
m. The CO was most likely acting to avoid inaction based on his internalization of the Fleet-wide
direction from Navy uniformed leadership to be transparent, ask for help early and tell superiors when the
mission cannot be executed. He learned from his experience as MCCAIN line of duty investigating
officer that COs are in a position to make a difference and that inaction can be deadly. He “did not want
to waste a day and potentially lose a Sailor” waiting on staff processes to work. Although the content of
his letter can be questioned and his choice of means to transmit the letter was unfortunate, his motives
appear to be sincere.
n. The Commander, CSG 9, stated he had not seen the CO’s letter and was not aware of the
concerns laid out in the letter until he got the email. However, he had been emailed the contents of the
letter in the form of a paper presented to him by the Warfare Commanders in support of their
recommended COA to C7F to push for hotel rooms. CCSG-9 advocated for this recommendation to C7F.
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Subj: PRELIMINARY INQUIRY INVOLVING USS THEODORE ROOSEVELT (CVN 7 1 )
This paper was later edited to a shorter version to become the CO’s letter. This narrative had been under
development for some time, and CCSG-9 endorsed it.
o. Although Commander, CSG-9, was in overall command of the Task Force, it is not clear either he
or the CO was in charge of crisply planning and executing what should have been a rapid and organized
egress of the crew into the relative safety of temporary facilities. Additionally, although CCSG-9 did not
encourage the tone of crisis among these leaders driven by the SMO, he did little to squelch it.
p. When the SMO signed the Medical Department letter, he not only missed the opportunity to
demonstrate leadership to his Medical team, but also endorsed a path that undermined his chain of
command.
6. Recommendations;
a. Issue revised Navy-wide COVID-I9 guidance to address the magnitude of the problem on
THEODORE ROOSEVELT and strategies for triaging crew members to limited numbers of makeshift
quarantine and isolation facilities both onboard the ship and at remote shore locations. Conduct
wargames and table-top exercises to optimize various scenarios and conduct shipboard training/exercises.
b. Using the THEODORE ROOSEVELT case history, develop warship-specific COVID-19
infection spread models.
c. Examine the impact of the ship’s decision to release personnel from isolation on 29 March and
use this to inform the infection spread model recommended in recommendation b.
d. Examine .shipboard and shore-based pre-positioned stores of personal protective equipment, test
gear and other equipment necessary to test, diagnose and if necessary ship test samples.
e. Identify key shore nodes for offload of infected crew members with suitable facilities and
infrastructure for isolation/quarantine. Institutionalize requirements to assess time/speed/distance to
ready nodes versus the delays that may be induced by going to a remote port without adequate facilities.
f. The actions of the following individuals merit consideration for disciplinary action:
(1) Senior Medical Officer, USS THEODORE ROOSEVELT (CVN 71)
(2) Ship’s Surgeon, USS THEODORE ROOSEVELT (CVN 71)
(3) Family Physician, USS THEODORE ROOSEVELT (CVN 71)
(4) Physical Therapist, USS THEODORE ROOSEVELT (CVN 7!)
(5) Right Surgeon, CARRIER AIR WING 1 1 (CVW 1 1)
g. The actions of the following individuals merit consideration for administrative actions:
(1) Commander, CARRIER STRIKE GROUP-9
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Subj : PRELIMINARY INQUIRY INVOLVING USS THEODORE ROOSEVELT (C VN 7 1 )
(2) Commanding Officer, USS THEODORE ROOSEVELT
h. Persons identified to be complicit in the leak of the CO’s email may merit consideration for
disciplinary or administrative action pending the FCC email trace.
i. Recommend DoD Inspector General conduct a review of this preliminary inquiry.
9
DEPARTMENT OF THE NAVY
CHIEF OF NAVAL OPERATIONS
2000 NAVY PENTAGON
WASHINGTON DC 20350*2000
5800
2 Apr 20
From: Chief of Naval Operations
To: Vice Chief of Naval Operations
Subj : PRELIM IN ARY INQUIRY INVOLVING USS THEODORE ROOSEVELT (CVN 7 1 )
Ref; (a) JAGMAN, Chapter II
1. Per reference (a) you are hereby appointed to inquire into events surrounding the
disembarkation of Sailors from USS THEODORE ROOSEVELT (CVN 71) in Guam, in
response to cases of Coronavirus Disease 2019 (COVID-19).
2. The purpose of this preliminary inquiry is limited in scope. Consider the command climate
relative to the health care professionals onboard and what, if any, impact their communications
with the commanding officer or other senior leaders had on the ship’s response. Consider also
the effectiveness of the communications between the commanding officer and the administrative
and operational chains of command.
3. You may assign others as needed to conduct this inquiry. Interview appropriate witnesses and
review relevant documentary materials. Repx>rt your summary of findings and recommendations
in letter form, consistent with reference (a). Include all evidence gathered during your inquiry.
Submit your report no later than 4 April 2020, unless an extension of time is granted by me.
Enclosure (1)
4
— Original Message —
From; Crozier, Brett E CAPT USN, USS Theodore Roosevelt
4b) (6). (b)
(5)cvn71.navy.mil>
Sent: Sunday, March 29, 2020 5:48 PM
To: Aquilino, John C ADM USN COMPACFLT PEARL HI (USA)
<(b) (6), (b) @navy.mil>; Miller, DeWolfe H VADM USN COMNAVAIRPAC SAN CA (USA'
<(b) (6), (b) (7) @navy.mil>; Baker, Stuart P RDML USN, CCSG-9
<(b) (6), (b) g)ccsg9.navy.mil>
Cc: (b) (6), (b) (7)(C) CAPT USN, CVW-11 CAG
<(b) (6), (b) (7)(C) (S)cvwll.navy.mil>; (b) (6), (b) (7XC) CAPT USN
CVN-71 (USA) <(b) (6), (b) (5)cvn71.navv.mil>;(b) (6), (b) (7)(C) CAPT USN,
CVW'll DCAG ^^'4!«aBZ»ICi-__j^'^‘'wll.navy.mil>;(b) (6), (b) (7)(C) cApy uSN
COMDESRON 23 (USA) i'T^&cvn71.navy.mil>;(b) (6), (b) CAPT USN, USS
Theodore Roosevelt •^) (®)t !@)cvn71.navv.mil>; (b) (6^(b) (7)(C) CAPT USN
COMPACFLT PEARL HI (USA) <Jb) (®)« (b) @navy.mil>; WloJ. CAPT
USN COMNAVAIRPAC (USA) <(b) (6). (b) {/){C) (S)navy.mil>
Subject: TR request for assistance
Fellow Naval Aviators,
It is with the utmost respect that I write to you requesting assistance. I
consider all of you incredible leaders and I'd gladly follow you into battle
whenever needed.
While I know there are many folks working hard to assist the TR as we
attempt to contain the spread of COVID-19 onboard, all efforts to date have
been inadequate and are unnecessarily putting Sailors lives at risk. I am
no longer confident that normal staffing processes will work, and I believe
we need decisive action now.
Make no mistake about it, if required we could get everyone back onboard,
set sail, and be ready to fight and beat any adversary that dares challenge
the US or our allies. The virus would certainly have an impact, but in
combat we are willing to take certain risks that are not acceptable in
peacetime. I told the SECNAV’s office the same, and will repeat to the CNO
if he calls today.
However, our current effort efforts to contain the virus and treat the
symptoms while pierside here in Guam are inadequate. By COB on 30 Mar, TR
will have over 20% ofthe crew ashore in 'quarantine areas' (open bay gyms)
or 'isolation' rooms (NGIS rooms with shared heads) onboard Naval Base Guam.
Enclosure (2)
These facilities are inadequate to contain the virus and we're already
seeing new positive cases from those residing at gyms with more likely to
follow. Based on the contact tracing of the 53+ CV positive TR Sailors to
date, over 50% of those still onboard (over 2,000) can be considered close
contact the real number is closer to the 4,000 still onboard due the
close proximity of the entire crew on a CVN.
The current situation is not ideal, and will only get better once v/e can
isolate the crew off ship in true isolation rooms with separate bathroom
^cilities. A CVN does not provide the necessary space to allow for ROM
separation lAW NAVADMIN 083 or CDC guidance with the majority of the crew
embarked. The Diamond Princess Cruise Ship example demonstrates that the
only way they were able to stop the spread was to remove everyone off the
ship. Considering that they already had some ability to quarantine onboard
with individual guest rooms, we should be extremely concerned with the virus
spread on a CVN.
I need approximately 500 Sailors to remain onboard to continue to operate a
Rx plant, man normal watches to support minimal operations (Q, lET, etc..),
and maintain aircraft readiness. Naval Base Guam is doing the best they
can, but they do not have adequate facilities and we can't wait much longer
for off island lodging to become available as our cases continue to
increase. While I understand that there are political concerns with
requesting the use of hotels on Guam to truly isolate the remaining 4,500
Sailors for 14+ days, the hotels are empty, and I believe it is the only way
to quickly combat this problem. Keeping Sailors local also allows me to
maintain the warfighting capability needed should the balloon go up. The
alternatives are to let this ride out, hope for the best, and pray we don't
lose Sailors to this invisible enemy. Naval Aviation is better than that,
and we owe it to the thousands of Sailors onboard, and those outside
watching, to take decisive action now.
I fully realize that I bear responsibility for not demanding more decisive
action the moment we pulled in, but at this point my only priority is the
continued well-being of the crew and embarked staff. As you know, the
accountability of a Commanding Officer is absolute, and I believe if there
is ever a time to ask for help it is now regardless of the impact on my
career.
Vr,
Chopper
CART Brett E. Crozier
Commanding Officer
USS THEODORE ROOSEVELT (CVN 71)
2
Enclosure (2)
DEPARTMENT OF THE NAVY
USSTHEOOORE ROOSEVELT(CVN 71)
UNITKXnSOBOXI
FPO AP 96632
30 Mar 20
Subj: REQUEST FOR ASSISTANCE IN RESPONSE TO COVID-IO PANDEMIC
BLUF: If required the USS THEODORE ROOSEVELT would embark all assigned Sailors, set
sail, and be ready to fight and beat any adversary that dares challenge the US or our allies. The
virus would certainly have an impact, but in combat we are willing to take certain risks that are
not acceptable in peacetime. However, we are not at war, and therefore cannot allow a single
Sailor to perish as a result of this pandemic unnecessarily. Decisive action is required now in
order to comply with CDC and NAVADMIN 083/20 guidance and prevent tragic outcomes.
1 . Problem Statement. With the crew embarked, TR is unable to comply with CDC protocols or
NAVADMIN 083/20 guidance. Based on CDC guidelines and TR observations, the only
effective method to preserve an individual's health is total isolation for H-t-days in accordance
with the NAVADMIN (i.e. Individual hotel/barrecks rooms with separate heads). Due to a
warship’s inherent limitations of space, we are not doing this. The spread of the disease is
ongoing and accelerating.
2. Inappropriate Focus on Testing. Testing has no direct influence on the spread of the COVID-
19 virus. It merely confirms the presence of the virus. Due to the close quarters required on a
warship and the current number of positive cases, every sin^e Sailor, regardless of rank, on
board ttie TR must be considered ’'close contact” in accordance with the NAVAI^IN. Testing
will only be useful as the ship returns to work after isolation or quarantine to confirm the
effectiveness of the quarantine period. Our focus now must be on quarantine and isolation in
strict compliance wiA CI3C and NAVADMIN guidance.
The COVID*19 test caiuiot prove a Sailor does not have the virus; it can only prove that a Sailor
does. As an illustration, of the first 33 TR Sailors diagnosed with COVlD-19, 21% (7 of those
33) infected Sailors were negative on a COVID-19 test, then subsequently presented with
symptoms of COVID'19 infection within I -3 days post-test
Based on data since TR’s first case, approximately 21% of the Sailors that tested negative and
are currently moving into group restricted movement ashore are currently infected, will develop
symptoms over the next several days, and will proceed to infect the remainder of their shore-
based restricted group.
3. Inappropriate Quarantine and Isolation. With the exceptions of a handful of senior officer
staterooms, none of the berthing onboard a warship is appropriate for quarantine or isolation.
Thousands of “close contact” Sailors require quarantine in accordance with guidance. TR has
begun to move personnel off ship into shore-based group restricted movement locations. Of the
off ship locations currently available, only one complies with the NAVADMIN guidance.
Infected Sailors reside in these off ship locations. Two Sailors have already tested positive in an
Enclosure (3)
Subj: REQUEST FOR ASSISTANCE IN RESPONSE TO COVID-19 PANDEMIC
open bay gymnasium equipped with cots. Although marginally better than a warship, group
quarantine sites are not a solution and are not in accordance with current guidance.
In order to stop the spread of the virus, the CDC and the Navy and Marine Corps Public Health
Center both recommend individual quarantine. They both recommend against group quarantine.
They recommend limited or no contact with other exposed individuals and no use of die same
facilities or items exposed individuals have touched. NAVADMIN 083/20 echoes this guidance.
The environment most conducive to spread of the disease is the environment the crew of the TR
is in right now, both aboard ship and ashore:
a. Large amounts of Sailors in a confined space
b. Open, shared berthing
c. Shared restroom facilities
d. Confined, shared workspaces and computers
e. Shared messing for large numbers
f. Meals cooked / food provided by exposed personnel
g. Mandatory watch/operational tasks demanding consistent close contact (food
preparation, service & cleaning, TFCC watches, unavoidable meetings to plan &
execute COVID response actions, etc.)
h. Movement about the ship requires consistent close contact with other exposed
individuals (confined passageways, previously touched ladder railings/hatch
levers/door knobs etc.)
4. Ineffectiveness of Current Strategy: Based on current limitations (lack of appropriate
quarantine and isolation facilities, inability to effectively achieve social distancing), TR has
instituted limited measures to slow the spread of the disease. We have moved a small percentage
of the crew off ship, increased the frequency of thorough cleaning and attempted some social
distancing. The current strategy will only slow the spread. The current plan in execution on TR
will not achieve virus eradication on any timeline.
5. Lessons Learned from the Diamond Princess: From an epidemiological research article on
the COVID- 19 infection onboard Diamond Princess (the only comparable situation encountered
thus for) (Roklov etal.) titled “COVID-19 outbreak on the Diamond Princess cruise ship:
estimating the epidemic potential and effectiveness of public health countermeasures:”
“Cruise ships carry a large number of people in confined spaces with relative homogeneous
mixing. On 3 February, 2020, an outbreak of COVID-19 on cruise ship Diamond Princess was
reported following an index case on board around 21-25 January. By 4 February, public health
2
Enclosure (3)
Subj: REQUEST FOR ASSISTANCE IN RESPONSE TO COVID-I9 PANDEMIC
measures such as removal and isolation of ill passengers and quarantine of non>ill passengers
were implemented. By 20 February, 619 of 3,700 passengers and crew (17%) were tested
positive. We estimated that without any interventions within the time period of 21 January to 19
February, 2920 out of the 3700 (79%) would have been infected. Isolation and quarantine
therefore prevented 2307 cases. We showed that an early evacuation of all passengers on 3
February would have been associated with 76 infected persons.” (As opposed to 619)
The final sentence of the abstract;
“Conclusions: The cruise ship conditions clearly amplified an already highly transmissible
disease. The public health measures prevented more than 2000 additional cases compared to no
interventions. However, evacuating all passengeis and crew early on in the outbreak would have
prevented many more passengers and crew from infection.”
The Diamond Princess was able to more effectively isolate people onboard than TR, due to a
much higher percentage of individualized and compartmentalized accommodations onboard for
paying customers. Their measures still allowed hundreds of people to become infected. TR’s
best-case results, given the current environment, are likely to be much worse.
6. Proposed N ew Strategy; There are two end states TR could achieve;
a. Maximize warfighting readiness and capacity as quickly as possible. No timeline
necessary. We go to war with the force we have and fight sick. We never achieve a COVID-
free TR. There will be losses to the virus.
b. Achieve a COVID-free TR. Requires strict adherence to CDC guidelines and a
methodical approach to achieve a clean ship. This requires immediate and decisive action. It
will take time and money.
As war is not imminent, we recommend pursuing the peace time end state.
TR has two primary goals in order to achieve that end state;
a. Prevent unnecessary deaths, reduce the number of Sailors that contract COVID- 1 9 and
eliminate future virus spread.
b. Regain and maximize warfighting readiness and capacity as quickly as possible.
In order to achieve these goals, a clean ship is required. Every Sailor onboard must be
guaranteed virus-fiee and the ship environment must be disinfected. One infected Sailor
introduced to the ship will spread the virus. Off ship lodging in compliance with CDC and
NAVADMIN guidance is required for over 4,000 Sailors to achieve a clean ship and crew.
7. Conclusion. Decisive action is required. Removing the majority of personnel from a
deployed U.S. nuclear aircraft carrier and isolating them for two weeks may seem like an
extraordinary measure. A portion of the crew (approximately 10%) would have to stay aboard to
3
Enclosure (3)
Subj: REQUEST FOR ASSISTANCE IN RESPONSE TO COVID-19 PANDEMIC
run the reactor plant, sanitize the ship, ensure security, and provide for contingency response to
emergencies. This is a necessary risk. It will enable the carrier and air wing to get back
underway as quickly as possible while ensuring the health and safety of our Sailors. Keeping
over 4,000 young men and women on board the TR is an unnecessary risk and breaks faith with
those Sailors entrusted to our care.
There are challenges associated with securing individualized lodging for our crew. This will
require a political solution but it is the right thing to do. We are not at war. Sailors do not need
to die. If we do not act now, we are failing to properly take care of our most trusted asset - our
Sailors.
Request all available resources to find NAVADMIN and CDC compliant quarantine rooms for
my entire crew as soon as possible.
4
Enclosure (3)
31 MARCH 2020
We are the physicians and medical professionals of USS THEODORE ROOSEVELT (CVN-71). Our immediate and primary
concern is the safety and well-being of our patients, the Sailors under our care. Our ship detected Novel Coronavirus on
board approximately seven days ago; three days ago we docked at Naval Base Guam. We are at war with COVI049 and
we are losing. This letter is to make you aware of our situation and to ask for your help.
This is our current situation: the virus is spreading exponentially on the ship. We have over 75 positive cases and rising.
We are attempting to transfer infected Sailors off the ship. We are attempting to isolate the close contacts of infected
Sailors, but at this point every single individual on the ship is a close contact. We continue to eat in groups. We continue
to sleep in open bays. We continue to use group bathrooms accommodating dozens of individuals. We continue to work
in confined spaces. We continue to expose ourselves to the virus on a daily basis. The construction of the ship makes it
impossible for us to practice social distancing. These concerns have been expressed to all levels of the chain of
command, but we have yet to see any demonstrable action taken to get our patients to safety that is in accordance with
COC guidelines and NAV AOMIN 083/20.
There is a high probability that USS THEODORE ROOSEVELT will experience fatalities as a result of COVID-19 and we
expect them to be within 10 days of penning this letter. While we have received the support of U.S. Naval Hospital
Guam, we expect to quickly overwhelm their limited resources. We expect to experience the well published case fatality
rate of0.5-l%forourage demographic if drastic action is not immediately taken. If this case fatality rate remains
constant we stand the potential to have SO or more fatal cases. We will not stand by while our fellow sailors continue to
be exposed to thb fatal virus.
The only solution to save the lives of our Sailors is to immediately get everyone off the ship into appropriate isolation or
quarantine. There is rx) other option. The time has come for aggressive measures to be taken and we are asking for your
help to save the lives of our patients.
As medical providers we have a moral responsibility to our patients. We will continue to fight this losing battle, but we
are asking foryour immediate support to help us win this war. Time is of the essence.
Our intent is to submit this letter to the public to demonstrate our concerns for the safety of our patients and your
sailors. _ _
(6716). (6) (7XC)
fbVfeObVTTVCl
Very Resp^tfuHv.
(6)(6).(b)(tXC)
LCOR MC USN
Surgeon
USS THFOOORF ROOSFVFI T frWN 7'rr
CA fh-K^r I Wbi''
Senior Medical Officer
USS THEODORE ROOSEVELT ICVN 71)
ft)Tm (BYTTlfO (b) (6). (b) (7)(C)
“LTMSCUSN _ _
wmrswK'
I rrWjMil^USN
Physical Therapist
RE ROOSEVELT (CVN 71)
Family Physician
USS THEODORE ROOSEVELT (CVN 71)
LT MC USN
Flight Surgeon
CWV-11
^(b) (6). (b) (7)
(C)
Enclosure (4)
Summary of Interviews
1 . Between 2 and 6 April 2020, 1 conducted multiple phone interviews as part of a preliminary
inquiry involving USS THEODORE ROOSEVELT (C VN 7 1 ). My Executive Assistant, Legal
Counsel and the Director of my Commander’s Action Group assisted me with these interviews.
Summaries of my interview notes follow. Quotations indicate exact words or phrases used by
those interviewed. All dates are given in Washington, DC, Eastern Daylight Savings Time.
2. Commander. U.S. Pacific Fleet (CPF). Multiple phone interviews between Thursday, 2 April
and Monday, 6 April. CPF recalled that a daily COVID sync began after USS THEODORE
ROOSEVELT (CVN 71) (THR) pulled into Guam on 28 March. He communicated to
Commander, U.S. Seventh Fleet (C7F), but was unaware what was relayed further down
operational chain of command. CPF retained some tactical decisions. For example, he cancelled
a C-40 flight carrying THR crew COVED- 19 samples to Osan, Korea, apparently without
understanding the impact of the cancelled flight (e.g., aircraft needed to retrieve swabs from
Korea, and cancellation delayed further testing of Sailors and subsequent movement off the
ship). CPF focused on increasing capacity to deal with COVED- 19 and pushing solutions down
chain. He developed Courses of Action (COAs) to fly infected Sailors to other countries. When
that became challenging due to political concerns, his focus shifted to COA in Guam. CPF did
not know the Concept of Operations (CONOP) for egress of THR Sailors. Regarding hotel
arrangements on Guam, CPF noted that CJRM spoke to the Governor of Guam on Monday, 30
Apr and that CPF spoke with her that evening after ensuring ADM Davidson, Commander, Indo-
Pacific Command, was aware.
3. Commander. Naval Air Forces (CNAF). Phone interview on Thursday, 2 April. CNAF
indicated a “hands-off’ approach to the administrative control of THR. He did not require
courtesy reports or synchronization sessions and spoke with CVN Commanding Officers (COs)
prior to deployment as a matter of routine to let them know the Type Commander (TYCOM) was
available for assistance during deployment. CNAF did not provide additional COVID- 19
guidance due to multiple guidance messages already circulating. After receiving THR CO’s
letter/email, spoke to CO and offered help. CNAF did not understand why CO felt need to write
letter and stated that CO indicated help was “not happening fast enough.”’
4. Commander. U.S. SEVENTH Fleet (C7F). Multiple phone interviews between Thursday, 2
April and Monday, 6 April. C7F indicated friction with CPF. For example, CPF required him to
request permission to move the C7F flagship, USS BLUE REDGE (LCC 19) (BLR). C7F was
focused on non-Guam options prior to decision to pull THR into Guam and house Sailors there.
C7F was unsure when COA shifted to decision to house Sailors in hotels in Guam. He indicated
Commander, Carrier Strike Group NE^E (CCSG-9) and CO, THR stood out among the strike
groups in C7F as having a “victim mentality.” C7F demonstrated the most ownership of a plan
for THR, but remained offsite aboard his flagship, BLR. C7F indicated frustration that THR was
not moving Sailors off ship fast enough, and that THR CO “wanted keys to a 4-star hotel” rather
than the resources available in Guam. Indicated he believed rooms were available for THR
Sailors when they arrived in Guam. C7F stated that, regarding leadership for coordination of
efforts to egress THR Sailors, CCSG-9 “said all the right things” but was not taking actions.
FOR OFFICIAL USE ONLY
Enclosure (5)
5. Commander. Carrier Strike Group NINE (CCSG-9~). Phone interviews on Thursday, 2 April
and Monday, 6 April. CCSG-9 indicated a lack of awareness or concern for COVID-19 impact
prior to deployment, stating it was “not really a factor.” However, he did conduct a Table-top
Exercise (TTX) on how to deal with COVID-19 before the THR Strike Group port visit in
Vietnam. CCSG-9 considered the Vietnam port visit low-risk and recommended execution to
C7F. He began daily calls with C7F after THR pulled into Guam, but did not provide a demand
signal for plan to get Sailors off ship. Additionally, CCSG-9 appeared to lack awareness of
disconnects - for example, he indicated many unknowns contributed to a “fog of war” and
appeared to lack knowledge of details regarding how to handle the COVID-19 crisis. Indicated
that confusion existed regarding what “isolation” and “quarantine” meant. CCSG-9 stated that
expectations for single rooms to be available in Guam were communicated to C7F and CJRM on
or about 26 or 27 March, close to the time that THR pulled in. Stated that he did not get the
sense from THR that there was a sense of panic or concern for fatalities aboard the ship as CO As
were being developed. When asked about the information paper the warfare commanders
produced for him to recommend for C7F action, CCSG-9 recalled a discussion about CO As
being discussed to get Sailors off the ship, but did not remember seeing “a formal paper.”
Explained that his role was to explain the need to “follow the process.”
6. Commander, Joint Region Marianas (CJRM). Phone interview on Thursday, 2 April. CJRM
began to plan for the Guam response to COVID-19 in January when CPF indicated U.S.
government discussions to have MA^ Westerdam dock in Guam for treatment of COVID-19
positive passengers. Although the plan for MA^ Westerdam changed and the ship did not pull
into Guam, CJRM directed CO, Naval Hospital (NAVHOSP) Guam and CO, Naval Base Guam
(NBG) to discuss lessons learned and how they would apply to a U.S. Navy ship in a similar
situation. CJRM stated he had “completely unencumbCTed communications” up and down the
administrative chain of command through C7F and CPF, and that they were fully supportive and
offered help, for example, in the form of augmentation from the III Marine Expeditionary Force
(III MEF). He noted that when an Echelon II command (Naval Reactors) attempted to direct
placement of Sailors into available housing in Guam, CJRM effectively sought C7F assistance to
push back. CJRM functioned within authorities, despite lack of a defined requirement when ship
pulled in to Guam. Specifically, he received no indication from THR or any other organization
regarding how many beds were needed, but directed preparation of 1000 beds based on an initial
“guess” that 800 would be required. CRJM also worked at a staff level with the government of
Guam to determine a path to secure hotel rooms before that COA was decided upon by C7F and
CPF.
7. Commanding Officer, USS THEODORE ROOSEVELT (CVN 71J (CO, THR). Phone
interviews on Thursday. 2 April and Monday, 6 April (with the former Executive Officer (XO)
and Acting CO, CAPT (b^ fb) ). CO, THR assumed command of THR in November 2019,
just before THR entered Composite Training Unit Exercise (COMPTUEX). He shared the THR
Senior Medical Officer’s (SMO) concern regarding accuracy of COVID-19 case reporting in
Vietnam prior to port visit and tended to a conservative approach towards COVID-19 risk
reduction. CO, THR acknowledged putting a “cumbersome plan” in place for crew liberty and
in-port activities. He appeared to lack clear, effective communications with CCSG-9, referring
to communications at that level as relaying to “staff’ and appeared focused on dealing with
COVID-19 as a pandemic, rather than triaging Sailors in the sub-optimal conditions aboard an
FOR OFFICIAL USE ONLY
2
Enclosure (5)
aircraft carrier, and then in Guam. During the interview CO, THR referred repeatedly to
discussions in the Warfare Commanders’ Board. He discussed the possibility of COVID-19
exponential growth aboard ship and potential COAs, including casualties and indicated the tenor
of discussions in this venue would have been different if they had been aware that housing
Sailors in hotels on Guam was an option. CO, THR did not articulate or communicate a plan for
ship to deal with COVID-19 and appeared to be unsure of the limits of his responsibilities for
dealing with crisis. CO, THR did not discuss the letter (Enclosure 2) he sent via email on 30
March (Enclosure 3) with CCSG-9 or C7F (his operational chain of command) prior to sending
it. He also did not refer to C7F or CPF COVID-19 guidance in his letter, only to Centers for
Disease Control and Prevention (CDC) and Naval Administrative (NAVDMIN) message
guidance. Regarding the suitability of available berthing on Guam, CO, THR stated that 4,000
hotel rooms would have been ideal, and that the open-bay quarters being used to house Sailors
looked like a “FEMA shelter.” He further stated that as a result of the close quarters and open-
bay berthing, more Sailors tested positive. CO, THR indicated that the limiting factor in
egressing Sailors off the ship was meal availability and access to restroom facilities, as well as
the poor conditions of the gyms and warehouses being offered. He considered that the available
berthing was “less healthy than the ship.”
8. Senior Medical Officer. USS THEODORE ROOSEVELT fCVN 70 tSMOl. Phone
interview on Thursday, 2 April. SMO stated that he considered COVID-19 during pre¬
deployment planning. He suspected Vietnam’s data regarding COVID-19 cases was inaccurate
and indicated a lack of trust in the decision to pull into Vietnam for a port visit. SMO referred to
burdensome administrative requirements and overwhelming data calls from chain of command
and indicated the ship was “getting hammered” from up the chain of command for not moving
Sailors ashore fast enough. However, he also stated C7F was demanding unreasonable pace and
frequency of testing before Sailors could move off ship. SMO provided the following timeline
of when he indicated concern up his operational and administrative chains of command:
• 25 Mar: emailed Executive Officer (XO) and CO that if COVID-19 cases on ship were
to increase exponentially from the first two Sailors who tested positive, they would
need 5,000 beds
• 28 Mar: emailed CPF, C7F, and CNAF surgeons, indicating ship’s positive cases
increased from two to 44 in four days
• 29 Mar: emailed Surgeon General (SG) of the Navy, indicating circumstances aboard
ship were “dire”
• 3 1 Mar: emailed SG with letter (Enclosure 4) from ship’s medical team
SMO indicated regret about elements of the letter signed by members of the medical team on
THR (Enclosure 4), including the tone and the closing statement that they intended to release it
to the public. SMO stated that it was not his intent to release the letter to the public, but that the
other members of the team were free to make up their own minds.
9. Fleet Surgeon. Commander. U.S. SEVENTH Fleet (C7F Fleet Surgeon). Phone interview on
Thursday, 2 April. The C7F Fleet Surgeon indicated she had good communications with CPF
Fleet Surgeon and has known him since college. She also indicated her communications with
SMO were regular, but she did not know him before their current assignments. C7F Fleet
Surgeon appeared able to balance operational and clinical risk decisions, but appeared unable to
FOR OFFICIAL USE ONLY
3
Enclosure (5)
find alignment between her recommendations and SMO recommendations. When SMO
expressed to her that his medical team was upset, she asked what they needed, and he replied “a
hospital for 5,000 people.” She indicated frustration with this answer and stated that her
response was “firm,” and that they would be limited in terms of what is available on Guam. She
understood SMO’s expectations were that when THR pulled into Guam, single rooms and single
beds would be available to move Sailors into and that “someone else” would “take over.”
Regarding testing, C7F Surgeon indicated the SMO perceived the testing regimen to be “non¬
standard” per CDC guidelines, but believed it was necessary to work with the Government of
Guam.
10. Executive Officer. USS THEODORE ROOSEVELT (CVN 711 (XO. THR). Phone
interviews on Thursday, 2 April and Monday, 6 April (with CO, THR). XO, THR indicated that
his CO’s letter (enclosure (2)) was an abridged version of an information paper to which all
CSG-9 06 warfare commanders (WCs), the XO, and the CO had contributed. He indicated CSG
and Fleet chum over why more available berthing on Guam was not occupied and discussed the
large number of Sailors requiring care and feeding, stating that inconsistent meal service and
availability of sanitary facilities led to Sailor complaints on Facebook. XO, THR appeared
fmstrated with discussion over COAs and stated that Commander, Carrier Air Wing ELEVEN
(C AG 1 1 ) emailed the WC information paper to CCSG-9 on 29 March. CCSG-9 responded that
the hotel COA was being considered but was not the most likely. XO, THR did not know how
CCSG-9 represented the hotel plan up the chain of command, but stated that COA was pushed
aside. He also became aware that the 5700 beds being discussed on Okinawa were not available.
When he woke up on 30 March, the CO was supposed to talk to the Chief of Naval Operations
(CNO) but the phone failed. XO, THR indicated that he prepared the email (enclosure (3)) to
which enclosure (2) was attached for the CO, who then reviewed and sent it. XO, THR indicated
that staff at C7F were “incompetent,” not asking the right questions and that the C7F Chief of
Staff was “an obstmction.” He also indicated that the C7F Fleet Surgeon was “marginalized.”
When asked about the decision to release Sailors from quarantined after berthing areas when in
port Guam, XO, THR stated that the SMO believed the quarantine aboard ship was “ineffective,”
and that the whole crew were “close contacts.” He further stated that the quarantine restrictions
were “causing human suffering unnecessarily,” which contributed to the decision to lift the
restrictions. Regarding the berthing options on Guam, XO indicated that CO, Naval Base Guam
was working to increase capacity, but that there was confusion about what was available and
what was ready for Sailors. Indicated that because THR Sailors were not allowed to leave the
pier due to Force Health Protection concerns, it was difficult to assess the suitability of available
berthing and that they “had to rely on others to be our eyes”. XO stated that CMC was allowed
to leave the ship to make an assessment on Sunday, 29 March.
11. Commander. U.S. Pacific Fleet Surgeon (CPF Surgeon). Phone interview on Friday, 3
April. CPF Surgeon relayed that discussion on Saturday and Sunday (28 and 29 March)
indicated the approach to testing was wrong, that testing was not a “cure,” and that THR needed
to get all Sailors off the ship. He indicated SMO had a pointed tone revealing frustration, which
he took as a “warning sign.” CPF Surgeon did not receive a direct request from the ship and did
not recall discussion about how to prioritize or assign Sailors to available berthing. He suggested
CPF Center for Naval Analyses (CNA) representative may have brought up potentially requiring
a Day 6 sample, but that it was not a CPF or C7F requirement. CPF Surgeon stated that while
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Enclosure (5)
C7F conducted daily medical leadership synchronization calls, THR did not consistently have a
representative.
12. Commander. Carrier Air Wing ELEVEN (CAG 11) and Commander. Destroyer Squadron
TWENTY THREE (CDS 23). Joint phone interview on Friday, 3 April. CDS 23 stated he was
not sure they had a “plan, plan,” but were involved in broad COA development to follow CDC
and NAVADMEN guidance to achieve a healthy ship free of COVID-19. Prior to pulling in, he
did not envision limitations of the base in Guam. CAG wondered “at what point does the whole
ship become quarantined?” They worked on first priority - contingencies to get ship underway
and how and indicated that as they tried to put Sailors ashore, there was no place to put them.
CAG 1 1 and CDS 23 did not know what was requested in the logistics support requirement
message (LOGREQ) and did not know details of any discussions between CCSG-9, CJRM, or
contractors and CO, NBG. They indicated they were “not in shore planning mode” and the chain
of command repeatedly asked what the plan was to get COVID off their ship. They stated
discussions centered on testing and limitations aboard the ship and they were told that hotels
were not an option and that Japan was being discussed. They also indicated that Sailors were not
allowed off ship to inspect houses, barracks, etc. and appeared frustrated about having to wait for
tests, and that they were not allowed to use local tests to get into hotel due to accuracy so they
had to wait to use Korea tests that were halted.
13. Command Master Chief. USS THEODORE ROOSEVELT (CVN 71) (CMC. THR). Phone
interview on Friday, 3 April. CMC expressed that ship’s leadership had concerns prior to Da
Nang port visit and had developed a plan to isolate/quarantine COVID positive Sailors or
persons under investigation. Their plan assumed a worst case of 33 Sailors. However, 39
Sailors required quarantine after staying at a hotel where two British citizens tested positive.
CMC observed that requests for information from higher headquarters were burdensome to
execute, that they had expended significant energy on the Okinawa COA and that they felt they
were waiting for a COA decision to be made. CMC stated that he asked CO, THR if he had sent
the letter to the press, and the CO responded that he had not. Regarding crew morale as the ship
pulled into Guam, CMC felt that the number of Sailors who were despondent about the situation
were in the minority, and that the majority understood the challenges and mission at hand.
14. Chief of Staff for Commander. U.S. SEVENTH Fleet (COS, C7F). Joint phone interview
with C7F on Monday, 6 April. Stated he did not know about CO, THR’s decision to release
quarantined Sailors from the aft berthing area of the ship when in port, Guam. Indicated that
“everyone understood” that a large number of people would have to leave the shift, and that as
early as 25 March, they were looking for off-island (Guam) resources. The number 4,000, rather
than being a specific request or requirement, was a “planning factor” determined based on how
many people would be required to operate the ship. Stated that he led a daily Video¬
teleconference for 06 leaders starting the day THR pulled into Guam. COS, C7F indicated he
“ended up” doing what a Combined Task Force commander should have been doing to
coordinate the efforts to egress THR Sailors. Further, he stated that he dealt with the ship
exclusively through CCSG-9, but that discussions with him “didn’t translate into actions.” COS,
C7F was not sure the ship could have led efforts “in the condition they were in.” Stated that a
detailed testing plan was never developed or promulgated, but the focus was to egress the crew
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Enclosure (5)
as quickly as possible, and that while there was still risk due to the sub-optimal housing options
in Guam, it was “better than leaving 4-5,000 people on the ship.”
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Enclosure (5)
Timeline (fiom TR perspective)
All times in Guam local time
Numbers of COVID-19 positive Sailors are fiom CPF reporting
Friday, 17Januaiy
• Departed San Diego on deployment.
Thiusday-Siuiday, 5-8 March
• Port visit Da Nang
• Before visit, ship had planned for 33 quarantine racks aboard ship.
• Port visit teniiiiiated early due to two British citizens testirrg positive for COVID-19 in hotel used
by TR Sailors.
• 39 people put irrto quararrtirre on TR.
Friday, 1 3 March
• TR CO serrds letter to family members indicating the ship has begun testirrg “select irrdividuals”
for COVID-19.
Friday, 2 2 March
• All 39 remain asymptomatic arrd are released fiom quararrtirre after 14-day ROM and rregative
COVID test.
Sanirday, 21 March
Morrday, 23 March
• First 2 TR Sailors show symptoms of COVID-19.
Tuesday, 24 March 3 positive
• First 2 TR Sailors test positive for COVID-19.
• TR serrds LOGREQ for arrival irr Guam on 27 Mar.
Wedrresday, 25 March 8 positive
• First 4 positives moved ashore via rotary wing.
• Discussions at tire staff level arnorrgst CSG-9, TR, JRM arrd C7F begirr about the need for 4,000-
plus occuparrcy, but rro clear requirement made for 4,000-plus isolation rooms.
• TR SMO tells TR XO that “if this goes exporrerrtial, we’re goirrg to treed 5,000 CDC-cornpliarrt
isolation rooms’’.
• TR CO serrds letter to family members irrdicatirrg “a few Sailors” have tested positive for
COVID-19, have been placed irr isolation, arrd work was in progress to fly those Sailors off the
ship as soon as possible.
Thrusday, 2 6 March - 25 positive
• Dining a discussion with C7F, in MEF Commanding General offers up to 5.000 rooms for
potential occupancy in Okinawa.
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Enclosiue ( 6)
• 1046: Email fioin CO, Naval Base Guam (NBG) to C7F/CCSG-9/TR 06s detailing plan for TR
anival. Priority after safe mooring is transpoiling COVID-positive and reactor department Sailors
to isolation rooms. CO, NBG’s scheme of maneuver brief shows 1 50 isolation beds and 493
quarantine beds (gyms: open bay).
• 1411: CCSG-9 issues outbreak Commander’s Guidance for anival in Guam expressing the
following priorities: 1) move all COVED-positive Sailors to isolation quarters; 2) identify key
groups needed to operate ship at sea in near-tenn; 3) move key reactor siq^ervisoiy persomiel into
isolation following testing; and 4) if additional quaiantine racks remain, prioritize by personnel
and by function. End state: in near-term, have sufficient personnel to get ship underway for
contingency operations.
• CCSG-9 to C7F email states that ship will nui out of quarautiue/isolatiou space ashore in Guam.
Friday, 27 Match 34 positive (231/596 beds occiqtied 39%)
• TR arrives Guam.
• Approximately 230 Sailors, those tested and presumed positive, and critical watchstanders,
moved ashore to available berthing.
• III MEF/C7F plamiing VTC refines Okinawa capacity to approximately 3,000 rooms, Atsugi is
also expected to have 400-600 rooms.
• C7F and CPF discuss Guam hotel option.
Saturday, 28 March 38 positive (382/1058 36%)
• C-40 with new COVED testing kit arrives Guam (12-14 days until calibrated and ready).
• Initial discussions about increasing capacity via hotels occurs between JRM COS and CJRM.
• Ship works to batch-test 200 persomiel moved ashore (did not have capacity to test them prior to
departure).
• TR SMO emails C7F, CPF, and CNAF surgeons indicating positive cases increased from two to
44 in four days and the rate was going exponential.
• Initial discussions between offices of JRM and Guam Governor about increasing capacity via
hotels.
• 1022: C7F placemat distributed showing rooms on Guam as available tliat were not yet ready.
Rooms on Okinawa listed as White Beach: 5,700 and CFA Okinawa: 0, althougli Commander,
Fleet Activity Okinawa owns White Beach. El MEF billeting is not located at White Beach.
• 1811: TR XO sends TR CO email (CMC/SMO are cc’d) regarding inability of TR to couply with
CDC or NAVADMIN 083-20 guidelines aboard ship. Estimates of “close contact” Sailors range
fi oin 1,400-2,000. XO recommends moving as many persomiel as possible off the ship into
lodging and reaffiims that sliip’s berthing is not in compliance with CDC or NAVADMIN
guidance. Ship emergency command center data [define] demonstrates that ship’s segregated
berthing plan is making the rate of transmission worse.
• TR CO sends letter to family members announcing arrival of ship in Guam. He indicates that
Sailors with test results or symptoms indicative of COVED- 19 are the first prioiity to get off the
sliip for evaluation at Naval Base Guam Hospital. He fiiither states that some Sailors will be
moved to open bay berthing off the ship and that parts of the ship will be used to quarantine
“close contact” Sailors.
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Sunday, 29 March 46 positive (535/1150 47%)
• Due to rate of infection increasing in segregated area of the ship (aft) faster than the uou-
segregated area (foiward), decision is made to lift aft segregation area reshictious. No longer
able to feed out of CPO mess. Positive and symptomatic Sailors remained in or were moved to
isolation.
• SMO emails Navy Surgeon General stating that circumstances aboard ship were “dire”.
• Diuiug daily C7F medical sync meeting, SMO makes fust off-ship mention of expectation for
4,000 CDC-compliant rooms.
• Ship down to last 100 test swabs, with more inbound expected after 2 April.
• CCSG-9 email to C7F states that they are developing a priority of flow to Okinawa and states that
Sailor's could be isolated quicker itsitig hotels in Gitam. CCSG-9 discitsses TR options with C7F,
who reaffinns commitment to Okinawa option, and states a large rrirmber of hotel options in
Gitarn is not likely.
• Military Assistant for Acting SECNAV contacts TR CO, proposing Sec, Modly visit TR on 1
April.
• 1101; CVW-11 CAGserrds CCSG-9 warfare commander paper with attachments, highlights:
testing cannot detennirre tlrat yon don’t have the vinrs. it can only corrfirm that you do (cannot get
to a safe/clean ship leveraging testing alone); lessons learned from Diamorrd Princess corrclnding
that 1) 500 additional infectious occiuied due to quarantine onboard versits isolation ashore and
2) 47% of positives were initially asymptomatic (Sailors thoirght safe are not and lack of
symptoms does not indicate lack of infection and negative test results to do trot irrdicate lack of
irrfectiorr).
• TR CO contacts Commander, Fleet Activities Okinawa, who states that Navy does not have
rooms available for TR Sailors (TR CO/XO nuaware that Okinawa option leveraged US Marine
Corps rooms).
• CPF disapproves C7F’s plan for moving TR crew to Okinawa, based on risk of accelerating
infection spread on the aircraft diuiug the 9-hoiu flight and complications with tire government of
Japan.
Monday, 30 March 53 positive (897/1 150 78%)
• 0730: JRM COS telcou with Governor of Guam COS positive indications of hotel option.
• 0800: CJRM discusses hotel option with Governor of Guam diu iug daily sync. Governor states
formal request required fr om CPF or IPC.
• 1152; CCSG-9 forwards COVID-19 CONOP to C7F. CONOP states that with exponential
growth of COVID, tire mortality rate could be as high as 10. Three CO As are presented: CO A 1
(fastest to sea) use of 4025 CDC-compliant quarantine spaces; COA 2 use of 2300 CDC-
compliant quarantine spaces; COA 3 (longest to sea) Naval Base Guam only (limited CDC-
compliant quarantine spaces).
• 1348; TR CO sends an email, containing the memo later made public, to CCSG-9, CNAF, and
CPF, copying the EAs for CNAF and CPF, the XO, and the foiu warfare commander's (10 people
total).
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Enclosiue (6)
Tuesday, 31 March 79 positive (951/1450 66%)
• CPF fonnally requests Guam hotel options and negotiations commence.
• TR SMO meets with medical team, signs and sends theii" letter to Navy Surgeon General.
• Approximately 1450 Sailors aboard TR in quarantine or isolation.
Wednesday, 1 April - 93 positive (959/1854 - 52%)
• C7F issues TASKORD to CTF-71 foi' recovery of THEODORE ROOSEVELT from COVID-19
infection.
• San Frarrcisco Chronicle pitblishes TR CO memo.
Tlntrsday, 2 Apr 114 positive (1240/2473 50%)
• TR CO serrds letter to family members regardmg the memo, statmg “It was rrever my irrtention to
have the letter made pitblic.” The letter states that every Sailor will be tested for COVID-19 and
those with negative test results will be moved to individual rooms off base for 14 days, while
those who test positive will be house on base in individual rooms. The letter indicates that some
Sailors will remain aboard to clean the ship befae movirtg off ship to complete their 14 days of
isolation.
Friday, 3 April - 137 positive (1563/2473 - 63%)
• TR CO relieved by Acting SECNAV.
Satrrrday, 4 April 155 positive (165 5/2473 67%) .
Sunday, 5 April 1 5 5 positive.
Morrday, 6 April 173 positive.
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Enclosme ( 6)
DEPARTMENT OF THE NAVY
VICE CHIEF OF NAVAL OPERATIONS
2000 NAVY PENTAGON
WASHINGTON DC 20350*2000
5800
Memo N09/20U 100519
14 Apr 20
MEMORANDUM
Subj: PRELIMINARY INQUIRY INVOLVING USS THEODORE ROOSEVELT (CVN 71)
Ref: (a) JAGMAN, Chapter II
(b) My Ur 5800 Ser N09D/20U 1008 18 of 7 Apr 20 w/encls
Enel: ( 1 ) Summary of Additional Interviews/Responses to Questions
1. Pursuant to reference (a), reference (b) was conducted to inquire into the events surrounding
the disembarkation of Sailors from the USS THEODORE ROOSEVELT (CVN 71) in Guam, in
response to cases of Coronavirus Disease 2019 (COVID-1 9).
2. On 13 April 2020, 1 was requested by you to conduct additional interviews to provide
clarification on timing of events regarding conversations between the USS THEODORE
ROOSEVELT (CVN 71) Commanding Officer (TR CO) and members of his operational and
administrative chaias of command, as well as whether there were observations of concern during
the Carrier Strike Group NINE (CSG-9) training cycle prior to deployment.
3. Enclosure (1) is a summary of telephonic interviews I conducted on 13 April 2020. My
executive assistant was present during these interviews. Quotations indicate exact words or
phrases used by those interviewed.
Summary of Additional Interviews/Responses to Questions
1. Commander, U.S. Pacific Fleet (CPF). Phone interview on Monday, 13 April. Phone
interview on 28 March (29 March Guam), CPF called the USS THEODORE ROOSEVELT
(CVN 71) Commanding Officer (CO) to advise him that the Acting Secretary of the Navy was
calling (the Acting Secretary of the Navy Chief of Staff called later that day). This call occurred
prior to the CO sending the email. During the call, ADM Aquilino asked the CO if he was
getting the support he needed, and he indicated that he was. Following receipt of the USS
THEODORE ROOSEVELT (CVN 71) Commanding Officer (CO) email, CPF called
Commander, Carrier Strike Group NINE (CCSG-9) on 29 March (30 March in Guam). ADM
Aquilino asked what actions he (CCSG-9) and the CO expected that they were not already
underway. CCSG-9 responded with words to the effect of “we need 4000 beds.” At this time
construction was in progress for makeshift facilities up to a capacity of 2700 beds. ADM
Aquilino responded to CCSG-9 by explaining he may not be able to provide 4000 beds, and that
he was working multiple options to get there, to include looking at the possibility of hotel rooms,
but that it was his job as Strike Group Commander to plan for how to work the crew through
quarantine and isolation with something less than the “perfect answer.”
2. Commander. Naval Air Forces (CNAF). Phone interview on Monday, 13 April. Following
the receipt of the CO email, CNAF spoke with the CO on 31 March (1 April in Guam. CO
relieved early morning of 3 April in Guam) to provide mentorship and counsel. During the call,
VADM Miller specifically probed into his relationship with the strike group commander, and his
assessment of the strike group commander with C7F. The CO responded that both relationships
were healthy, with good communications in both directions, and plenty of communications
opportunities. He also noted to VADM Miller that VADM Merz (C7F) was particularly
engaged, holding multiple VTCs each day regarding the situation on the TR. VADM Miller
followed with the question of why the CO then felt it necessary to send the letter, given his good
relationship and communications with the chain of command. The CO stated that he did not feel
the response was moving fast enough.
3. Commander. U.S. THIRD Fleet (C3F). Phone interview on Monday, 13 April. Overall,
during its Composite Training Unit Exercise (COMPTUEX), the overall score for Carrier Strike
Group NINE (CSG-9) was higher than the average of the last three CSGs and no issues were
identified. The leadership team was cited by Commander, Carrier Strike Group FIFTEEN
(CCSG-I5) as “strong” with a “disciplined, effective battle rhythm and planning processes” and
a “shared understanding of Commander’s intent, priorities and risk acceptance.”
4. Clarification to PI follow-on questions:
a. What phone calls were conducted between Commander, U.S. Pacific Fleet (CPF) and
Commander, Naval Air Forces (CNAF) with the USS THEODORE ROOSEVELT Commanding
Officer (CO)?
No phone calls were conducted between all three officers. Rather, CPF called the CO on 28
March (29 March Guam), to advise him of an expected phone call from the Acting Secretary of
the Navy later that same day, which ultimately was made by the A/SN’s Chief of Staff. CNAF
Enclosure (1)
called the CO on 3 1 March ( 1 April Guam) to ask him about any needed support and to provide
mentoring. These calls are detailed in paragraphs 2 and 3 above.
b. Is that the phone call where CPF first told the CO of the work being done to get hotel
rooms in Guam?
No. Work being done to get hotel rooms was not discussed with the CO, but rather with CCSG-
9 in a phone call made on 29 March (30 March).
c. When did CPF tell CO hotel rooms would be available, and when were they actually
available?
The CO was aware that an option to obtain hotel rooms was being worked as early as the
morning of 30 March (Guam time), but based on feedback from C7F (VADM Merz) when this
COA was being discussed at the daily synch, the CO did not think it would likely be approved,
and had considered that it was a low priority for the C7F staff (as compared to the Okinawa
option). He learned that the hotel option was approved on 31 March (Guam), the day after he
sent the email.
d. Were there any indicators or concerns revealed during the Carrier Strike Group NINE
(CSG-9) Composite Training Unit Exercise (COMPTUEX)?
See paragraph 3. Interview with C3F showed no indicators or concerns. In fact, C3F endorsed
the CCSG-I5 report that the CCSG-9 command team was above average, and also noted:
• Strong leadership team with a disciplined, effective battle rhythm and planning processes
• Shared understanding of Commander’s intent, priorities and risk acceptance
2
Enclosure (1)
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