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On Dec. 4 Gabriel Romero shot three people. The 22-year-old Navy sailor was assigned to the submarine the USS Columbia and had just shown up for routine guard duty at the Pearl Harbor Naval Shipyard.

Just minutes after he started his shift, he fired his M-4 rifle at a group of civilian workers, killing Roldan Agustin, 49, and Vincent Kapoi Jr., 30, and wounding Roger Nakamine, 36.

The deadly incident came seemingly without warning. Pearl Harbor Naval Shipyard is one of the state’s top employers and biggest industrial bases.

The Navy was tight-lipped about details of the shooting. But its 190-page report on the ensuing investigation, made public Tuesday, sheds light on the circumstances surrounding the shooting.

Investigators still don’t have a specific motive for the shooting after months of looking into Romero and interviewing fellow sailors, but the investigation paints a picture of a troubled young man struggling with his mental health and angry at the world around him.

The report ultimately concluded that no one could have predicted Romero would be a threat. He never expressed suicidal thoughts or homicidal intent toward anyone — though a forensic psychologist did note that his relationships with the women he dated in Hawaii were “chaotic” and that he was prone to jealousy.

But the investigation did find that a Navy psychologist “under-diagnosed and did not properly manage Romero’s mental health condition” likely in an effort to keep him from getting pulled from duty, and that medical providers failed to share information with commanders.

The investigation also found much broader problems aboard the Columbia that may have made it easy for Romero’s superiors to overlook him. Investigators raised concerns about the handling of mental health issues and whether the service is overworking members of its submarine fleet.

A command climate survey conducted in October 2019 for the Columbia found 35.5% of those on the crew knew someone who thought of suicide and that 6.6% knew someone who had attempted suicide. There were also 34% who did not feel comfortable talking about difficulty at work with their immediate supervisors.

One anonymous comment in response to the survey says, “Everyday (sic) I have to convince my self (sic) to get out of bed to come to work. I pray that on the driver (sic) I get in a car accident and die. Often times I considering (sic) putting my pistol in my mouth and ending it all or just throwing myself into the dry dock basin.”

The response to the survey elicited alarm. The Columbia’s chief of boat recalled reviewing a list of 15 to 20 sailors with a history of family, medical and disciplinary issues that the commanders had been monitoring. 

Romero’s name was on the list, but the investigation said that “Romero did not cross the COB’s mind at all when he reviewed” the comments because “other Sailors worried the COB more at the time.”

A Normal Recruit

Romero was born in Dearborn, Michigan, on April 4, 1997. He was raised by his mother along with two older brothers and a younger sister, growing up in Texas. They moved frequently during his teenage years; he attended three different high schools, two in Texas before graduating from Woburn Community High School in Massachusetts.

As a student he struggled with academics but excelled at hockey. After high school he joined a hockey association in Casper, Wyoming, that trains young players for college teams. He eventually returned to San Antonio and enrolled in community college. 

He continued to struggle academically, and on Nov. 17, 2017, he decided to drop out and enlist in the U.S. Navy.

His medical screening raised no red flags. He had no history of criminal behavior, drug use or mental health issues — though his mother would later note that he suffered several concussions during his time playing hockey. He required no medical or criminal waivers. 

After completing training he was assigned duty with the USS Columbia at Pearl Harbor as a Machinist Mate Auxiliary Fireman Recruit, reporting for duty on June 28, 2018. No one noticed any problems. He successfully completed weapons qualifications training that September and by December qualified to be a member of the sub’s armed defense force.

But on Dec. 13, 2018, he was involved in a motorcycle accident. He went to the emergency room at Tripler Army Medical Center four days later for injuries he received in the crash and was diagnosed with acute traumatic pain in his left testicle and released. 

After that, he began to have problems at work, showing up late frequently and struggling to perform tasks proficiently.

He returned to Tripler just a few months later. On March 4, 2019 he reported problems “concentrating, focusing, and staying engaged” after attending traffic court earlier that day for a speeding ticket and telling staff he couldn’t stay focused. Romero denied having any violent or suicidal thoughts during his visit to Tripler. 

Staff called Romero’s division chief to inform him of the visit, but told him Romero was not a threat to himself or others. Romero told his superior that he was having trouble sleeping and was concerned about other health issues. Those were redacted in the report.

Tripler staff noted that he may have attention deficit disorder, and wrote a referral in his electronic medical record to the Naval Submarine Support Command’s Embedded Mental Health Program, or eMHP, clinic at Pearl Harbor before discharging him.

The investigation noted that the clinic cannot receive outpatient referrals through the electronic medical record system and that Tripler didn’t tell the clinic about the referral or inform the medical division aboard Columbia. Romero didn’t make an appointment.

Romero’s superiors began noting continued tardiness and disciplinary problems.

‘Phase Of Life Problem’

Romero continued to frequently show up late for work, frustrating both superiors and fellow sailors. A third-class petty officer told investigators of a time in May or June 2019 where Romero was crying. He approached Romero to talk but Romero told him he was tired of work and of people calling him stupid.

In his private journal, Romero wrote about “dumb, fucking rats and animals” on his crew who assumed he was “some horrible lazy, shitbag, that doesn’t give two shits about the Columbia and the crew.” In calls home to his mother he described a hostile work environment, a drawn out submarine qualification process and a feeling that none of the work he did was meaningful.

At one point a fellow sailor found him with injured knuckles; Romero told him that he had been punching a locker. Another sailor told investigators that while talking to Romero about his problems in the summer of 2019 he recommended seeking therapy. Romero reacted angrily and yelled at him. However, he never expressed a desire to harm anyone.

On Sept. 11 Romero received a write-up for sitting down during roving patrol duties and was told that he would have to do remedial training to prove he could do his job properly. That month Romero finally went to the eMHP Clinic when his division chief became increasingly concerned about Romero, noting he was upset and was acting increasingly withdrawn. 

The chief of boat arranged for Romero to have an appointment with a psychologist, who described Romero as “odd, awkward, guarded, and confused.” But ultimately the psychologist didn’t diagnose Romero with a mental disorder.

The psychologist determined Romero was having a “Phase of Life Problem” and an “Unspecified Problem Related to Unspecified Psychosocial Circumstances.” Romero remained qualified for submarine duty without limitations. However, the psychologist recommended Romero continue individual therapy with a behavioral health specialist, a non-licensed enlisted corpsman. 

Romero attended several sessions. The investigation noted that on Oct. 22 “Romero agreed that they should discontinue care because all goals had been met.” He continued with additional peer support sessions but the investigation found that “the Force Psychologist did not properly supervise the behavioral health technician’s care of Romero.”

After the shooting a forensic psychologist determined that Romero showed symptoms for “Autistic Spectrum Disorder; Attention Deficit and Hyperactivity Disorder; Social Anxiety Disorder; Personality Disorder (Avoidant and Borderline features); Anxiety Disorder; Depressive Disorder; and Adjustment Disorder.”

Almost all of those would have been disqualifying for submarine duty. But the force psychologist told investigators that he didn’t diagnose Romero with a disorder because his behavior was ultimately consistent with many other submarine crew members, who he said often tended to be smart and have strong analytical skills, but sometimes exhibit poor social skills.

The psychologist argued that if he pulled everyone who acted strangely off a sub, there wouldn’t be enough sailors to man the fleet.

A Toxic Climate

Romero’s problems didn’t raise attention because they didn’t appear unusual. In April 2019 during a leadership workshop on the Columbia, evidence of wider problems began to emerge. At the time, 80% of the crew believed the performance of the Columbia was on a downward trend and 10% believed that it was at a low point. 

The two points sailors emphasized were the departure of several respected and experienced leaders and frustration with being in a shipyard rather than operations at sea. 

However, sailors at that time still reported relatively high levels of job satisfaction and quality of life, expressing hopes for improvement. They said their commanding officer did a good job of communicating expectations. But their appraisal of non-commissioned officers onboard was far less generous.  

“The crew expressed trepidation in addressing mental health issues with some E-5 and below crew members stating that they would be unwilling to seek help for mental health issues due to fear of negative impacts on their security clearance or job,” the report noted.

Crew also reported that discipline was poor and that leaders regularly failed to ensure sailors meet their qualifications and job proficiency. The sub ranked near the bottom of the fleet in terms of performance. 

By August 2019, the sub was beginning to show modest improvement in terms of performance, but by the time of the command climate survey in October, morale had plummeted.

The anonymous response to the command survey that referenced suicide also noted a deep frustration with leadership on the sub. It also noted a resentment of civilian dock workers at the shipyard, complaining that the crew of the sub often had to clean up after them.

“Not having a purpose and just being here to clean, we work in an industrial environment, you can only sweep the decks so much,” the comment stated. “They take cleaning way to (sic) serious for ship that is going through an overhaul and do not hold shipyard workers accountable for the mess they leave.”

Though only one comment directly mentioned suicide, other comments echoed similar frustration with the sub’s leadership. Common complaints were unpredictable schedules, lack of planning, late working hours and last minute assignments from leaders.

Leaders on the sub ultimately decided that additional suicide prevention training wasn’t worth it as they had just completed a round in September. They also decided that the morale problems weren’t abnormally bad for a vessel assigned to an industrial environment.

The investigation later found that “the organizational culture tolerated a below-average command climate because USS COLUMBIA was in an industrial environment.”

‘Tell Sailors To Stop Complaining’

No one in Romero’s chain of command discussed his emergency room visit or his eight eMHP Clinic visits between September and November with Romero’s primary care provider, a senior enlisted medic on the sub.

Romero’s division chief later told investigators he didn’t want to see the medic because he would “tell Sailors to stop complaining.” Columbia’s chief of boat said the medic “could be brash with junior sailors, but he was a top performer.”

The investigation found that the chain of command could have taken “more intrusive actions to direct additional mental health evaluation or remove Romero from armed watchstanding” given his long-developing problems.

In November, Romero was assigned temporary duty aboard the submarine USS Chicago to complete his qualifications and earn his submarine warfare pin. The report noted that while aboard the USS Chicago, Romero “did not interact much with other Sailors, demonstrated a low level of knowledge and gave the impression that he did not want to be there.”

Upon returning to the Columbia the sub’s leaders held a disciplinary review board on Nov. 21 regarding Romero’s repeated failure to arrive on time and failure to meet qualifications. “As Romero often did when counseled for poor performance, he began crying,” the report noted.

On Nov. 26 he was told he had failed the Naval Advancement Exam and would not be promoted. On Dec. 3, Columbia’s executive officer wrote that Romero knew his responsibilities but “was derelict in the performance of those duties in that he has shown a pattern of misconduct.” 

The report said that the officer then asked Romero “if his mother would be happy if she knew he was squandering the opportunity the Navy gave him.” Romero began to cry and told the officer he wanted to stay in the Navy.

The officer decided not to refer him to discipline by the sub’s commanding officer for non-judicial punishment, instead writing in a form in all caps that read “IF I AM LATE TO WORK AGAIN, I WILL BE HELD ACCOUNTABLE.”

The officer intended to follow up to talk with Romero the next day and have him sign it, but that would never happen.

On Dec. 4, Romero entered his barracks room soon after midnight, according to surveillance footage. At 3:13 a.m. he left to go see his girlfriend. At 7:38 a.m. he returned to the barracks and left shortly after for small arms training on Ford Island from 8:30 a.m. to 11 a.m.

While there he was in touch with his girlfriend, texting her a screenshot of prospective landlord contact information at 9:42 a.m. and calling her at 9:52 a.m. No one reported him behaving out of the ordinary. He returned again to his barracks at 1:19 p.m. to prepare for duty at the shipyard.

At 2:04 p.m. he reported for duty, meeting the sailor currently on roving patrol watch. The two exchanged the standard words “I am ready to relieve you” and “I am ready to be relieved.” Romero armed himself with the M-4 rifle and M-9 pistol the sailor had been using. 

At 2:15 p.m. Romero began a roving patrol around Dry Dock 2. A few minutes into his patrol, he turned around on the starboard side of Dry Dock 2 before he had circulated the entire dry dock and approached three civilian workers from behind.

He chambered a round in the M-4 and opened fire on the three men. As they fell to the ground Romero drew the M-9 pistol and shot himself. The entire incident lasted less than a minute.

‘Better Balance Must Be Achieved’

The investigation concluded that the eMHP is a valuable program but noted that “a review of Romero’s care and eMHP Clinic diagnostic data indicate a potential pattern of under-diagnosis to maintain patients on submarine duty.”

The report’s authors also wrestled with how to balance an individual’s right to privacy, and the military’s responsibility to ensure the safety of those they work with, noting that the “DoD policy on confidentiality is central to removing the stigma of seeking mental health treatment and building trust between medical providers and patients.”

But the authors added that a “better balance must be achieved between confidentiality and sharing information to improve care, and ensure that high-risk personnel are identified and appropriately monitored, especially where Sailors are given access to means that can kill or cause serious injury.”

The military continues to place heavy demands on the Navy as American forces in the Pacific region mount frequent training exercises across the region and patrols of the South China Sea as tensions rise between China and other countries.

Since the coronavirus pandemic began, tensions at sea have only escalated. A recent report found that military suicides have increased as as the armed forces feel the strain of continuous deployments and the new restrictions the pandemic brings.

But solving these problems will be an ongoing challenge.

“The evidence does not establish with certainty why Romero chose to shoot three civilians and kill himself,” the authors of the investigation wrote. “But it does show that he had several stressors in his life in the months leading up to the shooting that, when taken together, likely led him to choose violence.”

Read the full report below.