DEPARTMENT OF THE NAVY
CHIEF OF NAVAL OPERATIONS
2000 NAVY PENTAGON
WASHINGTON DC 20350-2000

 

5800
Ser 100002
19 Jun 20

FINAL ENDORSEMENT

From: Chief of Naval Operations
To: File

Subj: COMMAND INVESTIGATION CONCERNING CHAIN OF COMMAND ACTIONS
WITH REGARD To COVID-19 ONBOARD USS THEODORE ROOSEVELT
(CVN 71)

Ref: ADM R. Burke, USN 5800 Ser of 27 May 20 (w/encl)

I reviewed reference the Command Investigation, and I approve the report except as
noted herein.

Preliminary Statement

After my review of reference and the enclosures and references that inform it, I have
determined that reassigning CAPT Crozier as the Commanding Of?cer (C0) of the
USS THEODORE ROOSEVELT (CVN 71) is not in the best interest of Navy.

I make this decision fully recognizing that his email, which was leaked to the media and
is the genesis of this investigation, was sent with the well-being of the crew of the
USS THEODORE ROOSEVELT (CVN 71) as his top concern. Also, I am mindful that the
actions of those involved must be considered with the understanding of the unprecedented nature
of the challenge, the fast-pace of the crisis, and the dif?culties involved with evolving guidance.

It is clear to me following this investigation, CAPT Crozier did not act according to the
standards I expect of our commanding of?cers?to adapt in the face of adversity, exercise
ingenuity and creativity in crisis, demonstrate resilience, communicate effectively up the chain of
command, and to take bold and appropriate action early and often. His actions and inactions in
the timeframe before sending the email fell well short of what I expect from our of?cers in
command.

With this backdrop in mind, there are three fundamental principles that I considered as I
made this decision: the nature of command at sea, the fundamental importance of the chain of
command, and standards of performance in command.

Subj: COMMAND INVESTIGATION CONCERNING CHAIN OF COMMAND ACTIONS
WITH REGARD TO COVID-19 ONBOARD USS THEODORE ROOSEVELT
(CVN 71)

Command at Sea

Title 10 of the US. Code requires that all commanding of?cers ?take all necessary and
proper measures .. to promote and safeguard the morale, the physical well-being, and the
general welfare of the of?cers and enlisted persons under their command or charge.? The US.
Navy Regulations further emphasize this principle by noting in Section 0802: ?The
responsibility of the commanding of?cer for his or her command is absolute The authority of
the commanding of?cer is commensurate with his or her responsibility [and delegation of
authority from him] Shall in no way relieve the commanding of?cer of continued responsibility
for the safety, well-being, and ef?ciency of the entire command.? This Navy Regulation goes on
to state: ?The commanding of?cer Shall exercise leadership through personal example, moral
responsibility and judicious attention to the welfare of persons under their control or supervision.
Such leadership shall be exercised in order to achieve a positive, dominant in?uence on the
performance of persons in the Department of the Navy.? These laws and regulations underlie the
nature and responsibility of command at sea, without which our Navy could not perform its
critical functions. CAPT Crozier?s letter and email were one means of exercising his
responsibility as a commanding of?cer.

I believe CAPT Crozier had two critical obligations. First was to take every appropriate
action possible?as quickly as possible?to safeguard the well-being of his crew in order to
ensure maximum operational readiness of the THEODORE ROOSEVELT, and second, to
forcefully and fearlessly communicate his observations, concerns, and recommendations up the
chain of command. CAPT Crozier desired to ensure the welfare of his crew, and to accomplish
this end, desired to get as much of the crew off the ship and into Spaces that would allow for
maximum separation. In so doing, he believed that he could ensure a ?clean ship? that was ready
to set sail if and when ordered to do so.

I am certain that CAPT Crozier had the best interest of the crew and the readiness of the
ship he commanded in mind. However, he did not have the luxury of the best possible
circumstances or time in which to meet those obligations. AS explained in more detail below,
CAPT Crozier did not forcefully and expeditiously execute the best possible and available plan,
or do enough, soon enough. When faced with barriers to his primary course of action (COA),
CAPT Crozier waited for others to act rather than doing what we expect of our commanding
of?cers?to take immediate and appropriate action and to drive outcomes.

Chain of Command

A second bedrock principle essential to the function of the US Navy is the primacy of the
chain of command. Those superior to the CO have the responsibility to clearly communicate
decisions and orders down the chain of command and to consider the feedback from subordinates
while the CO has the responsibility and authority to plan, decide, act and communicate up the
chain of command. I expect commanding of?cers to fearlessly communicate up the chain of
command and to have their facts straight when doing so. In the matter at hand, CAPT Crozier

Subj: COMMAND INVESTIGATION CONCERNING CHAIN OF COMMAND ACTIONS
WITH REGARD To COVID-19 ONBOARD USS THEODORE ROOSEVELT
(CVN 71)

failed to effectively communicate his concerns up the chain of command, at key moments,
despite numerous opportunities to do so.

The email and the letter CAPT Crozier sent was not delivered outside the chain of
command and was not intended by him to be released to the media. However, CAPT Crozier did
not ensure he had all of the relevant facts and did not use available avenues to inform his chain
of command prior to his sending of the letter. Speci?cally, he failed to pre-brief his immediate
superior, Commander, Carrier Strike Group NINE who was co-located on the ship,
and he excluded Commander, U.S. SEVENTH Fleet (C7F) as an addressee on his email.
Importantly, his email and letter were sent hours after a decision had been made by the
Government of Guam to open hotels for CAPT Crozier?s crew. His email neither accelerated
that decision nor had any positive impact on the outcome.

Performance in Command

CAPT Crozier?s performance during this unprecedented crisis fell short in several key
ways. Speci?cally, during the ship?s transit to Guam CAPT Crozier took some steps to slow the
Spread of throughout the ship, but he did not ensure physical distancing was
implemented onboard. While this is challenging on an aircraft carrier, it remained an essential
preventative measure to mitigate widespread transmission.

During the critical initial 72 hour period THEODORE ROOSEVELT was inport Guam
before sending his email, he did not plan for and egress sailors off the ship and onto the base fast
enough. If there were obstacles to expeditious egress, he did not aggressively seek solutions.
Instead, he was improperly focused on the ideal COA (hotels) and not the most likely COA (on
base facilities). He narrowly focused on what he considered to be obstacles outside of his
control rather than ?owning the plan? by quickly and effectively implementing available options
within his span of control. As well, he failed to openly communicate his concerns to senior
leaders regarding the need for additional support. For instance, he did not take advantage of
available opportunities to brief the entire chain of command during daily VTCS. I also hold
CCSG-9 accountable for the lack of an egress plan and more rapid egress off the ship.

He also exercised questionable judgment when he released Sailors from aft quarantine
onboard the ship. This allowed for increased spread of the virus onboard the ship. He placed
comfort of the crew ahead of safety of the crew at a time when he should have been focused on
doing everything he could to slow transmission of COVID-19 by moving Sailors ashore.

Additionally, the COA to debark the crew and place them into Guam hotels was his most
desirable COA, but also the most constrained. Supporting commanders, particularly Commander
Joint Region Marianas, were in direct contact with the Government of Guam on the hotels
Option. CAPT Crozier should have been more focused on the planning and execution of the
COA to egress sailors to the facilities available on Naval Base Guam. That COA was the best
path available to immediately segregate, quarantine, and isolate his crew and thus meet his ?rst

Subj: COMMAND INVESTIGATION CONCERNING CHAIN OF COMMAND ACTIONS
WITH REGARD TO COVID-19 ONBOARD USS THEODORE ROOSEVELT
(CVN 71)

critical obligation?to safeguard the well-being of his crew in order to ensure maximum
operational readiness of the THEODORE ROOSEVELT.

Finally, he did not ensure he had a full understanding of the facts before sending the
email or include key members of his chain of command in the email chain. The letter did not
have a positive effect on the plan in place and indeed placed undue pressure on the Governor of
Guam at the time she was ?nalizing plans to open hotels.

Opinions
I endorse the Opinions found in reference as follows:
Da Nang Port Visit (Opinion 1)

I concur that the decision to execute the Da Nang, Vietnam port Visit was appropriate for
the reasons stated in the report. While it is likely that COVID-19 was introduced to the
THEODORE ROOSEVELT as a result of this port visit, the decision-making prior to and during
the visit was reasonable based on the rationale for the visit and the information known at the
time.

Decisions During Transit to Guam (Opinion 2)

The THEODORE ROOSEVELT leadership decisions during the transit were generally
sound but lacked effective implementation. I note that decisions were made during a time when
our knowledge of COVID-19 and its method of spread was limited and dynamic. CAPT Crozier,
did, for example, enforce cleaning of ship twice daily and reminded the crew daily of the
necessity to do so. Daily screening for COVID-19 were also conducted; numbers of
patrons in the ships? store were limited; additional precautions were taken with respect to food
preparation and meal service. The one controlling action that fell short was effective social
distancing. CAPT Crozier and the rest of the leadership team directed the crew to practice social
distancing, but the report reveals compliance was inconsistent. I fully recognize that effective
social distancing is not easily accomplished at sea, though the THEODORE ROOSEVELT
leadership should have worked aggressively to enforce it.

Egress of the Crew in Guam (Opinions 4 9)

The and THEODORE ROOSEVELT leadership did not do enough to effectively
plan for and execute a rapid egress of the crew in Guam consistent with the constraints and
restraints present at the time. I concur with the report?s conclusion that more effective planning
for COAS short of off?base, fully CDC-compliant single occupancy rooms should have occurred.
Speci?cally, CAPT Crozier and CCSG-9 should have both pushed for the most effective COA of
CDC-compliant rooms, while at the same time doing everything possible to egress the crew onto
Naval Base Guam.

Subj: COMMAND INVESTIGATION CONCERNING CHAIN OF COMMAND ACTIONS
WITH REGARD TO COVID-19 ONBOARD USS THEODORE ROOSEVELT
(CVN 71)

However, the slow egress of the crew after arrival in Guam was in?uenced by numerous
contributing factors. I believe each was within CAPT Crozier?s span of in?uence to either
resolve himself or seek support from his chain of command. This includes initial confusion over
testing requirements prior to egress; perceived versus actual quality of berthing accommodations
on Naval Base Guam; and planning requirements for the Okinawa contingency COA.

As the C0 of THEODORE ROOSEVELT, CAPT Crozier should have forcefully owned
the plan to quickly egress the crew given the applicable constraints and restraints, should have
vigorously communicated his concerns about Obstacles and resource constraints, should have
insisted upon more information about ongoing efforts to secure hotel rooms, and should have
pursued the interim solution of on-base berthing for his crew. However, make no mistake, the
shortfalls in execution Of the egress are not borne by CAPT Crozier alone. as well as
his staff also bear responsibility for the slow egress from the ship onto NBG.

Decision to Release Crew Members from Quarantine (Opinion 3)

The decision to release crew members from their quarantine location in the aft portion of
the ship was inappropriate. I understand CAPT Crozier?s conclusion that the onboard quarantine
area was crowded, uncomfortable, and may have been leading to a higher rate of infection within
that area of the ship. I also understand his conclusion that numerous new positive cases onboard
the ship outside of the quarantine area may have suggested that the quarantine was ineffective.
CAPT Crozier?s stated intent in releasing Sailors from aft quarantine was to allow for greater
social distancing onboard the ship. However, he should have continued to contain the spread of
the virus through quarantine while simultaneously doing everything possible to move the crew
ashore. His determination that onboard quarantine was ineffective should have led to an
acceleration of Sailors to ashore accommodations. It did not.

CAPT Crozier?s Email and Letter (Opinions 10, 12 15)

In sending the letter, CAPT Crozier?s intentions were sound and I concur with the
report?s conclusion that he sent the letter as a ?genuine plea for help.? However, I also concur
that the letter was unnecessary, had no positive impact on actions already underway, and should
have been preceded by a clear and fulsome discussion with CAPT Crozier?s immediate superior
in the chain, the Commander of Carrier Strike Group NINE. While I do not believe he intended
the letter to leak to the press, CAPT Crozier did intentionally omit the Commander of US.
SEVENTH Fleet from the email. These were signi?cant errors in judgment. Poor
communication on the part of the C7F staff was a signi?cant contributing factor in the overall
poor communication throughout this chain of events. However, this does not warrant going
around a member of the chain of command.

Forthright, fearless, and clear communication up and down the chain of command is
essential tO effective military operations, particularly when faced with a dynamic and novel
threat such as COVID-19. The breakdown in communication and trust revealed in the report is
troubling and certainly hampered the response to the COVID-19 outbreak.

5

Subj: COMMAND INVESTIGATION CONCERNING CHAIN OF COMMAND ACTIONS
WITH REGARD TO COVID-19 ONBOARD USS THEODORE ROOSEVELT
(CVN 71)

In the end, the email and letter sent by CAPT Crozier were unnecessary. Although it
advocated for the best COA and the one that was eventually executed, actions were already
underway to acquire CDC-compliant, off?base individual hotel rooms for the crew. Before
sending a direct communication three echelons up the chain of command, it is imperative that all
facts are known and all other means of communication within the chain have been thoroughly
exhausted. In this, CAPT Crozier fell short.

Medical Department Letter (Opinion 11)

I concur that the letter signed by certain members of the THEODORE ROOSEVELT
medical department was ill-conceived and inappropriate. While I do not question the desire for
the medical department members to advocate for the health of the crew, it was exceedingly poor
judgment to include in the letter a threat to release the letter to the public. The Senior Medical
Of?cer (SMO) did indeed miss a leadership opportunity by signing the letter as written, even if
he did not have an actual intent to release the letter. Similarly, CAPT Crozier missed a
leadership opportunity when he, rather than issuing a direct order to not release the letter to the
public, simply encouraged the SMO to not release it. The release of the letter, 24 hours after
CAPT Crozier sent his email, was unnecessary.

Recommendations

(1) CAPT Brett Crozier. I concur that CAPT Brett Crozier will not be reassigned as the
Commanding Of?cer of USS THEODORE ROOSEVELT (CVN 71) or to a future command,
either at sea or ashore. Commander, US. Paci?c Fleet (COMPACFLT) may consider and
impose administrative measures as appropriate, based on reference and based on my
conclusions in this memo. CAPT Crozier?s deep experience and strong history of performance
should be positively considered in future assignments to key Navy positions.

(2) Administrative Measures. The promotion of RDML Baker is held in abeyance
pending a separate review. Any decision to recommend the detachment for cause of the Senior
Medical Of?cer (SMO) assigned to THEODORE ROOSEVELT will rest with COMPACFLT
and the operational chain of command. Additionally, COMPACFLT may consider and impose
administrative measures on other personnel involved in this chain of events if warranted,
including leaders not speci?cally listed in Recommendation 2.

(3) OPNAV Study. I concur that a study of coastal state transparency as it relates to
COVID-19 is useful and will help inform future port visits. 1 direct the Director of Navy Staff to
task this project to the appropriate OPNAV staff(s).

(4) Update of NTRP 4-02.10. I concur with the need to update relevant health guidelines
as a result of what we have learned and continue to learn about COVID-19. The Surgeon

General and the Naval Warfare Development Command are directed to collaborate and update
NTRP 4-02.10.

Subj: COMMAND INVESTIGATION CONCERNING CHAIN OF COMMAND ACTIONS
WITH REGARD TO COVID-19 ONBOARD USS THEODORE ROOSEVELT
(CVN 71)

(5) Cultural Workshop for THEODORE ROOSEVELT. While I do not concur that the
report established a systemic or widespread lack of integrity, I do concur that operational and
administrative hazards result from a breakdown in communication. COMPACF LT may consider
use of a Cultural Workshop to help the THEODORE ROOSEVELT CSG identify the root causes
of the communications barriers involved in this case, and develop a learning culture that prevents
similar events in the future.

(6) THEODORE ROOSEVELT Medical Department Debrief. I direct the Surgeon
General or his designee to debrief the THEODORE ROOSEVELT Medical Department to
determine and publish best practices with regard to at-sea prevention, mitigation, and
response.

(7) THEODORE ROOSEVELT as Case Study. I direct the Vice Chief of Naval
Operations to use this chain of events, the report, and my endorsement as a case study to identify,
analyze, and publish lessons learned regarding the importance of clear, forthright, appropriate
communication during crisis action planning and crisis response. This study and its use must
provide principles or guidelines on when and how a leader might choose to bypass a member of
the chain of command.

(8) CSG Commander Training. I concur with the recommendation as written and direct
Director, Navy Staff to coordinate responsive action.

(9) CSG Training and Certi?cation Events. I concur with the recommendation as written
and direct Commander, U.S. Fleet Forces Command and COMPACFLT to coordinate responsive
action.

Copy to:

VCNO

COMPACFLT

SG

JAG

DNS

Report of the Command Investigation Concerning

Chain of Command Actions
With Regard to 
Onboard USS Theodore Roosevelt (CVN 71)
May 27, 2020

 

FOR OFFICIAL USE ONLY
On the front cover:
Background: USS Theodore Roosevelt (CVN-71) is moored pierside at Naval Base
Guam on May 15, 2020 (US Navy Photo)
Top left: USS Theodore Roosevelt (CVN 71) anchored off the coast of Da Nang,
Vietnam, March 5, 2020 (U.S. Navy/MC3 Nicholas V. Huynh)
Top center: Vans await to transport USS Theodore Roosevelt Sailors to quarantine and
isolation facilities ashore on Guam (US Navy Photo)
Top right: US Navy Sailors assigned to local commands deliver meals to quarantined
USS Theodore Roosevelt (CVN 71) Sailors in Guam hotel (US Navy Photo)
Bottom right: Naval Base Guam Task Force Revive Command Center (US Navy Photo)
Bottom center: Expeditionary Medical Facility established on Guam to support USS
Theodore Roosevelt (CVN 71) Sailors (US Navy Photo)
Bottom left: US Navy and USMC medical personnel conduct daily health screenings of
USS Theodore Roosevelt (CVN 71) Sailors in quarantine in Guam hotel (US Navy
photo)

2

 FOR OFFI CIAL USE ON LY
DEPARTMENT OF THE NAVY
VI C E CHIEF OF NAVAL OPERATIONS
2000 NAVY PENTAGON
WA S HIN G T O N DC 20350·2000

5800
Ser N09D/20U100825
27 May 20
From: Vice Chief of Naval Operations
To:
Chief of Naval Operations
Subj: COMMAND INVESTIGATION CONCERNING CHAIN OF COMMAND ACTIONS
WITH REGARD TO COVID-19 ONBOARD USS THEODORE ROOSEVELT
(CVN 71)
Ref:

(a) Your ltr 5800 Ser NOOJ of 30 Apr 20

Encl: (1) Final Report
1. Reference (a) directed me to inquire into the communications, decisions and actions that took
place within the Navy chain of command related to the following matters:
a. Planning and execution of the Da Nang, Vietnam port visit.
b. Transit of USS THEODORE ROOSEVELT (CVN 71) to Guam, including air
movements during transit and planning for the ship' s arrival and provisions for the crew.
c. Actions following arrival of USS THEODORE ROOSEVELT (CVN 71) to Guam,
including movement of the crew to on-base and off-base lodging.
d. Preparation and email delivery of the fonner commanding officer's letter dated 30 March
2020, further handling of that email, and response to the email and letter by the chain of
command. I was directed to include in my report transcripts or summaries of public statements
made by Department of the Navy officials related to the relief of the fonner commanding officer,
without rendering opinions or recommendations on the relief or the rationale behind it.
2. Enclosure (1) is my final report into these matters.

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Table of Contents
Preliminary Statement
Executive Summary
Chapter 1 - Introduction
Chapter 2 - Planning and Execution of Port Visit to Da Nang, Vietnam
Chapter 3 - Actions during Transit to and Arrival in Guam
Chapter 4 – Development of and Response to Commanding Officer’s Letter
Chapter 5 – Opinions and Recommendations
Appendix A – Appointing Letters
Appendix B – Investigation Team
Appendix C – Timeline of Events
Appendix D – Findings of Fact
Appendix E – Preliminary Inquiry
Appendix F – Analysis of Binnacle List
Appendix G – Master List of Citations
Appendix H – Supporting Documents
Appendix I – Transcript of Public Statements
Appendix J – Classified Supporting Documents

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Preliminary Statement
This command investigation inquired into the communications, decisions, and actions
that took place within the Navy chain of command related to the Coronavirus Disease
2019 (COVID-19) outbreak aboard USS Theodore Roosevelt (CVN 71) (TR). It
expanded upon the work done for the preliminary inquiry (located at Appendix E) to
investigate more deeply into four key areas, and to ensure more complete
documentation of events. The Navy has already implemented the institutional and
procedural changes recommended by the preliminary inquiry.
In order not to risk the possible reintroduction or spread of COVID-19, the command
investigation team did not travel to visit the TR. Instead, the command investigation
team relied primarily upon video-conferences, telephone calls, and electronic means to
collect evidence, with the full support of all command levels involved.
All times in this report are Guam Local Times (Chamorro Standard Time), unless
otherwise noted (e.g., for events that occurred in the continental United States or Pearl
Harbor, Hawaii).
The command investigation team did not encounter any difficulties during the course of
their investigation, and received the full cooperation of every witness who was
interviewed.
The command investigation team took great care to understand the perspective of a
leadership team dealing with an unprecedented challenge. The learning curve for
COVID-19 has been steep, and the investigation team made every effort to consider the
findings relative to guidance existing at the time of the events described in this report.
With respect to the specific matters the investigation was tasked to examine, the team
concluded:
1. The decision process and calculus for approving TR’s port visit to Da Nang was
appropriate. The planning for the Da Nang port visit was done with careful,
methodical and thorough consideration of the status of the COVID-19 outbreak in
Vietnam at the time. The risk analysis was advised by experts and data from the
U.S. Centers for Disease Control and Prevention (CDC), the World Health
Organization (WHO), and after consultation with the government of Vietnam to
better understand their methods and measures for COVID-19 control. At that
time, based upon the data available, it reasonably appeared to be safer in
Vietnam than many domestic U.S. Navy fleet concentration areas. The visit was
executed with sensible precautions, based on the world’s understanding of
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COVID-19 at the time.
2. During the transit of TR from Vietnam to its mission operating area, and then to
Guam, with 39 Sailors in quarantine, no significant additional precautions were
taken for the remainder of the crew until fifteen days after leaving Da Nang.
Sailors had reported to the Medical Department as early as three to four days
after leaving Da Nang, but the symptoms were not able to be correlated with
COVID-19, even with assistance from embarked Biological Defense Research
Directorate (BDRD) teams and their limited COVID-19 surveillance testing
capability. After the first Sailors began to test positive for COVID-19 on March
24th, few additional precautions were directed for those not isolated or
quarantined, despite the known potential for asymptomatic transmission.
3. After arrival in Guam, available off-ship berthing was not aggressively used, due
to the TR leadership insisting on fully CDC compliant quarantine quarters.
Although the off-ship makeshift berthing was not perfect, it provided vastly
improved ability to socially distance crewmembers. Miscommunication over
testing requirements also contributed to significant delays in egressing the crew,
initially. The TR and Commander, Carrier Strike Group Nine (CCSG-9)
leadership spent the majority of their efforts finding flaws with the Commander,
U.S. 7th Fleet (C7F) intended way ahead, while offering no practicable solutions
and neglecting to supervise and coordinate the crew’s egress to temporary offship quarantine facilities. Finally, due to an erroneous conclusion that the
shipboard quarantining efforts were causing more Sailors to be infected, the ship
ceased its quarantine efforts on March 29th, with over 4,000 Sailors still aboard.
This was done without consultation or notification to higher headquarters, and
apparently was not discovered by higher headquarters leadership until the
preliminary inquiry. The combination of these actions likely contributed to
increased spread of the infection to more TR Sailors.
4. As to the former TR CO’s email and attached letter, he was present at C7F staff
meetings where discussions took place regarding the efforts in progress to
secure longer-term, CDC compliant quarters for his crew. He, therefore, knew or
should have known of the actions that were already underway up echelon, but
was dissatisfied with the interim quarters. Rather than lead his team to work with
the shore establishment to improve upon them, he elected to send his email and
attached letter. When it was later leaked to the media, it complicated the Navy’s
negotiation with the Government of Guam for use of hotel rooms in Guam. The
identity of the person leaking the email remains unknown.

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It is clear that TR received exceptional support and resources from all levels of the
chain of command. It is also clear that the dynamically evolving situation required
robust and rapid communications from Echelon I down to the command level. The
findings of this investigation identified that typical leadership style differences, combined
with the complexity of the problem, and an absence of lessons learned from which to
draw, all contributed to some communications breakdowns up and down the chain of
command. However, these communications breakdowns were largely inconsequential.
At the core of this set of seemingly coincidental and perhaps even understandable
minor errors was an unpredictable virus spreading exponentially among the crew, a
sense of moral responsibility to protect the health of the Sailors, and lack of a clear and
effective command element, from the strike group and down. These factors led to a
command team becoming biased by groupthink, emotion and a loss of perspective as to
the real risk at hand. Their actions did not align with the fleet commander’s efforts to
help get the crew off of TR rapidly, and they were seemingly unaware of the efforts
being worked on their behalf by multiple entities. The commanding officer’s email and
letter changed nothing – all of the actions requested were in play before he sent the
email.
It is difficult to comprehend how the entire command team, driven by an overwhelming
concern for the crew’s safety, took little to no action within their own span of control to
improve the crew’s safety. The leadership team was missing in action when it came to
leveraging available temporary facilities, organizing and then leading a quick and
effective egress from the ship. Not recognizing their missed leadership opportunity, it
became necessary, in their minds, to further disregard good order and discipline by
“jumping the chain” [of command] with an urgent plea.
After 40 plus days to reflect on their actions since arrival on Guam, many of the principal
members of the ship and strike group leadership team maintain that their actions to
protect the crew were proper, and that the actions requested would not have occurred
without the former commanding officer’s email and letter.
Setting aside the combination of factors that led to delays in getting the TR crew ashore,
there are two significant actions that were inconsistent with existing guidance at the time
and had significant consequences for the spread of the virus throughout the ship:
1. The lack of measures taken for the majority of the crew after March 24th.
2. The release of Sailors from quarantine aboard the ship on March 29th.
Following the COVID-19 outbreak, the level of support to TR from multiple individuals
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and organizations, including the Governor of Guam and her staff, Commander, Joint
Region Marianas (CJRM) and his staff, Commanding Officer, Naval Base Guam (CO,
NBG) and his staff, III Marine Expeditionary Force (III MEF) element, and Commander,
Task Force (CTF) 75 was both extraordinary and unprecedented. TR’s Sailors have
helped our Navy and nation learn much in our response to the COVID-19 crisis.
To date, the Navy has had over 50 ships with COVID outbreaks and each of them has
responded with vigor to control and manage the spread of the virus in order to remain
mission ready. The Navy took the valuable lessons learned from TR and rapidly revised
and improved upon fleet-wide COVID prevention, mitigation, recovery, and predeployment guidance, providing risk-informed direction to afloat units regarding how to
better manage the virus.
As the world continues to learn every day about COVID-19, it is becoming clear that the
young and healthy demographic that the U.S. Navy enjoys with its Sailors means that
we can confidently fight through any future outbreaks on our warships. That said, if we
have the operational flexibility, we will not ask that of our Sailors or their families.

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Executive Summary
Introduction
On March 24, 2020, three Sailors aboard USS Theodore Roosevelt (CVN 71) (TR)
tested positive for COVID-19 while the ship was underway in the western Pacific Ocean.
TR was a little more than two months into a five and one-half month long deployment,
and at the time of the discovery, was transiting the 2,500 miles between her last port
call in Da Nang, Vietnam, and her next one in Guam. The events that transpired before
TR’s port call in Vietnam, during the transit to and following her arrival in Guam are the
subject of this investigation.
As TR began her deployment, the world was starting to understand an illness that
began in China and whose spread quickly challenged nations around the globe. The
chronology of the outbreak aboard TR in March, 2020 parallels that of the illness’s
spread throughout the world. As governments, including our own, have learned about
COVID-19’s transmission, symptoms and nature, the United States Navy has learned
from TR’s experience regarding how to prevent, mitigate and recover from an outbreak
in the unique environment of a deployed naval vessel.

Port Visit in Vietnam
On January 17, 2020, the TR and Carrier Strike Group Nine (CSG-9) departed San
Diego for deployment. The same week, C7F began tracking COVID-19’s spread in the
Pacific. By early February, as TR and one of the destroyers in the strike group, USS
Pinckney (DDG 91), pulled in for their first port visit to Guam, WHO had declared the
COVID-19 outbreak a “Public Health Emergency of International Concern.” WHO
confirmed the virus was a pandemic on March 11th.1
The same week in March 2020, TR pulled into Da Nang, Vietnam for a visit intended to
fulfill an agreement between the U.S. and Vietnam. The port visit, only the second by a
U.S. aircraft carrier to the country since the Vietnam War, was timed to commemorate
the 25th anniversary of bilateral relations between the two countries.2 At the time of
TR’s arrival in Da Nang, there were no State Department, Defense Department or CDC
travel restrictions for U.S. citizens to Vietnam.3
1

“WHO Timeline - COVID-19.” World Health Organization, www.who.int/news-room/detail/27-04-2020-who-timeline---covid-19
CPF Statement dtd 17 May 20
3
INDOPACOM J07 Country Health Risk to Force for COVID-19 dtd 4 Mar 20
2

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On March 8th, the Vietnamese Government notified CSG-9 that Sailors on liberty from
TR and the USS Bunker Hill (CG 52) (BKH) may have been exposed to COVID-19 at a
hotel in Da Nang, as two tourists who stayed at that hotel tested positive for the virus.4
TR and BKH curtailed the port visit and got underway shortly thereafter with 39 Sailors
in quarantine aboard the carrier.5

Transit from Vietnam to Guam
On March 9th, TR got underway from anchorage in Da Nang Bay, Vietnam, and
resumed normal operations in the C7F area of operations. An outbreak of norovirus in
February led the ship’s crew to clean common touch areas, which continued throughout
the visit to Da Nang.6 Although the CO limited self-service in the galley,7 other ship’s
services continued as usual, such as barbershops, ship’s store, chapel and gyms.8
From the time the ship left Da Nang on March 9th until March 23rd, seven Carrier
Onboard Delivery (COD) flights originating out of Clark Air Force Base in the Philippines
brought a total of 29 passengers and COD detachment personnel to the carrier,9 all of
whom screened negative for COVID-19 symptoms upon their arrival.10 Later, four of
those personnel tested positive for the virus, however analysis of the time of their
positive results indicates that they were likely not the source of the introduction of the
virus. Having arrived via COD on March 3rd, the prospective TR Executive Officer (XO)
conducted a planned turnover with his relief on March 11th.11
As TR sailed to Guam, the island’s government declared a public health emergency on
March 14th, even though no COVID-19 cases had yet been identified on the island.12 By
March 17th, all 50 U.S. states had confirmed cases of the virus13 and by March 20th,
Guam had 12 confirmed cases of COVID-19.14
On March 22nd, after a 14-day quarantine period, all 39 Sailors potentially exposed to
4

Email - AMB to Vietnam - Status of Sailors from Vietnam dtd 8 Mar 20
TR XO Statement dtd 16 May 20
6
TR XO Statement dtd 16 May 20, TR SMO Statement dtd 17 May 20
7
Email - TR CO to TR SMO - Follow Up dtd 9 Mar 20; TR SUPPO Statement dtd 18 May 20; TR XO Statement dtd 16 May 20
8
TR SMO Statement dtd 17 May 20 “The barber shops, ship’s store, chapel, and gyms remained open and there was no discussion
about closing them down at this time, nor was this the recommendation put out by higher headquarters.”
9
COD Completed Travel Log/Manifest, TR SMO Statement dtd 17 May 20
10
Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; CVW-11 CAG Statement dtd 19 May 20
11
Email - TR XO - TR Investigation dtd 7 May 20
12
Government of Guam Executive Order 2020-03
13
CORONAVIRUS: DOD RESPONSE TIMELINE (15 May 20) https://www.defense.gov/Explore/Spotlight/Coronavirus/DODResponse-Timeline/
14
Email - NBG CO to TR CO - TR PVST dtd 20 Mar 20
5

10

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COVID-19 in Da Nang remained asymptomatic, tested negative for COVID-19 and were
released from quarantine.15 However, on March 23rd, two air wing (CVW-11) Sailors
aboard TR began showing symptoms of the virus.16 Those two, and an additional Sailor
from the ship’s nuclear reactor department, tested positive for COVID-19 on March
24th.17 None of these three Sailors were among the 39 who had been potentially
exposed to the virus in Da Nang and subsequently placed in quarantine.
By the next day, four Sailors were positive for COVID-19, and TR moved them ashore
to Naval Hospital Guam via helicopter.18 On March 25th, discussions began at the staff
level among CSG-9, TR, CJRM, and C7F regarding the potential need for 4,000-plus
people to move off the ship.
During the transit from Vietnam, based on Preventative Medicine theory, TR and CSG-9
informed C7F on March 25th that the quickest way to return TR to sea would be “to
house all personnel in individual isolation for two weeks.”19 CSG-9 requested
permission from C7F to discuss the feasibility of contracting hotel rooms with JRM to
ensure they were not surprising the Government of Guam.20 C7F COS stated that “this
is a big ask” and did not express confidence that such a course of action had a high
probability of success, and that C7F wanted to explore other options.21 The courses of
action that relied on housing 4,000 Sailors ashore on Guam were deemed the most
constrained and least likely. Accordingly, C7F focused their attention predominantly on
the COA to transport Sailors to Okinawa.
Using every available resource on the remote Pacific Island, CO, NBG offered berthing
arrangements that met many but not all of the requested parameters. The discussion of
CDC compliant, individual rooms was not brought up again by CSG-9 or TR until the
C7F staff meeting on March 29th, although CJRM continued to work for hotel rooms on
Guam in parallel on March 28th, 29th and 30th.22
As concern elevated up TR’s operational and administrative chains of command, on
March 26th (CONUS), the Commander, U.S. Pacific Fleet (CPF) and the Chief of Naval
Operations (CNO) exchanged emails noting that the plan was to test the entire TR crew
15

C7F COS Statement dtd 21 May 20; Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; TR SMO
Statement dtd 17 May 20
16
Email - TR SMO to CCSG-9 - COVID-19 Update dtd 24 Mar 20
17
Email (SIPR) - CCSG-9 COS to C7F COS - Hotel Option dtd 25 Mar 20; Email - TR SMO to CCSG-9 - COVID-19 Update dtd 24
Mar 20
18
“Sailors tested positive on USS Theodore Roosevelt, extent of exposure unclear” Pacific Daily News (26 Mar 20)
https://www.guampdn.com/story/news/local/2020/03/26/sailors-tested-positive-uss-roosevelt-extent-exposure-unclear/5084652002/#
19
Email - TR SMO to CCSG-9 - COVID-19 Update dtd 24 Mar 20
20
Email - TR SMO to CCSG-9 - COVID-19 Update dtd 24 Mar 20
21
Email - TR SMO to CCSG-9 - COVID-19 Update dtd 24 Mar 20
22
Email – CJRM to VCNO EA - RE: Follow-up RFI dtd 6 Apr 20

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for COVID-19.23 These notes would later be construed by some to mean that testing
would be required prior to the crew leaving the ship and setting foot on Naval Base
Guam, causing confusion and delaying crew egress.
On March 27th, TR arrived in Guam and moored at the pier24 with 36 COVID-19 positive
Sailors aboard the carrier.25

Arrival Guam
A number of factors converged to delay TR Sailors from occupying all available facilities
on Guam. Providing food for the number of TR Sailors ashore in isolation and
quarantine was a challenge.26 As this capacity continued to ramp up, and the number
of Sailors ashore increased, contracted food delivery lagged initially, and TR Sailors
expressed their concerns on social media. This was relayed to the TR CO and TR
XO.27 Additionally, the ship's leaders were concerned that the temporary open-bay
facilities did not meet CDC guidelines. In reaction to the social media posts and out of
concern for the living conditions ashore, the TR CO prevented Sailors from leaving the
ship until a guarantee of sufficient meal service was available.28
A lack of clarity about the quality and type of facilities ashore, as well as lack of clarity
over testing requirements before leaving the ship, also contributed to delays in
disembarking the TR crew. Prior to TR’s arrival, CO, NBG, C7F and CCSG-9 agreed
on a plan to transport Sailors who were COVID-19 positive and Reactor Department
Sailors (key backup watchstanders) to rooms ashore immediately. On TR’s first day in
port, 264 Sailors moved ashore.29 However, there was no plan at that time to move
ashore the large number of Sailors now quarantined on the ship, nor was there clarity
on any requirement to test crew members prior to going ashore to NBG. Prior to the
hotels becoming available, the testing requirement for Sailors going ashore was not well
understood by the TR CO, XO, and Senior Medical Officer (SMO).30 During interviews,
the C7F COS stated that 100 percent testing was not required and that message was
clearly communicated, however e-mails from him and C7F prior to the ship’s arrival

23

Email (SIPR) - CPF to CNO and INDOPACOM - TR Recovery and Disposition Plan dtd 26 Mar 20
Facebook Post - Family and Friends of the Rough Riders, Crozier, B. CAPT (27 Mar 20)
https://www.facebook.com/USSTheodoreRoosevelt/photos/a.489137065779/10156700551025780/?type=3&theater 
25
Email (SIPR) - C7F - C7F COVID daily CDRs update (26 Mar) dtd 27 Mar 20
26
NBG CO Statement dtd 18 May 20; TR XO Statement dtd 16 May 20
27
Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; TR PAO Interview Summary dtd 23 May 20
28
Crozier, B. CAPT Statement dtd 15 May 20
29
Email - CJRM - Follow-Up Summary of Interview dtd 8 May 20
30
Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; TR SMO Statement dtd 17 May 20
24

12

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implied testing was required.31 Similarly, several emails from higher headquarters, to
include the Office of the Chief of Naval Operations (OPNAV) and CPF, implied the
same.32 This was being driven by a belief at the time that 100 percent testing of the
crew could be quickly completed, and a relatively modest number of TR crew members
could be left on Guam to recover, allowing the ship to return to sea. This belief also
reflected the complete lack of understanding that existed at the time of the limitations of
the available testing means. Combined with imprecise communications, confusion
ensued. For example, during interviews, the TR CO stated that testing was required,
the XO stated that 100 percent testing was not being conducted, and the SMO stated
that he was confused over testing requirements but did not agree with 100 percent
testing.33 This contributed to the delay in getting potentially non-infected crewmembers
off the ship into available facilities on Guam,34 that, although not ideal and not meeting
the strict CDC guidance of single room and single bathroom per individual, did offer
better protection from infection than the ship’s berthing compartments and messing
facilities.
C7F believed that the TR CO and CCSG-9 were resisting sending the crew ashore
because available facilities were not fully CDC compliant.35
On March 28th, C7F tasked CCSG-9 and TR to develop plans to airlift crew members to
Okinawa. C7F prioritized other COAs over the Guam hotel room option at this point due
to the conditions under which the Navy had obtained permission to bring TR into the
naval base – the Navy had agreed that Sailors would remain on the naval base, and
that the Navy would not ask for help from the Government of Guam, as Guam was itself
in a state of public health emergency. C7F was aware and although CJRM is not under
his authority C7F asked him to work directly with the Governor of Guam to entertain the
hotel option.
The TR CO, unaware of C7F’s work with III MEF to obtain 5,000 CDC compliant rooms
on Okinawa, contacted an acquaintance, Commander, Fleet Activities Okinawa
(CFAO), on the same island. CFAO was also unaware of the III MEF work, and told the
TR CO that 5,000 rooms were not available for TR Sailors.36 The CSG-9 COS and
CVW-11 CAG both stated that they believed the 5,000 beds never existed. As a result
of this lack of clarity in the Okinawa plan, further friction developed between the TR CO,
31

C7F COS Statement dtd 21 May 20; Email (SIPR) - C7F COS to CSG-9 COS - Triage and Procedure dtd 27 Mar 20
Email (SIPR) - C7F to CPF - Evening Update and COVID 29 Mar dtd 29 Mar 20
33
C7F COS Statement dtd 16 May 20; Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; TR SMO
Statement dtd 17 May 20
34
C7F COS Statement dtd 21 May 20; Crozier, B. CAPT Statement dtd 15 May 20;TR XO Statement dtd 16 May 20
35
C7F COS Statement dtd 16 May 20
36
Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; Email - CAPT Crozier to Commander, Fleet
Activities Okinawa – Subj: New Normal dtd 29 Mar 20, 1818
32

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XO, CVW-11 CAG, CSG-9 COS and the C7F staff.37 The TR CO made no effort to
confirm the status of the Okinawa rooms with anyone in his chain of command.
By the ship’s fourth day in Guam, the TR CO and Warfare Commanders began to
believe there were no plans to move 4,000 crew off the ship into isolation and
quarantine in CDC compliant facilities.38 In the meantime, the commander of the Carrier
Air Group (CVW-11 CAG) embarked on TR led a collective effort with the Warfare
Commanders and TR senior leadership to develop courses of action to improve the
situation for TR’s crew. The CSG-9 leaders wanted to minimize the number of Sailors
exposed to COVID-19 and regain warfighting readiness as soon as possible.39 CSG-9
leaders grew increasingly frustrated with the proposed way ahead and wanted CCSG-9
to address what they believed was a crisis by demanding the crew be offloaded as soon
as possible to hotel rooms in Guam.40 At the same time, CCSG-9 believed the use of
hotels in Guam was not currently an option for TR because of political concerns.41
Unsatisfied with the response he had received so far from his efforts to ask CCSG-9 to
champion the hotel room COA with C7F, on March 30th, the TR CO sent an email to
“Fellow Naval Aviators” with a memo requesting “all available resources to find
NAVADMIN and CDC compliant quarantine rooms for my entire crew as soon as
possible.”42 The San Francisco Chronicle published this memo online the next day.43
At the time of this writing, the individual(s) responsible for releasing the letter to the SF
Chronicle remains unknown.
Additionally, although the TR CO stated that he was not fully aware of the status of
efforts underway to open Guam hotels to TR Sailors, he should have known by his
presence at C7F briefs and through discussions with CCSG-9.44 The TR CO also
stated that he did not anticipate the potentially negative implications his letter could
have had to ongoing negotiations that same day between CJRM and the Governor of
Guam.45

37

Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; CVW-11 CAG Statement dtd 19 May 20; CSG-9
COS Statement dtd 18 May 20
38
Crozier, B. CAPT Statement dtd 15 May 20; TR SMO Statement dtd 17 May 20; CVW-11 CAG Statement dtd 19 May 20
39
CVW-11 CAG Statement dtd 19 May 20
40
CSG-9 COS Statement dtd 18 May 2020
41
CCSG-9 Statement dtd 18 May 20; Email (SIPR) – CSG-9 COS to C7F COS – (U) HOTEL OPTION dtd 25 Mar 20
42
TR CO Email and Ltr - Request for Assistance in Response to COVID-19 Pandemic dtd 30 Mar 20
43
“Exclusive: Captain of aircraft carrier with growing coronavirus outbreak pleads for help from Navy” SF Chronicle (31 Mar 20)
https://www.sfchronicle.com/bayarea/article/Exclusive-Captain-of-aircraft-carrier-with-15167883.php, accessed May 8, 2020
44
Crozier, B. CAPT Statement dtd 15 May 20; Email - CJRM - Follow-Up Summary of Interview dtd 8 May 20; CCSG-9 Statement
dtd 15 May 20; C7F Statement dtd 18 May 20
45
Crozier, B. CAPT Statement dtd 15 May 20; Email - CJRM - Follow-Up Summary of Interview dtd 8 May 20

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Actions after Publication of Memo
CCSG-9 did not understand the rationale for the TR CO’s memo, as he knew at the
time, and thought the TR CO knew, efforts to pursue all requested courses of action
were already underway. According to CCSG-9, the memo’s publication created tension
between with the Navy and the Government of Guam, potentially complicating
negotiations for the ship’s crew to occupy hotels on the island.46
On April 1st, Commander Naval Air Force, U.S. Pacific Fleet (CNAP) called the TR CO
in Guam to provide mentorship and counsel and to learn why he felt the need to write
the email and memo. TR CO relayed that his relationship with C7F and CCSG-9 were
healthy, with good communications in both directions, and plenty of communication
opportunities. The TR CO also noted C7F was particularly engaged, holding multiple
video-teleconferences each day regarding the situation on the TR. In response to
CNAP’s question, the TR CO stated his rationale for sending the memo was that he did
not feel the shore establishment’s response was moving fast enough.47
The TR SMO also sent a letter off the ship on March 31st, outlining areas of concern of
the medical staff aboard, and a threat to release the letter to the media if immediate
actions were not taken. This letter did not outline specific requests but did relay a sense
of urgency. It calculated that at least 50 Sailors would die from COVID-19 based on
data received and analysis conducted on the potential mortality rate.48 The SMO
emailed the medical letter to eight people initially, addressed to the Surgeon General of
the Navy and copying seven others. The SMO then emailed the letter to over 160
additional email addresses, primarily individuals within the Navy Medical community and
outside his operational and administrative chains of command.49
However, no new actions were taken as a result of either the TR SMO’s or the TR CO’s
email and letter, as the actions they desired were already in motion.50 In fact, CJRM
had begun staff level discussions with the Governor’s office about the possibility of
securing hotel rooms on March 28th, and spoke with the Governor herself later that day,
receiving a positive response.51 This allowed Navy to finalize staffing up to
Commander, United States Indo-Pacific Command (INDOPACOM), where it was
decided that CPF would call the Governor of Guam to formally request assistance on
                                                            
46

CCSG-9 Statement dtd 15 May 20; Email - CJRM - Follow-Up Summary of Interview dtd 8 May 20
CNAP Statement dtd 13 May 20
48
Email – SMO to Surgeon General - Medical Dept Letter dtd 30Mar20
49
Email – SMO - FWD: Medical Dept Letter dtd 30Mar20
50
Email – CJRM to VCNO EA - RE: Follow-up RFI dtd 6 Apr 20; C7F Statement dtd 18 May 20
51
Email – CJRM to VCNO EA - RE: Follow-up RFI dtd 6 Apr 20; Email - CJRM - Follow-Up Summary of Interview dtd 8 May 20;
C7F Statement dtd 18 May 20
47

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March 31st.52 The positive response also allowed Navy to begin formal negotiations
with GHRA regarding the number of hotels and the conditions for their
utilization.53 CJRM was extremely sensitive to the publicly stated Navy position to not
over burden Guam resources and as a result, information on those efforts was not
widely known outside of the principals on the various staffs.54 However, according to
C7F and CCSG-9, TR CO was aware of these efforts.55
CNO ordered a preliminary inquiry into the events surrounding the disembarkation of
Sailors from TR in Guam, in response to cases of COVID-19 on April 2, 2020.56 While
this preliminary inquiry was pending, the A-SN at the time decided to relieve the TR CO
and announced his decision in a press conference with the CNO, stating that “at [his]
direction, the CO of [TR] . . . was relieved by [CCSG-9].”57
The A-SN subsequently traveled to Guam where he spoke with members of the TR
crew via the public address system (1MC). Those remarks were recorded by members
of the crew and released to the press by means of a written transcript followed by the
actual audio recording.58 Following his visit to TR and subsequent calls for his
resignation, including from House Armed Services Committee Chairman, Adam Smith
(D-WA),59 the A-SN offered his resignation to the Secretary of Defense on April 7th,
2020,60 and his resignation was accepted that same day.61 The preliminary inquiry
ordered by CNO was also completed on April 7th, and had been submitted to CNO prior
to the A-SN’s resignation.

Current Status of TR Crew
Although most TR Sailors with the virus displayed mild symptoms, 45 Sailors were
admitted to Naval Hospital Guam for treatment for COVID-19. Of these Sailors, six
required oxygen support and one was placed on a ventilator for respiratory failure. The
majority were admitted for close observation and did not require additional
intervention.62 One Sailor died due to complications attributed to COVID-19. A
                                                            
52

C7F Statement dtd 18 May 20; CPF Statement dtd 17 May 20
Email - CJRM - Follow-Up Summary of Interview dtd 8 May 20
54
Email - CJRM - Follow-Up Summary of Interview dtd 8 May 20
55
C7F Statement dtd 18 May 20; CCSG-9 Statement dtd 15 May 20
56
CNO Ltr Ser 5800 dtd 2 Apr 20
57
Transcript: DON Press Briefing with Acting Secretary of the Navy Thomas B. Modly and CNO Admiral Gilday dtd 2 Apr 20
58
How a Ship’s Coronavirus Outbreak Became a Moral Crisis for the Military, NY Times, (6 Apr 20)
https://www.nytimes.com/2020/04/06/us/politics/coronavirus-navy-secretary-roosevelt-crozier.html (containing audio recording of ASN remarks)
59
Press Release: "Smith Calls for Modly's Removal After Mishandling U.S.S. Theodore Roosevelt COVID-19 Outbreak" dtd 6 Apr
20
60
A-SN Resignation Letter of 7 Apr 20
61
SECDEF Ltr of 7 Apr 20
62
CO NHG Statement dtd 18 May 20
53

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separate line of duty investigation into the circumstances of his death has been
completed.
As of the writing of this report, a total of 1,248 TR crewmembers were infected with the
COVID-19 virus, 1,546 TR Sailors remain in Guam, and 498 are positive, continuing
quarantine and testing, with one currently hospitalized. TR is at sea today, conducting
operations. Over 100 other ships are also at sea, operating around the world, without
known COVID cases aboard.

17

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Summary of Opinions
The following 18 key opinions were derived from this investigation into the COVID-19
outbreak aboard TR:
1. Based upon the pre-event risk analysis, the decision to execute the Da
Nang port visit was appropriate. The visit was executed with sensible
precautions, based on the world’s understanding of COVID-19 at the time.
2. The former TR CO initially responded appropriately by quarantining 39
Sailors following the Da Nang port visit. However, after three Sailors tested
positive for COVID-19 aboard TR on March 24, 2020, the former TR CO
failed to put adequate additional measures in place for the rest of the crew
to further slow the spread of COVID-19 throughout the ship.
3. The TR SMO’s recommendation and the resulting release by the former TR
CO of crewmembers in quarantine from the aft portion of the ship on March
29, 2020 likely resulted in infection to a larger portion of the crew.
4. The embarked CSG-9 Warfare Commanders (WCs) (TR CO, CVW-11 CAG,
DESRON Commodore) and the TR SMO displayed an abundance of
concern for the safety of the crew as their primary focus, yet they were
unable to develop COAs prior to or even by four days after arrival in Guam
that provided for the short-term safety of the crew. Instead, they focused
efforts on the most constrained and least executable COA (at the time),
while taking insufficient parallel steps that would have resulted in more
immediate segregation, quarantine and isolation of the crew. As a result,
efforts to move the crew off the ship were uncoordinated, unsupervised
and slow. The extended time Sailors remained on the ship, while no longer
segregated, likely increased the number of infections.
5. CCSG-9, the embarked CSG-9 WCs, and the former TR CO and TR SMO did
not demonstrate effective leadership when they initially took few actions to
overcome obstacles to aggressively utilize the approximately 2,300 beds
that were made available by Naval Base Guam, likely resulting in infection
to a larger portion of the crew.
6. C7F’s early focus on the Okinawa option over the Guam hotel option
resulted in the TR Strike Group key Captains (CSG-9 COS, former TR CO,
TR XO, TR SMO and CVW-11 CAG) believing that C7F did not feel their
same sense of urgency for providing proper long term quarantine and
isolation quarters. This led these Captains to distrust the C7F staff and
hampered their ability to deal with the crisis with the resources that were
available, or develop alternate courses of action other than the request for
4,000 CDC compliant rooms, which at the time was the most constrained
and least likely COA.
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7. The former TR CO did not demonstrate forceful backup, effective
communication or adequately communicate with his Immediate Superior in
Command (CCSG-9, embarked in TR) in that he did not discuss his concern
with the lack urgency he perceived from C7F and CCSG-9 on the Guam
Hotel option being pursued, prior to sending his letter.
8. CCSG-9 did not provide effective leadership to the former TR CO and the
embarked CSG-9 WCs in that he did not effectively address and correct a
growing, divisive and counterproductive narrative among his senior
officers regarding distrust of C7F or any course of action that did not fit
their immediate sense of urgency. Additionally, he did not direct decisive
action to ensure prompt execution of the egress of the TR crew. Finally, it
is not clear that he effectively advocated for TR’s needs to higher
headquarters or provided clear feedback to his team when those needs
could not meet TR leadership’s timeline.
9. The TR SMO developed a flawed, worst-case crew casualty narrative that
the CVW-11 CAG reinforced and frequently amplified at Warfare
Commander Boards, and that had an impact on the mindset of the former
TR CO and TR XO. The TR SMO fostered distrust of HHQ actions, and put
his leadership in an untenable situation.
10. The TR CO sent his email and letter as a genuine plea for help from CPF
and CNAP. Each leader received and acted upon it as such, responding via
phone and email, respectively, within minutes of receipt, with CNAP also
ensuring C7F and CJRM were made aware of the request. Further, CPF
considered the matter of sending the letter closed after his conversation
with both CCSG-9 and TR CO.
11. When asked to sign a letter that contained a flawed, worst-case crew
casualty narrative as well as an ultimatum concerning an intent to submit
the letter to the public, the TR SMO missed a leadership opportunity to
correct subordinates. Instead, he signed the letter, and transmitted it
outside the chain of command, essentially endorsing the effort to
undermine Navy leadership.
12. The former TR CO intended for his email to be a “red flare” to accelerate
needed support and ensure attention to what he believed to be insufficient
courses of action. The former TR CO wrote his email to break down
communication barriers on plans, resources and support, and did not
intend for it to be released to the public. However, he did not personally
inform his Immediate Superior in Command, CCSG-9, of the letter and
instead transmitted information of a very sensitive nature about a capital
warship on an unclassified network.
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13. The exclusion of C7F on the former TR CO’s email, as well as the lack of
advanced coordination by the former TR CO with CCSG-9 and others,
bypassed the operational chain of command and demonstrated poor
judgment.
14. The former TR CO’s email and the attached letter of March 30, 2020 were
unnecessary, and had no positive impact on actions already being
aggressively pursued by higher headquarters (CJRM, C7F, and CPF).
15. Release of the former TR CO’s letter to the San Francisco Chronicle
complicated the Navy’s negotiations with the Government of Guam for use
of hotel rooms in Guam.
16. Detailed patient history analysis of the 29 personnel received aboard TR via
COD following the Da Nang port visit concluded that CODs were not the
likely source for the COVID-19 outbreak. Although the pre-event risk
analysis for the Da Nang port visit was assessed as sufficiently thorough
and the decision to the execute the port visit was appropriate at the time,
the Da Nang port visit was found to be the most likely source of the
outbreak on TR.
17. Detailed analysis of TR sick call logs revealed that COVID-19 was likely
present, yet undetected, as early as March 11, 2020.
18. The use of personal protective equipment (PPE) and employment of tactics,
techniques, and procedures (TTP) by the TR Medical Department were
likely effective, as there was only one COVID-19 infection among TR
Medical Department personnel.

20

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Chapter 1 – Introduction
On March 24, 2020, three Sailors aboard USS Theodore Roosevelt (CVN 71) (TR)
tested positive for COVID-19 while the ship was underway in the western Pacific Ocean.
TR was transiting the 2,500 miles between her last port call in Da Nang, Vietnam, and
her next one in Guam. By the time TR arrived in Apra Harbor, Guam on March 27th, 36
Sailors had tested positive for COVID-19, and many more were being isolated to
prevent further infections due to their close contact with the ill Sailors. Three days later,
on March 30th, TR’s Commanding Officer (CO) emailed senior officers, attaching a letter
detailing his concerns about the developing situation and potential impact to TR Sailors.
The San Francisco Chronicle obtained, and on March 31st, published, the TR CO’s
letter. On April 2nd, in Washington, D.C., the CNO directed the Vice Chief of Naval
Operations (VCNO) to conduct a preliminary inquiry into the events surrounding the
disembarkation of Sailors from the TR in Guam. On April 3rd (Guam date), the A-SN
directed CCSG-9 to relieve the TR CO of command. On April 7th (Washington, D.C.
date), the VCNO submitted the completed preliminary inquiry to the CNO, and later that
day, the A-SN resigned.

Scope of Investigation
In a memorandum dated April 29, 2020, the A-SN directed the CNO to convene a
command investigation into the communications, decisions, and actions that took place
within the Navy chain of command related to an outbreak of the Coronavirus Disease
2019 (COVID-19) aboard TR. On April 30, 2020, and in response to A-SN’s
memorandum, CNO appointed the VCNO as the investigating officer to complete an indepth investigation to inform CNO’s review of the status of the former commanding
officer of the TR, and to enable full consideration of the following matters:
1. Planning and execution of the Da Nang, Vietnam port visit.
2. Transit of TR to Guam, including air movements during transit and planning
for the ship’s arrival and provisions for the crew.
3. Actions following arrival of TR in Guam, including movement of the crew to
on-base and off-base lodging.
4. Preparation and email delivery of the former commanding officer’s letter dated
March 30, 2020, further handling of that email, and response to the email and
letter by the chain of command.
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CNO directed VCNO to report findings of fact, opinions, and recommendations in writing
to CNO no later than May 27, 2020.
The command investigation followed and expanded upon a preliminary inquiry VCNO
completed at the direction of CNO that focused on communications involving the ship’s
health care professionals, commanding officer, and administrative and operational
chains of command. The preliminary inquiry also outlined events related to the ship’s
port visit in Da Nang, Vietnam, and subsequent arrival in Guam.
This report does not evaluate the actions of non-Department of the Navy agencies.

Methodology
The VCNO assembled an investigation team comprised of subject matter experts in
safety investigations, naval supply systems, carrier aviation, intelligence, human factors,
law, medicine, and other unrestricted line communities. Appendix B contains a roster of
team members.
The investigation team reviewed documents, interviewed witnesses, and conducted
field observations and met daily to relay and synchronize findings and determine the
need for additional information.
Members divided into three teams to focus on 1) the port visit to Da Nang; 2) actions
during TR transit to and arrival in Guam; and 3) development of and response to TR’s
Commanding Officer letter dated March 30, 2020.

Report Organization
The report is organized in chapters that analyze the major elements of the appointing
order. Chapter 2 examines the planning and execution of the ship’s port visit to Da
Nang, Vietnam from March 5 through 9, 2020. Chapter 3 examines actions of various
organizations and individuals during TR’s transit to and arrival in Guam. Chapter 4
examines the development of and response to TR’s Commanding Officer’s letter of
March 30, 2020. Chapter 5 provides detailed Opinions and Recommendations.

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Background 
USS Theodore Roosevelt (CVN 71) (TR) is America’s fourth Nimitz-class aircraft carrier
with a crew of about 4,800 Sailors who support and conduct air operations at sea.63
The TR is part of CSG-9, which is comprised of a total of about 7,000 Sailors, and
includes, in addition to the aircraft carrier, an air wing, a cruiser and five destroyers.
Prior to deploying for the western Pacific on January 17, 2020, CSG-9 deployed in
support of Operations Inherent Resolve and Freedom’s Sentinel, as well as maritime
security cooperation efforts in U.S. 5th and 7th Fleet areas of operations from October
2017 to May 2018. In March 2020, CSG-9 was deployed and operating under the
command of U.S. 7th Fleet, having reported a change in operational control (“chopped”)
from U.S. 3rd Fleet during the transit across the Pacific from San Diego.
The aircraft carrier is a lethal, high-end, survivable platform capable of full spectrum
warfare and provides a wide range of options to the U.S. government, from
demonstrating presence, to deterring adversaries, to reassuring our allies and partners.
Because carriers operate in international waters, their aircraft do not need to secure
landing rights on foreign soil. These ships also engage in sustained operations in
support of other forces. When deployed as a strike group, the ships and aircraft may
take on a variety of roles, all of which involve the attainment and maintenance of sea
control, such as protecting commercial and military shipping, protecting a Marine
Amphibious Force, or establishing naval presence, all in support of our National
Defense Strategy.
COVID-19 is a newly identified viral respiratory disease caused by the SARS-CoV-2
virus. It is responsible for a large pneumonia outbreak in Hubei Province, China
resulting in the exportation of cases globally. On March 11, 2020, WHO declared the
global outbreak of COVID-19 a Pandemic (global spread of a new disease) due to virus
sustainment on more than six continents, exceeding 120,000 infected persons
worldwide. Public health measures continue to be implemented and executed in hopes
of viral containment such as social distancing, teleworking and minimizing social
gatherings to consist of no more than 10 people. State emergencies were declared
throughout the United States to enforce these measures and many Governors issued
statewide Stay at Home orders. On March 29, 2020, President Trump extended the
social distancing order until April 30, 2020.64

                                                            
63

OPNAV Instruction 5450.337B Missions, Functions, and Tasks of Commander, United States Pacific Fleet dtd 21 Jan 16
Remarks by President Trump, Vice President Pence, and Members of the Coronavirus Task Force in Press Briefing (30 Mar 20)
https://www.whitehouse.gov/briefings-statements/remarks-president-trump-vice-president-pence-members-coronavirus-task-forcepress-briefing-14/

64

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Relevant Chains of Command 
This investigation spans multiple chains of command, from the ship to U.S. Pacific
Fleet. The Navy’s command structure is more complex than other military services in
that there are two chains of command: operational and administrative. They sometimes
overlap, and depending on assignment, a unit can be part of both or can switch
between two different operational chains of command as it transits the world’s oceans.
The operational chain of command is responsible for carrying out specific missions such
as operations and exercises. The administrative chain of command takes care of
personnel, education, training, repairs and supply chains to get ships, squadrons, and
strike groups ready for those missions.65 CSG-9 administrative and operational chains
of command are outlined below and depicted in Figure 1.

Administrative Chain of Command
CSG-9’s administrative chain of command runs through CNAP. CNAP is
administratively responsible to the four-star Commander, U.S. Pacific Fleet (CPF) for
ensuring the readiness of all assigned naval aviation units, including aircraft carriers,
deploying in the Pacific Fleet. The three-star admiral who serves as CNAP is also the
Commander, Naval Air Forces (CNAF), the Type Commander (TYCOM) responsible to
CPF for the readiness of all naval aviation units worldwide. This report focuses on the
role of CNAP in relation to CSG-9.

Operational Chain of Command
When operating in or near home port in San Diego, California, CSG-9 is part of U.S. 3rd
Fleet, which leads naval forces in the near Pacific and provides the realistic, relevant
training necessary before forces deploy away from U.S. shores. U.S. 7th Fleet, the U.S.
Navy’s largest numbered fleet, conducts forward-deployed naval operations in support
of U.S. national interests in the Indo-Pacific area of operations. The three-star admirals
commanding U.S. 3rd Fleet (C3F) and U.S. 7th Fleet (C7F) coordinate to plan and
execute missions based on their complementary strengths to promote ongoing peace,
security, and stability throughout the entire Pacific theater of operations. This report
covers a timeframe in which CSG-9 was predominantly within the C7F operational chain
of command.
                                                            
65

OPNAVINST 5400.45 Standard Navy Distribution List Administrative Organization of the Operating Forces of the U.S. Navy dtd 1
Apr 20

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CSG-9 itself consists of the following ships and subordinate commands:
1. Carrier Strike Group 9, commanded by a rear admiral (O7) who serves as the
strike group’s composite warfare commander and will be referred to
throughout as the Commander, Carrier Strike Group 9 (CCSG-9)
2. USS Theodore Roosevelt (CVN 71), commanded by a captain (O6)
3. USS Bunker Hill (CG 52), a Ticonderoga-class guided missile cruiser,
commanded by a captain (O6)
4. Destroyer Squadron 23, commanded by a captain (O6), and comprising five
Arleigh Burke-class destroyers, each commanded by a commander (O5):


USS Russell (DDG 59)



USS Paul Hamilton (DDG 60)



USS Pinckney (DDG 91)



USS Kidd (DDG 100)



USS Rafael Peralta (DDG 115)

5. Carrier Air Wing (CVW) 11, commanded by a captain (O6) (CVW-11 CAG),
and comprising nine other units, all but one commanded by a commander
(O5):


Four Strike Fighter Squadrons (VFA): VFA-31, VFA-87, VFA-146 and
VFA-154



Carrier Airborne Early Warning Squadron (VAW) 115



Electronic Attack Squadron (VAQ) 142



Helicopter Maritime Strike Squadron (HSM) 75



Helicopter Sea Combat Squadron (HSC) 8



Fleet Logistic Support Squadron (VRC) 30 Detachment 3 (O4 Officer in
Charge)
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CNAP/ CliAJ:

San Diego, CA

TR

IINiN
HI

-

MMtMM
:
_J

o p-erau ona l Chatn o f c ommand
Adm in istrative Cha in o f Command

COS-23

USS Bun ke r Hill

fm borked mTR

{CG S2)

--3.Sler

06

C7'

- -VRC30, Det3
(C-2)

all
•1

•lijlf•

14111

Figure 1. Theodore Roosevelt Carrier Strike Group Chains of Command

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Chapter 2 – Planning and Execution of USS Theodore Roosevelt (CVN 71) Port
Visit to Da Nang, Vietnam
Preparation for Da Nang, Vietnam Port Visit
The CSG-9 port visit in Da Nang, Vietnam was scheduled for March 5-9, 2020 with both
the USS Theodore Roosevelt and the USS Bunker Hill scheduled to participate.66 This
historic port visit fulfilled an agreement between the two nations’ top leaders and was
only the second visit by a U.S. aircraft carrier to the country since the Vietnam War.67
The visit also marked a significant milestone commemorating the 25th anniversary of
bilateral relations highlighting continued cooperation between the U.S. and Vietnam.68
A visit of such significance draws interest from and requires coordination among United
States Department of State, The Office of the Secretary of Defense, INDOPACOM,
Commander, U.S. Pacific Fleet (CPF), Vietnamese Ministry of Foreign Affairs,
Vietnamese Ministry of Defense, and U.S. Embassy Vietnam.69
In order to demonstrate U.S. support for a strong, prosperous, and independent
Vietnam and to strengthen relations, many interpersonal interactions were scheduled,
including distinguished visitor engagements, special events, and tours, highlights for
Sailors as well as for the people of Vietnam. Beyond celebrating and strengthening
relations, the Strike Group deployment and port visit served many other purposes.
Naval presence in the Pacific region is routine and has helped maintain peace for more
than 70 years. Operating in the region supports regional security, stability, and
prosperity. Operating in accordance with international laws, rules, standards, and
norms across the region enables us to reassure our allies and partners, and keeps
global trade flowing.
As CSG-9 continued planning and preparing for the port visit to Vietnam, on December
31, 2019, Wuhan Municipal Health Commission, China, reported a cluster of cases of
pneumonia in Wuhan, Hubei Province which was eventually identified as novel
coronavirus. On January 13, 2020, officials confirmed a case of COVID-19 in Thailand,
the first recorded case outside of China.70

                                                            
66

CPF Statement dtd 17 May 20
TRNOTE 5050 TR and CVW-11 Liberty Plan dtd 22 Feb 20; CCSG-9 Statement dtd 15 May 20 
68
CPF Statement dtd 17 May 20
69
TR AAR For 5-9 March Vietnam PVST dtd 17 Mar 20
70
WHO Timeline - COVID-19.” World Health Organization, World Health Organization, www.who.int/news-room/detail/27-04-2020who-timeline---covid-19
67

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On January 17th, CSG-9 departed San Diego for deployment.71 On January 20th, in an
email to TR leadership, TR XO reminded them that six weeks remained until the Da
Nang port visit. Compared to the March 2018 USS Carl Vinson (CVN 70) Da Nang port
visit After Action Report, the TR XO believed they still had a lot of work to do,
considering they had not done much internal planning, to ensure a successful visit.72
C7F began COVID-19 planning and socialization at the end of January and on January
25th, they sent slides to all CTF surgeons.73
On February 2nd, two cases of norovirus were documented aboard TR.74 Noroviruses
are very contagious and are the most common cause of gastroenteritis in the U.S.
Symptoms include diarrhea, vomiting, nausea, and stomach cramping.75 Within 24
hours, ship-wide precautions were established including: stopping self-service on the
main galley line and requiring the culinary specialist to serve the food in order to prevent
the spread of germs, thorough cleaning periods, termed “bleach-a-palooza,” and
general messaging regarding handwashing and personal hygiene. These swift and
sweeping actions led to eradication of the norovirus on TR prior to arrival Da Nang.76
On February 7th, TR and USS Pinckney arrived in Guam for a scheduled port visit.77
Two weeks later, the C7F flagship, USS Blue Ridge (LCC 19),78 and ships from the
America Expeditionary Strike Group (AESG), USS America (LHA 6), and USS Green
Bay (LPD) had port visits in Thailand.79 On January 30th, the WHO Director General
declared the COVID-19 outbreak a “Public Health Emergency of International
Concern.”80 Following this declaration, INDOPACOM directed a formal response to the
pandemic81 and the C7F Fleet Surgeon provided CPF a COVID-19 Concept of
Operations (CONOPs).82 On February 15th, C7F published Tasking Order (TASKORD)
20-057 for force health protection against COVID-19 and a week later, on February
22nd, TR released the liberty plan for Da Nang83 with no mention of COVID-19 or
                                                            
71

CNAP Statement dtd 13 May 20
Email - XO to TR Leadership - Vietnam Planning dtd 20 Jan 20
73
C7F Surgeon Statement dtd 23 May 20
74
Email: CSG-9 – Response to RFI dtd 17 May 20
75
NTRP 4-02.10 dtd Sep 14
76
TR PA Statement dtd 12 May 20
77
USS Theodore Roosevelt and USS Pinckney Arrive in Guam for Scheduled Port Visit USS Theodore Roosevelt PAO (7 Feb 20)
https://www.c7f.navy.mil/Media/News/Display/Article/2077194/uss-theodore-roosevelt-and-uss-pinckney-arrive-in-guam-forscheduled-port-visit/
78
USS Blue Ridge, 7th Fleet staff arrive in Thailand USS Blue Ridge Public Affairs (22 Feb 20)
https://www.cpf.navy.mil/news.aspx/130560
79
USS America, Green Bay arrive in Thailand for Cobra Gold Zline, V. MC3 (23 Feb 20) https://www.cpf.navy.mil/news.aspx/130559 
80
WHO Director-General's statement on IHR Emergency Committee on Novel Coronavirus (2019-nCoV)
https://www.who.int/dg/speeches/detail/who-director-general-s-statement-on-ihr-emergency-committee-on-novel-coronavirus-(2019ncov)
81
Naval Message (SIPR): USINDOPACOM, Response To Novel Coronavirus EXORD DTG 040649Z FEB 20
82
Naval Message (SIPR): USINDOPACOM, Response To Novel Coronavirus EXORD DTG 040649Z FEB 20
83
TRNOTE 5050 TR and CVW-11 Liberty Plan dtd 22 Feb 20
72

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coronavirus. On February 25th, Vietnam suspended entry for all travelers from COVID19 affected areas.
On February 23rd, C7F published Fragmentary Order (FRAGORD) 001 to TASKORD
20-057, revising disease surveillance and screening requirements due to updated
country risk. On February 24th, the CDC posted information for travelers regarding
apparent community transmission in Singapore, Thailand, and Vietnam, and
recommended travelers reconsider cruise ship voyages in Asia.84 At this point, 16
confirmed cases had been reported in Vietnam, all located 30 miles outside of Hanoi,
and more than 450 miles from Da Nang. On February 25th, Vietnam suspended entry
for all travelers from COVID-19 affected areas.
Senior medical experts at all levels in the chain of command (TR SMO, C7F and CPF
Fleet Surgeons) were in close coordination throughout the port visit planning process.
As part of their discussions, they noted that the number of COVID-19 cases reported in
Vietnam for the two weeks prior to the visit remained constant, causing them to question
the validity of the reported data. To resolve this concern, the CPF Surgeon conducted a
phone call with the CDC director on-site in Vietnam, who relayed strong confidence in
the reported data because of first-hand observations of Vietnam’s transparency in
executing COVID testing, prevention and mitigation actions.85 CPF had a discussion
with the U.S. CDC Country Director in Vietnam (USCDCVN). USCDCVN informed CPF
that there was “no direct/indirect evidence to suggest an undetected coronavirus
outbreak within the country.” He also stated “that he feels the visit is truly low risk and
that the Vietnamese response to the COVID outbreak is truly impressive.”86 This
assessment resulted in medical staff concurrence that the health risk for the port visit
was low when conducted in accordance with the February 27th, 2020 CPF COVID-19
EXORD. The medical team, however, recommended to and gained approval from
C7F87 to significantly curtail exchange events ashore, reducing the time and numbers of
TR Sailors ashore.88
On February 29th, Vietnamese media reported the CDC removed Vietnam from its list of
areas experiencing widespread or sustained community transmission of COVID19. The CDC and the U.S. Department of Health and Human Services “lauded Vietnam
for achieving positive results in tackling COVID-19 epidemic.” As of February 29th, the
number of confirmed cases in Vietnam remained at 16. WHO continued to advise
                                                            
84
Update Public Health Response to the Coronavirus Disease 2019 outbreak - United States (24 Feb 20)
https://www.cdc.gov/mmwr/volumes/69/wr/mm6908e1.htm
85
Email - CPF Surgeon to TR SMO and C7F Surgeon - Discussion with CDC Director dtd 26 Feb 20
86
Email - CPF Surgeon to TR SMO and C7F Surgeon - Discussion with CDC Director dtd 26 Feb 20
87
Email - C7F to VCNO EA - COMREL Rel and Med Visits in Da Nang dtd 15 Apr 20
88
Email - C7F to VCNO EA - COMREL Rel and Med Visits in Da Nang dtd 15 Apr 20

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against the application of travel or trade restrictions to countries experiencing COVID-19
outbreaks.89 On February 25th, the last person (#16) left a Vietnamese hospital after
testing negative for COVID-19, leaving no active cases of COVID-19 in the country.90
In preparation for the growing pandemic, on February 29th, C7F requested support from
Navy Environmental and Preventive Medicine Unit (NEPMU) teams, with equipment
from Navy Medical Research Center (NMRC) for forward deployable preventative
medicine units to mitigate the potential outbreak of COVID-19 aboard America
Expeditionary Strike Group (AMA ESG) and CSG-9 ships. Based on this assessment
C7F concluded that COBRA GOLD was a higher risk than Vietnam and the medical
support was deployed to the Blue Ridge and AMA ESG.91
Reviews were completed daily up until the day prior to the port visit. Having considered
this latest information and issued preventative guidance regarding COVID-19, CPF
recommended to Commander, INDOPACOM on March 4th that the port visit continue as
planned.92
CDC personnel in Da Nang worked with the Vietnam Country Team and provided
information to INDOPACOM. CDC and Country Team continued to support TR’s port
visit to Da Nang, also assessing it as low risk to the ships’ crews.
The TR SMO emailed TR’s crew a COVID-19 screening plan, which required all
personnel to be screened for COVID-19 symptoms prior to boarding the ship, and again
seven days after getting underway. At this point, it was not widely known that
asymptomatic carriers could spread the virus.
The Da Nang Medical Treatment Plan called for inbound aircraft flights to be screened
at the Department Level. This screening consisted of monitoring for flu-like illness, and
if present, sending them for an immediate medical evaluation vice waiting for routine
sick call. TR leadership (TR XO, CMC, and SMO) made initial preparations for potential
quarantine quarters aboard ship by identifying appropriate berthing compartments and
discussing the general plan for execution.93
Before the port visit, the ship had outlined three quarantine plan options:
1. Distinguished Visitor (DV) Row
                                                            
89
WHO Recommendations for International Traffic (29FEB20) https://www.who.int/news-room/articles-detail/updated-whorecommendations-for-international-traffic-in-relation-to-covid-19-outbreak
90
Nguyen, Trang H D, and Danh C Vu. “Summary of the COVID-19 outbreak in Vietnam - Lessons and suggestions.” Travel
medicine and infectious disease, 101651. 2 Apr. 2020, doi:10.1016/j.tmaid.2020.101651
91
C7F Surgeon Statement dtd 23 May 20
92
Email (SIPR) - CPF to USINDOPACOM - DECISION: Theater Posture Operations dtd 4 Mar 20
93
TR XO Statement dtd 16 May 20; TR CMC Statement dtd 17 May 20; TR SMO Statement dtd 17 May 20

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

Six rooms (two-person officer staterooms, used for guests, cots for
additional patients)

2. Berthing


Chief Petty Officer overflow berthing (open-bay berthing)



Admin Department male berthing (open-bay berthing, currently occupied)



Medical Quiet Room (four bunks with an attached bathroom)

3. Brig


Up to 20 bunks (between two cells, open-bay berthing)

They also planned for use of specific heads, food delivery, laundry delivery, trash and
medical checks.94 Although not listed in the presentation, quality of life items such as
exercise equipment and computer and phone availability were also planned.95
The TR crew liberty brief stated that COVID-19 is a respiratory virus spread mainly
person to person when an infected person coughs or sneezes.96 The brief noted that 82
percent of COVID-19 cases are classified as a mild illness, and that CDC did not
recommend those feeling well wear face masks, which was correct for that timeframe.97
The brief directed Sailors to report to a Medical Detachment at Fleet Landing prior to
boarding the ship if they experienced fever, body aches, cough, or felt sick.98 The
liberty brief also contained information on gun shops and weapons, tattoo/piercing
establishments, local pharmacies, designated liberty/leave area, hotel/lodging, unofficial
tours, and other items.99
The Community Relations Project (COMREL) CONOPs, dated March 1st, showed the
scope of precautions being taken in Vietnam. For example, the CONOPs noted that the
Agent Orange Victims Center, one of the sites for which a COMREL was planned, was
“closed to students due to COVID-19, so Sailors will conduct community service events
such as maintenance, repairs, and improvements to center.”100
                                                            
94

TR SMO PowerPoint - Quarantine Plan and COVID Mitigation Measures "En Route to 'Nam"
TR CMC Statement dtd 17 May 20, TR XO Statement dtd 16 May 20; CVW-11 CAG Statement dtd 19 May 20
96
TR Da Nang Port Visit Overview Brief dtd Mar 20
97
TR Da Nang Port Visit Overview Brief dtd Mar 20
98
TR Da Nang Port Visit Overview Brief dtd Mar 20
99
TR Da Nang Port Visit Crew Brief dtd Mar 20
100
COMREL CONOPs dtd 1 Mar 20
95

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On March 2nd, health officials announced the first two U.S. deaths tied to coronavirus
that occurred among patients in a suburb of Seattle, Washington, as well as the first
known U.S. cases of the virus among health care workers who had treated coronavirus
patients.101 Some individuals infected with COVID-19 have no symptoms, but can still
transmit the virus—a phenomenon that changed the face of the virus and presented a
new obstacle to researchers trying to curb transmission of the virus.”102 It was reported
that for the majority of cases, patients show mild symptoms. According to researchers
from the University of Hong Kong, most mild cases of the virus were indistinguishable
from a common cold, and that other symptoms could include mild fatigue and a low
fever.103
On March 2nd, TR’s Prospective Executive Officer (PXO) arrived via COD.104
On March 3rd, TR facilitated two distinguished visitor (DV) daylight-only visits to the
ship.105 The first visit consisted of 17 Vietnamese nationals nominated by the
Government of Vietnam (GVN) while the second consisted of 14 U.S. country team
members who planned the port visit. Tour routes were designed to minimize internal
access to the ship and visitor use of handrails and other touch surfaces.106
The next day, CPF forwarded the final port visit decision recommendation to
INDOPACOM, who approved it.107 The day’s INDOPACOM Country Health Risk to
Force for COVID-19 indicated that Vietnam’s current risk status was “yellow,” signifying
moderate risk where COVID-19 cases occur in the community without known contacts
or exposures and/or with small outbreak clusters, swiftly handled by public health
interventions that limit disease transmission. The risk level was projected, in seven
days, to be “green,” signifying low risk countries with no reported cases of COVID-19, or
countries that have cases that were imported from another country, or countries that
have isolated transmission exclusively attributed to travel, household contacts or
healthcare settings. The CDC and State Department reported Level 1 for Vietnam,
which recommended practicing usual precautions.
It is unusual for CPF and INDOPACOM to be involved in the decision regarding a port
                                                            
101

America Has Suffered Its First Coronavirus Deaths-and First Infections of Health Care Workers.” Advisory Board- Daily Briefing,
www.advisory.com/daily-briefing/2020/03/02/corona-deaths
102
“America Has Suffered Its First Coronavirus Deaths-and First Infections of Health Care Workers.” Advisory Board- Daily Briefing,
www.advisory.com/daily-briefing/2020/03/02/corona-deaths
103
“Some Coronavirus Patients Don't Show Symptoms. Here's Why That's a Problem.” Advisory Board Daily Briefing,
www.advisory.com/daily-briefing/2020/03/02/asymptomatic-coronavirus
104
TR XO Statement dtd 16 May 20
105
TR Da Nang Port Visit Overview Brief dtd Mar 20
106
TR PAO Interview Summary dtd 23 May 20
107
Email (SIPR) - CPF to USINDOPACOM - DECISION: Theater Posture Operations dtd 4 Mar 20

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visit.108 However, because COVID-19 had begun spreading beyond China, there was
heightened interest and scrutiny from upper echelons to ensure appropriate risk
analysis and mitigation measures were implemented to keep the crew safe and execute
as much of the port visit mission as possible.109

TR and USS Bunker Hill Port Visit to Da Nang
TR anchored in Da Nang Bay and USS Bunker Hill (BKH) moored pier side in Da Nang
on March 5th.110 At the time of TR’s arrival in Da Nang, there were no State Department,
Defense Department, or CDC travel restrictions for U.S. citizens to Vietnam. Vietnam
restricted travel only from China, Republic of Korea, Iran, and Italy before the day of
arrival.111
When the TR and BKH arrived in Da Nang, a Vietnamese delegation formally received
the United States Ambassador to Vietnam, Ambassador Kritenbrink, CPF, CCSG-9, and
the Commanding Officers of USS Theodore Roosevelt and USS Bunker Hill on the
pier.112 The group posed for a photo prior to a press conference attended by more than
100 reporters. The Vietnamese Ministry of Foreign Affairs moderated the 60-minute
press conference. Ambassador Kritenbrink, CPF and CCSG-9 participated with two
Vietnamese representatives - Mr. Huynh Duc Truong, Director of Da Nang Department
of Foreign Affairs and Mr. Ho Ky Minh, Vice Chairman of Da Nang People’s Committee.
Reuters, Channel News Asia and Da Nang Newspaper, were among the media outlets
called upon for questions focused on the visit’s historical significance, the U.S.-Vietnam
bilateral relationship, and Naval operations in the South China Sea.
Ambassador Kritenbrink, CPF, Consulate General Damour (Ho Chi Min City) and
CCSG-9 attended office calls with the Chairman of the Da Nang People’s Committee
and Vietnamese Commander of Navy Region 3.
On March 5th, although all reported COVID-19 cases in Vietnam were reported as clear,
CSG-9 and local authorities continued to take precautions to prevent the spread of the
virus. Some events were cancelled, and liberty restrictions were enforced.113 TR and
BKH Sailors were limited to visiting only Embassy-vetted locations and hotels. Both TR
and BKH cleaned the ships with bleach and disinfectant daily. High sea-states limited
                                                            
108

CPF Statement dtd 17 May 20
CPF Statement dtd 17 May 20
110
CPF Statement dtd 17 May 20;
111
INDOPACOM J07 Country Health Risk to Force for COVID-19 dtd 4 Mar 20
112
TR AAR For 5-9 March Vietnam PVST dtd 17 Mar 20
113
CCSG-9 Statement dtd 15 May 20; XO, TR CMC Statement dtd 17 May 20; Crozier, B. CAPT Statement dtd 15 May 20
109

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the ability of TR Sailors to attend liberty events, resulting in the cancellation of two
planned sporting events, many tours and community relations events, often the
highlights of a port visit for a ship’s crew. However, more than 100 other strike group
personnel and U.S. Country Team members fulfilled all the other Community Relations
Project obligations, which included interacting with residents at the Vocational Charity
Center, Dorothea’s Project Legacy Charity Center (attended by Ambassador
Kritenbrink, CPF and CCSG-9), Agent Orange Victims Center, Hoa Mai Orphanage and
Dong A University. Local media covered these events and interviewed strike group
personnel.
CPF hosted a formal reception for 500 guests on March 6th. Originally scheduled to be
held aboard TR, the event was moved to Da Nang Golden Bay Hotel due to concerns
with safely transferring guests to and from the carrier because of an increased sea
state. CPF, AMB Kritenbrink and Mr. Ho Ky Minh, Da Nang People's Committee vice
chairman, provided formal remarks during the ceremony, which was accompanied by
military courtesies and protocol standard for such events.
Due to the dangerous sea state and the resulting inability to get members of the media
safely to TR immediately after the press conference, approximately 65 reporters visited
BKH for one hour to film b-roll footage and capture still imagery the next day. Reporters
toured the bridge, hangar bay, fo’c'sle, aft missile deck, and other areas of the ship.
Outlets in attendance included Reuters, Channel News Asia, Dat Viet Newspaper, Tuoi
Tre Newspaper, VN Express, and Da Nang Newspaper.
On Saturday, March 7th, a group of 30 reporters traveled by boat to TR for a tour of the
hangar bay and flight deck. This was the only group to visit TR for a tour of the ship
during the port visit. Due to the dangerous sea state and the resulting inability for other
tour groups to visit TR safely, ship tours were shifted to BKH. 400 guests from the local
Border Guard, Vietnam People’s Navy, Military Region, municipal government, Vietnam
Veterans, and American Chamber of Commerce visited the cruiser between March 5th
and March 6th.114
COVID-19 concerns impacted other planned port visit events as well. The Government
of Vietnam cancelled shipboard tours for 100 additional guests on Sunday, March 8th.
The U.S. Pacific Fleet band modified their performance schedule in accordance with
Vietnamese direction to refrain from large public gatherings. However, the band
performed at several events, including a Vietnamese-hosted dinner, a Charity Center
COMREL, a CPF-hosted reception, a Hoa Mai Orphanage COMREL and an event at
the Nguyen Huu Dinh Opera Theatre.
                                                            
114

TR AAR For 5-9 March Vietnam PVST dtd 17 Mar 20

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Three planned professional exchanges, in which Vietnamese air traffic controllers,
firefighting personnel and meteorologists would have toured TR were cancelled due to
sea state and/or COVID-19 concerns. U.S. Country Team representatives supported a
Humanitarian Assistance and Disaster Relief (HA/DR) professional exchange ashore,
focusing on disease prevention at Da Nang Hospital for Women and Children.
Members of the media attended, but CSG-9 members did not.
During the port visit, concerns regarding COVID-19 rose at all levels. On March 4th,
both Thailand and Vietnam were classified as HPCON “A” (Normal) with a Department
of State Advisory Level “1” (practice usual precautions). On March 6th, Exercise
COBRA GOLD (a joint combined Navy/Army/USMC event) concluded in Thailand,
involving 4,500 U.S. personnel.115 None of those personnel developed COVID-19.116
On March 8th, the Vietnamese Government notified CSG-9 that Sailors may have been
exposed to COVID-19 during a stay at the Vanda Hotel in Da Nang, because two British
citizens who had been guests of that hotel had tested positive for COVID-19.117 TR and
BKH suspended liberty for the remainder of the day, and ultimately the remainder of the
port visit.118 All remaining planned tours and professional engagements were cancelled.
TR’s Public Affairs Officer (PAO) (Command Duty Officer on March 8th) set up an
emergency command center in the Strike Operations center aboard TR and information
was gathered to form a list of people who stayed or had interactions at the Vanda Hotel
grounds.119 TR leadership quickly identified the location of 37 Sailors known to have
stayed at the hotel. Of those, 11 TR Sailors identified as having stayed at and still
present at the hotel were screened, tested on-site, and released to TR for quarantine.
26 other TR Sailors identified as having stayed at the hotel, but no longer there were
removed from TR to the pier, screened, tested and returned to TR for quarantine. Later
that day, two additional Sailors reported to TR medical staff that they had also visited
the hotel. These two Sailors were not tested, but were quarantined on TR. All 39
Sailors remained in quarantine120 for 14 days. TR remained at anchor one additional
day due to sea state, and on March 9th, departed Da Nang.
 

                                                            
115
The 39th Iteration of Cobra Gold Concludes with a Combined Arms-Live Fire Exercise and Closing Ceremony U.S. Army Public
Affairs Office (6 Mar 20)
https://www.army.mil/article/233549/cobra_gold_20_the_39th_iteration_of_cobra_gold_concludes_with_a_combined_arms_live_fire
_exercise_and_closing_ceremony
116
C7F COS Statement dtd 21 May 20; Email – C7F – Response to RFI dtd 15 May 20
117
Crozier, B. CAPT Statement dtd 15 May 20
118
Crozier, B. CAPT Statement dtd 15 May 20
119
TR CDO Report dtd 8 Mar 20
120
Crozier, B. CAPT Statement dtd 15 May 20

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Chapter 3 - Actions during USS Theodore Roosevelt Transit to and Arrival in
Guam

Underway Quarantine and Initial COVID-19 Positive Sailors Aboard TR
On March 9th, TR got underway from anchorage in Da Nang Bay, Vietnam, with 39
Sailors in quarantine (see Figures 2 and 3), and resumed normal operations in the C7F
area of operations. At this time, with the exception of the quarantined area, the entire
operational chain of command believed that TR was a COVID-free ship.

Figure 2: 200521-N-SH180-3010 PHILIPPINE SEA (May 21, 2020) - U.S. Sailors sit in a crew lounge area that was
one of the first quarantine spaces aboard USS Theodore Roosevelt (CVN 71).
(U.S. Navy photo by Mass Communication Specialist 3rd Class Zachary Wheeler)

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Figure 3. 2200521-N-SH180-3014 PHILIP/NE SEA (May 21, 2020)-A reactor berthing compartment that was one
of the first quarantine spaces aboard USS Theodore Roosevelt (CVN 71).
(U.S. Navy photo by Mass Communication Specialist 3rd Class Zachary Wheeler)

The outbreak of norovirus earlier in the deployment resulted in a continuing effort to
clean common touch areas throughout the ship with an appropriate disinfecting agent.
The crew used bleach solution, approved for shipboard use, to clean the ship daily. All
ship's services contin ued as usual. The ship's crew received daily reminders to wash
their hands, maintain social distancing, and not touch their faces. These messages
were delivered in several ways: TR's XO made daily announcements on the public
address system (1 MC) and the TR CO made similar announcements every other day.
Department Heads received information to inform their department personnel, and the
medical staff created a video that was broadcast continuously on the ship's closedcircu it television channel. Add itionally, in compl iance with guidance at the time, the TR
SMO had every department conduct verbal COVID-19 screenings of all Sailors (asking
for flu-like symptoms: fever, chills, cough , sore throat, shortness of breath and body
aches) daily for a period of seven days. After March 16th, Sailors were requested to
self-assess and report to Medical if having any symptoms. 121
TR's CO restricted self-service on the main galley lines on March 9th, however selfservice remained an option for other food selections such as the salad bar.
121

Email - TR SMO to All Officers, All CPOs, All E-6 and below - 14 days of screening following port visits dtd 16 Mar 20

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During the transit, the TR communicated to the medical and operational chains of
command that they were unable to fully comply with the requirements contained in the
C7F TASKORD (C7F TASKORD for Force Health Protection against COVID-19).122
CPF and C7F Fleet Surgeons requested TR continue to do the screening they were
conducting.123
From the time the ship left Da Nang on March 9th until March 23rd, seven COD flights
originating out of Clark Air Force Base in the Philippines brought a total of 29
passengers and COD detachment personnel to the carrier.124 All 29 screened negative
for COVID-19 symptoms upon their arrival,125 following the screening protocols required
by the February 23, 2020 C7F FRAGORD.126 Later, four of those personnel tested
positive for the virus, however the investigation team as well as the NMCPHC
concluded that none of these Sailors were the likely source of the outbreak on TR
(details in Appendix F).
From March 9th to March 23rd, up to nine Sailors presented to TR Medical with ILI
symptoms. Sailors that presented with one or more ILI symptoms were screened by
members of the embarked BDRD team for common respiratory pathogens using the
BioFire Respiratory Panel (RP-2). If a positive test result was returned, the screening
was halted. In each of these nine cases, a positive test result for common respiratory
illnesses was returned.127
On March 23rd, TR stopped receiving COD flights from the Philippines.128 The TR CO
stated that due to the increasing number of COVID-19 cases in the Philippines, an
internal decision was made to push all future passengers and parts to Kadena AFB or
Anderson AFB and avoid further flights to the Philippines.129 The investigation team
concluded through analysis the following:


Patients that presented with ILI symptoms prior to Da Nang were not likely
COVID-19 positive cases.



There is no indication that the virus came aboard TR via COD.



There were indications of possibly undetected COVID cases aboard TR

                                                            
122

Email – TR SMO - Post-Danang Update dtd 17 Mar 20
TR SMO Statement dtd 17 May 20; Email – TR SMO to CCSG-9 – Post-Danang update – dtd 18 Mar 20
124
COD Completed Travel Log/Manifest
125
Crozier, B. CAPT Statement dtd 15 May 20, TR XO Statement dtd 16 May 20; CVW-11 CAG Statement dtd 19 May 20 
126
TR SMO Statement dtd 17 May 20
127
(b) (6) LCDR Statement dtd 23 May 20
128
COD Completed Travel Log/Manifest
129
Crozier, B. CAPT Statement dtd 15 May 20
123

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following the Da Nang port visit.
A more detailed analysis of the probable source of COVID-19 on TR can be found in
Appendix F of this report.
The prospective XO, who embarked prior to the ship’s arrival in Da Nang, completed
turnover with the outgoing TR XO, and officially assumed the role on March 11th.130
On March 13th, the TR CO sent letters to family members indicating the ship had begun
COVID-19 testing for select individuals.131 Members of Navy Forward-Deployed
Preventive Medicine Units and Naval Medical Research Center, per the request of C7F,
embarked TR132 on March 14th while the 39 quarantined Sailors tested negative.133
Members of the BDRD team tested the 39 Sailors on the Applied Biosystems Inc.
StepOne Plus instrument, using the COVID-19 test, which had been approved for
research-use only at that point.134 Operations in 7th Fleet continued; USS Blue Ridge
(LCC 19) arrived in Singapore for a previously scheduled port visit, Guam declared a
state of public health emergency, even though no cases had yet been identified on
Guam.135
On March 16th, the TR SMO emailed the crew of TR explaining that C7F released a
revision to the Tasking Order (TASKORD) for Force Health Protection against COVID19.136 By March 17th, all 50 U.S. states had confirmed cases of the virus.137 By March
20th, Guam had 12 confirmed cases of COVID.138
As TR prepared for their Guam port visit, scheduled for April 3rd – 10th, the TR CO and
NBG CO correspondence regarding the same illustrated that TR was not seen as a
COVID-threat to Guam, but significant efforts would need to be taken to ensure TR
remained COVID-free, which would result in changes from their recent February port
call to Guam.
On March 17th, the TR CO emailed139 CO, NBG to propose three possible courses of
action (COAs) for liberty during the TR’s upcoming Guam port visit:
                                                            
130

Email - TR XO - TR Investigation dtd 8 May 20
Crozier, B. CAPT Ltr to families dtd 13 Mar 20
132
Navy Preventive Medicine Teams Embark Ships in 7th Fleet, INDOPACOM, (03 Mar 20)
https://www.pacom.mil/Media/News/News-Article-View/Article/2122302/navy-preventive-medicine-teams-embark-ships-in-7th-fleet/
133
Email - TR SMO - Post-Danang Update dtd 14 Mar 20 
134
(b) (6) LCDR Statement dtd 23 May 20
135
Government of Guam Executive Order 2020-03
136
Email - TR SMO - Coronavirus screening - Update dtd 16 Mar 20
137
CORONAVIRUS: DOD RESPONSE TIMELINE (15 May 20) https://www.defense.gov/Explore/Spotlight/Coronavirus/DODResponse-Timeline/
138
Email - NBG CO to TR CO - TR PVST dtd 20 Mar 20
139
Email - NBG CO to TR CO - TR PVST dtd 20 Mar 20
131

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1. Full Guam liberty, similar to the previous port visit,
2. NBG liberty with base access (busses to Navy Exchange (NEX), beach, etc.),
and limited off-base liberty (golf, small group tours, etc.),
3. Or pier liberty with limited access to NBG (busses to NEX, beach, etc.) and
MWR pier support (food/beer/entertainment/wifi).
CO, NBG responded that Guam now had 12 confirmed COVID-19 cases and although
none of the cases were on base, he deemed that the possibility of exposure on base to
the TR was a threat for their port visit and forwarded NAVBASE Guam Notice 6210,
“U.S. Naval Base Guam Maritime Vessel Quarantine Procedures for a Clean Ship.”
CO, NBG stated that only COA 3 was appropriate and that further mitigation measures
were needed to afford TR Sailors access to the NEX and that TR medical personnel
would be required to assist in screening and sanitization inspections.140
On March 22nd, TR CO emailed CO, NBG and provided a summary of the TR liberty
plan for the upcoming Guam port visit that complied with the limitations of COA 3. TR
CO outlined in detail that liberty would be confined to the pier with limited NBG access.
He requested support equipment and supplies for beer sales, barbeques, Wi-Fi, and
games. In addition to pier activities, TR CO requested exclusive access to Gab Gab
beach for TR Sailors with the availability of MWR rental equipment such as
paddleboards and volleyball. TR CO requested limited access to NBG locations such
as the NEX, Liberty Center, movie theater, gym, ballfields, and hiking areas.141
CO, NBG responded to TR CO that his first priority was the safe mooring of the ship
and proper husbanding while in port, all while ensuring that the ship and crew remained
“clean.” He stated that “once we have that locked in we will focus on the quality of life.”
CO, NBG attached the below general schematic for Kilo Wharf (Figure 4) and the
potential Force Health Protection Enclave (FHPE) that would be employed to enable the
required separation for TR Sailors to base support personnel.142

                                                            
140
141
142

Email - NBG CO to TR CO - TR PVST dtd 20 Mar 20
Email – NBG CO to TR CO - RE TR PVST dtd 23 Mar 20
Email – NBG CO to TR CO - RE TR PVST dtd 23 Mar 20

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Figure 4. Kilo Wharf, Naval Base Guam, laydown for TR's arrival on March 27, 2020.

First COVID-Positive Tests
On March 22nd, after a 14-day quarantine period, all 39 Sailors potentially exposed to
COVID-19 in Da Nang remained asymptomatic, tested negative for COVID-19 a third
time, and were released from quarantine.143 However, on March 23rd, two Sailors, both
from the air wing, began showing COVID-19 symptoms. 144 Those two, and an
additional Sailor from the nuclear reactor department, tested positive for COVID-19 on
March 24th_ 145 None of these th ree Sailors were among the 39 who had been potentially
exposed to the virus in Da Nang and subsequently placed in quarantine.
From this point forward, despite no known COVID cases aboard, the ship did not
implement actions such as enforcing social distancing measures on the mess decks146
(i.e., no seats were removed , lines continued to form without six feet of separation
between Sailors and condiments were available for common use).147 Gyms, chapel,
and ship's store remained open.

143 C7FCOS S
tatement dtd 21 May 20; Crozier, B. CAPTStatement dtd15 May 20; TRXOStatement dtd16 May 20; TRSMO
Statement dtd 17 May 20; C7F SurgeonStatement dtd 23 May 20
144
Email (SIPR) -CCSG-9to C7Fand C3F- POSITIVECOVID-19TESTSONTR(initial report) dtd 24Mar 20
145
Email (SIPR) - CCSG-9- Positive COVID-19 tests onTR(update#9) dtd26 Mar 20; Email -TRSMOto CCSG-9-COVID 19
update24 March dtd 24 Mar 20, 0440
146 AME
1Statement dtd 13May 20; CSC Statement dtd,13 May 20; TRCMC Statement dtd 17 May 20
147
Email -TR SMO toTRCO - FollowUp dtd 9 Mar 20; TRSUPPO Statement dtd 18 May 20; TRXOStatement dtd 16 May 20

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Planning for Arrival in Guam
As TR confirmed the first Sailors with COVID-19 aboard TR, two commercial cruise
ships, Diamond Princess and Grand Princess, were experiencing more than 800 total
COVID-19 cases while at sea, including 10 deaths. As the first U.S. Navy warship to
have a COVID outbreak underway, CSG-9 and TR leadership paid close attention to
observations from the cruise ship Diamond Princess and other cruise ships
experiencing COVID outbreaks. They recognized two significant differences between
Diamond Princess and TR. First, berthing onboard TR was primarily open bay group
berthing with shared heads, while the Diamond Princess berthing was comprised mainly
of staterooms (accommodating one or two people). Secondly, the demographics of the
ships were different. TR had a younger, healthier population, while Diamond Princess
had an older demographic. Cruise ships were experiencing difficulty in obtaining
authorization from host nations to enter port and in the case of the Diamond Princess
and Grand Princess, required extraordinary levels of support to manage the movement
of embarked guests ashore. Guam had denied entry to cruise ship MS WESTERDAM
over COVID-19 concerns on February 7th, even though there were no known COVIDpositive people aboard.148
TR was originally scheduled for a port visit to Guam from April 3rd to April 10th.149 On
March 25th, TR sailed for Guam at USS Bunker Hill's best speed based on maximum
allowable fuel burn rate for the planned transit150 and TR sent a logistics request
(LOGREQ) for a March 27th arrival in Guam.
C7F suggested using the ship’s hangar deck for segregated berthing, and considered
flying the Command Element and the air wing off the ship to Anderson Air Force Base,
Guam. Anderson Air Force Base had significant concerns about COVID-positive
patients flying to that base.151 Commander, Task Force (CTF) 75 offered tents with air
conditioning and cots for 400 Sailors to be available on the pier if needed.152 After the
third Sailor tested positive for COVID-19, the TR CO conducted a 1MC call informing
the crew that antiseptic wipes and hand sanitizer were available throughout the ship,
that self-service was secured on the mess decks, the Chief Petty Officers’ mess and
wardrooms, dental services were now limited, and “bleach-a-palooza” would occur twice
daily.153 C7F was aware of the preventive measures currently being taken aboard
                                                            
148
Guam denies entry to ship over coronavirus concerns, USA Today (07 Feb 20)
https://www.usatoday.com/story/news/local/2020/02/07/guam-denies-entry-ship-over-coronavirus-concerns/4687803002/
149
Email - CSG-9 – Response to RFI dtd 20 May 20
150
Crozier, B. CAPT Statement dtd 15 May 20; C7F COS Statement dtd 16 May 20; , TR XO Statement dtd 16 May 20; TR RO
Statement dtd 18 May 20
151
Email (SIPR) – C7F to CCSG-9, C7F CoS, CSG-9 CoS – RE: (S) Positive COVID tests on TR (Update #2) dtd 24 Mar 20
152
Email (SIPR) – CTF 75 to C7F – COVID-19 Commander's perspective 22 Mar dtd 24 Mar 20
153
Email – TR PAO – TRSG RTQ dtd 24 Mar 20 0149 (containing 200323 TRSG Positive COVID 1MC Remarks)

42

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TR. 154 The SMO requested assistance from Navy Medicine upon arrival in Guam. 155
C?F and CPF Fleet Surgeons concurred with the SMO that at this point "anyone who is
defined as [having influenza-like illness symptoms] is a presumptive [positive] COVID19 and should be treated as such ."156
By March 25th, TR had four Sailors positive for COVID-19, and moved them ashore to
Naval Hospital Guam via helicopter.157 On March 25th, the CSG-9 COS notified the C?F
COS of the need for 4,000 rooms to house Sailors in single isolation for two weeks.158
As COVID-19 cases rose to eight,159 the TR CO sent letters to fami ly members
indicating "a few Sailors" had tested positive for COVID-19, had been placed in
isolation, and work was in progress to fly those Sailors off the ship as soon as
possible.160 (Figures 5 and 6 depict Sailors working aboard the ship using social
distancing measures).

Figure 5: 200521-N-MQ442-1006 PHILIPPINE SEA (May 21, 2020) - U. S. Sailors work in the aviation ordnance
shop aboard the aircraft carrier USS Theodore Roosevelt (CVN 71). Seven Sailors typically work in this space.
(U.S. Navy photo by Mass Communication Specialist 3rd Class Dartanon D. De La Garza)

Email - C7F PAO toTR PAO- FWD: Proposed Statement dtd 26 Mar 20
Email - TRSMOto CPF and C7FFleet Surgeons - WARNORDfor BUMEDdtd 24 Mar 20
155 Email - TRSM
Oto CPF and C7FFleet Surgeons - WARNORDfor BUMEDdtd 24 Mar 20
157 CO NHGStatem
ent dtd 18 May 20; Sailors tested positive on USS Theodore Roosevelt, extent of exposure unclear, Pacific Daily
News (23Mar 20) https:/lwww.guampdn.com/story/news/1ocaV2020/03/26/sailors-tested-positive-uss-roosevelt-extent-exposureunclear/5084652002/#
158 Email (SIPR
) - CSG-9COS toC7FCOS - HOTEL OPTIONdtd25 Mar 20
159 Eight sailors fromUSS Theodore Roosevelt have coronavirus, raising concerns about pandemic's strain on m
ilitary, USA Today
(24 Mar 20) https://www.usatoday.com/story/news/politics/2020/03/24/coronavirus-3-sailors-test-positive-military-readinessaffected/2910165001
160 Email - C
rozier, B. CAPTtoTR Ombudsmen - TRletter tofamilies- with Letter toTRFamilies and Friendsdtd24 Mar 20
154
155

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Figure 6: 200521-N-XX200-2116 PHILIPPINE SEA (MAY 21, 2020) - U.S. Sailors work in an Air Department work
center aboard the aircraft carrier USS Theodore Roosevelt (CVN 71). Up to eight Sailors typically work in this space.
(US Navy photo by Mass Communication Specialist Seaman Erik Melgar)

TR's positive COVID-19 cases grew from eight to 33 by March 26th. 161 With numbers of
cases increasing, C?F continued coord inating efforts to develop a plan for disembarking
TR Sailors. During a discussion with C?F, the Commanding General of Ill Marine
Expeditionary Force (Ill MEF) offered up to 5,000 rooms for potential occupancy in
Oki nawa. 162 An email from CO, NBG to the C?F COS and CSG-9 COS detailed a plan
for TR's arrival to Guam and provided the slides in figures 7 through 9 below.163 The
priority after safely mooring was to transport Sailors who were COVID-19 positive and
20 Reactor Department Sailors (key watchstanders who were being protected as
backu ps and kept in reserve) to isolation rooms . CO, NBG's scheme of maneuver brief
shows the availability of 150 isolation beds and 493 quarantine beds in gyms and open
bay faci lities upon TR's expected March 27th arrival. 164

16 1 Email

(SIPR) - CCSG-9 - Positive COVID-19 tests on TR (update 119) dtd 26 Mar 20
C7F Statement dtd 18 May 20
163 Email (SIPR) - CO NBG - NBG Task Force TR REVIVE dtd 26 Mar 20
164 Email (SIPR) - CO NBG - NBG Task Force TR REVIVE dtd 26 Mar 20
162

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Figure 7: Kilo Wharf Laydown 165

Figure 8: Route to Isolation Homes 166

165
166

Email (SIPR) - CO NBG - NBG Task Force TR REVIVE dtd 26 Mar 20
Email (SIPR) - CO NBG - NBG Task Force TR REVIVE dtd 26 Mar 20

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FOOD ROUTE
MWR TNT - Food Vendor

ISOLATION Area
Harbor View Homes

Figure 9: Food Roufe167

Navy published definitions of quarantine and isolation, derived from CDC guidance , on
March 23rd_ 168 Quarantine referred to the separation of a person or group from others
as a resu lt of suspected exposure to a comm unicable disease to prevent its spread.
Quarantine was to be imposed on those with no COVID-19 symptoms who had either
recently returned from a high-risk location (CDC Travel Health Notice Level 2 or 3), or
had close contact with a known COVID-19 positive person. The recommended
quarantine period was 14 days. The same Navy guidance defined isolation as the
separation of a person or group from others due either to the development of potential
COVID-19 symptoms or as a result of a positive COVID-19 test. A third definition of
Restrictions on Movement (ROM) applied to personnel directed to remain at home or in
a comparable setting for 14 days from the day of contact with a COVID-19 positive
person. For transient personnel and those residing in close quarters such as
unaccompanied housing or ships, temporary lodging meeting CDC guidance of
separate sleeping and bathroom facil ities shall be arranged, when available.
On March 25th, CCSG-9 issued Commander's Guidance to the strike group for arrival in
Guam expressing the following priorities:
1. move all COVID-positive Sailors to isolation quarters;
2. identify key groups needed to operate ship at sea in near-term;

167
168

Email (SIPR) - CO NBG - NBG Task Force TR REVIVE dtd 26 Mar 20
NAVADMIN 083/20 Restriction of Movement /ROM) Guidance 23 Mar 20

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3. move key reactor supervisory personnel into isolation following testing; and
4. if additional quarantine racks remain, prioritize by personnel and by function.
The desired near-term end state was to have sufficient personnel to get the ship
underway for contingency operations.169 This was a reasonable and appropriate set of
priorities given the size of the outbreak at the time and the limited knowledge of what
COVID-19 PCR testing could actually do.
As concern for TR elevated up operational and administrative chains of command, CPF
emailed the first of a series of TR Recovery and Disposition Plan updates to the fourstar admiral commanding U.S. Indo-Pacific Command (INDOPACOM) and to the CNO.
CPF noted that the plan was to test the entire TR crew for COVID-19.170
On March 26th, C7F emailed the Deputy Chief of Naval Operations (DCNO) for
Operations, Plans and Strategy (N3/N5) recommending Echelon I engagement and
support for additional resources for testing 100 percent of the TR crew.171 The C7F
COS stated that testing before moving to quarantine was not required and that C7F was
clear to CCSG-9 that the intent was to move Sailors ashore as fast as possible.172
With one day remaining before TR’s arrival in Guam, CCSG-9 emailed C7F that TR
would run out of quarantine and isolation space ashore in Guam. Adding complexity to
the situation, an email response from the CNO to CPF stated his understanding that
100 percent of the crew would be tested and a response on the same email thread from
C7F stated that “100 percent was desired but likely not possible.” In the same email
thread, the DCNO (OPNAV N3/N5), who was responsible for Navy’s overall plan to
combat COVID-19, replied to C7F that the “Crew of TR will not leave pier, with the
exception of positive Sailors, who will be sequestered in base berthing facilities.” The
email thread continued the same day with the CNO again stating for clarification to CPF
that he understood that CPF’s intent was 100 percent testing for the TR crew.173 On
March 28th, C7F emailed CCSG-9 to address an earlier conversation in which CCSG-9
reported he was sending Sailors to ashore quarantine without an initial test. C7F stated
in his email, “You get no credit for those folks.”174 CCSG-9 replied, “Copy all and
WILCO,” implying he now understood a 100 percent testing requirement for Sailors to
move ashore.175 This perceived direction from higher authority was in opposition to the
                                                            
169

Email (SIPR) – CCSG-9 to Crozier, B. CAPT, CVW-11 CAG – (S) OUTBREAK COMMANDER’S GUIDANCE dtd 26 Mar 20
Email (SIPR) – CPF to CNO and INDOPACOM - TR Recovery and Disposition Plan dtd 26 Mar 20
171
Email (SIPR) – C7F to OPNAV N3/N5 – RE: (U//FOUO) FOR INFORMATION: TR Recovery and Disposition Plan dtd 26 Mar 20
172
C7F COS Statement dtd 16 May 20
173
Email (SIPR) – N3/5 to C7F – RE: (U//FOUO) FOR INFORMATION: TR Recovery and Disposition Plan dtd 26 Mar 20
174
Email (SIPR) - C7F to CCSG-9 – SUBJ: (S) 28 Mar TB - follow-up dtd 28 Mar 20
175
Email (SIPR) - C7F to CCSG-9 – SUBJ: (S) 28 Mar TB - follow-up dtd 28 Mar 20
170

47

 FOR OFFICIAL USE ONLY
plan to remove the healthy 840 “Tier I” personnel needed to steam the ship and caused
further confusion among the warfare commanders.176

Arrival and Initial Disembarkation
On March 27th, TR arrived in Guam and moored at the pier177 with 36 COVID-19 positive
Sailors aboard the carrier. Upon arrival, CCSG-9 and TR planned to rapidly move both
confirmed COVID-positive Sailors and key watchstanders known to have avoided
contact with any positive Sailors off the ship. 264 Sailors moved ashore to available
berthing according to this plan. There was no plan at this time to move ashore the large
number of Sailors quarantined on the ship, nor was there clarity on testing requirements
prior to sending Sailors ashore to NBG. Compounding the confusion, the C7F COS
emphasized to CSG-9 that all people must be tested before they leave the ship.178
TR closed the remaining gyms aboard ship once in port and created a pier gym for
Sailor use.179 Creation of this pier gym was inconsistent with published Navy and Fleet
guidance. Additionally, the ship continued to conduct Command Urinalysis screening
despite the release of Navy guidance180 on March 27th (NAVADMIN date – March 28th
Guam) authorizing commanding officers to pause the program in response to the strict
enforcement of social distancing measures.181 In contrast, Navy facilities ashore and
units at sea had by this date (March 24th) secured gyms and religious services and
mandated social distancing in dining facilities consistent with NAVADMIN 080/20
released on March 22nd.182
As the TR arrived in Guam, C7F said he was “crystal clear” to CCSG-9 that C7F wanted
as many Sailors off the ship as quickly as possible.183 Once CPF received word that
Korea could test 1,000 samples per day, CPF directed testing of TR’s entire crew.184 In
order to do this, CPF directed getting the entire crew tested, the ship cleaned and
declared clear of the virus as soon as possible so the crew could get back to the ship
and get underway.185 The fastest means to achieve this was to establish a testing rate
                                                            
176
CVW-11 CAG Statement dtd 19 May 20; Crozier, B. CAPT Statement dtd 15 May 20; Email – CVW-11 CAG to CCSG-9 –
PROPOSED PAPER / COURSE OF ACTION FROM WARFARE COMMANDERS dtd 29 Mar 20
177
Facebook Post - Family and Friends of the Rough Riders, Crozier, B. CAPT (27 Mar 20)
https://www.facebook.com/USSTheodoreRoosevelt/photos/a.489137065779/10156700551025780/?type=3&theater
178
Email (SIPR) - C7F COS to COS CSG-9 - Triage and Procedure dtd 27 Mar 20
179
Email – TR Afloat Rec Specialist – Gym's Secured dtd 29 Mar 20
180
NAVADMIN 092/20 Urinalysis Policy Update dtd 27 Mar 20
181
TR MA2 to TR Crew - URINALYSIS POLICY UPDATE dtd 29 Mar 20
182
NAVADMIN 080/20 Navy Mitigation Measures in Response to Coronavirus Outbreak Update 3 dtd 21 Mar 20
183
C7F COS Statement dtd 16 May 20
184
C7F COS Statement dtd 16 May 20
185
C7F COS Interview dtd 16 May 20

48

 FOR OFFICIAL USE ONLY
of 500 tests per day to match available shipboard testing capacity, as a goal. Upon
arrival, TR could only swab approximately 200 Sailors per day without outside medical
support personnel.186 C7F stated that they were aware of the testing capacity limitation
as well as ongoing efforts to supply sufficient swabs, however they felt continual
pressure from CPF to attain the 500 per day goal, and to ultimately expand to the
advertised capacity of 1,000 per day for the lab in Korea.187 CCSG-9 and TR felt
continuous pressure from these requirements, and they felt distracted from egressing
the crew in a timely manner. There was no meaningful discussion at leadership
meetings on when these samples should be taken – before leaving the ship or after. TR
was executing the samples before allowing Sailors to leave. C7F said he believed TR
was “slow-rolling” Sailors leaving the ship. In contrast, TR and CCSG-9 leaders viewed
the testing as an unnecessary distraction.188
While CCSG-9’s guidance established movement of COVID-19 infected Sailors to
isolation ashore as the first priority, the next priority was preserving the ability to get
underway rapidly for contingency operations, and accordingly key watchstanders that
had been protected from spread of infection were quarantined next. The lack of clarity
about available facilities ashore and plans for testing Sailors aboard ship contributed to
delays in getting potentially non-infected crewmembers off the ship.189
On March 28th, TR’s CO sent letters to family members announcing the ship’s arrival in
Guam. He indicated that Sailors with positive test results or symptoms indicative of
COVID-19 were the first priority to get off the ship for evaluation at NBG Hospital. He
further stated that some Sailors would be moved to open bay berthing off the ship and
that parts of the ship would be used to quarantine “close contact” Sailors.190
The same day, TR received new higher capacity COVID-19 testing kits, but they
required 12-14 days of preparation before use.191 After previously stressing that all
Sailors would be tested prior to departing the ship, CCSG-9 decided to move people off
the ship as quickly as possible and test later.192 The ship worked to batch-test 200
people who had already moved ashore before the ship was able to test them. A batch
test ran the samples of multiple Sailors at once enabling the medical team to determine
if a COVID-19 case was in the tested group. A batch test does not individually diagnose
Sailors. If a batch were to test positive for COVID-19, the medical team would take
                                                            
186

Email – TR SMO to CSG-9 Staff – Testing Planning Factors dtd 27 Mar 20
Email – C7F COS– RE: Signed C7F COS statement dtd 22 May 20
188
Email – CVW-11 CAG to CCSG-9 – PROPOSED PAPER / COURSE OF ACTION FROM WARFARE COMMANDERS dtd 29
Mar 20
189
Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20
190
Email – Crozier, B. CAPT to TR Ombudsmen – (none) with Letter to TR Families and Friends dtd 24 Mar 20
191
Email (SIPR) – CNO to CPF – INFO TR recovery and disposition update 27 Mar 20 dtd 28 Mar 20
192
Email (SIPR) – CCSG-9 - 28 Mar TB - follow up dtd 28 Mar 20
187

49

 FOR OFFICIAL USE ONLY
additional measures, such as isolating the Sailors whose samples were in the batch,
and depending on the Sailor's symptoms, potentially medically evacuating them off the
ship to a shore facility for testing.193
Providing food for the number of TR Sailors ashore in isolation and quarantine was a
challenge.194 As the number of Sailors ashore increased, the contracted food delivery
had difficulty keeping up with the increasing demand. TR Sailors complained of
problems195 that leadership addressed as quickly as they could. Sailors expressed their
concerns on social media and this was relayed to the TR CO and TR XO.196
Contributing to this sense of “helplessness,” NBG did not allow (at the time) any TR
supervisors to review the temporary facilities for their Sailors, but neither did TR
leadership address this with NBG or others.197
The ship's leaders were also concerned that the temporary open-bay facilities did not
meet CDC guidelines and cots were not initially arranged to enable social distancing. In
reaction to the social media posts and out of concern about the living conditions ashore,
the TR CO established policy that no Sailors would leave the ship until guarantee of
sufficient meal service was available.198 Additionally, the CO requested the ability for
ship's company to inspect isolation and quarantine facilities for suitability prior to moving
Sailors (e.g., adequate meal service, heads, and physical separation).199 Figures 10
through 14 below depict a sampling of the shore facilities in place for TR Sailors.

                                                            
193

Navy Preventive Medicine Teams Embark Ships in 7th Fleet, INDOPACOM, (03 Mar 20)
https://www.pacom.mil/Media/News/News-Article-View/Article/2122302/navy-preventive-medicine-teams-embark-ships-in-7th-fleet/
194
NBG CO statement dtd 18 May 20; TR XO Statement dtd 16 May 20
195
AME2 Statement dtd 16 May 20; AN Statement dtd 16 May 20; TR CMC Statement dtd 17 May 20; TR XO Statement dtd 16 May
20
196
Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; TR PAO Interview Summary dtd 23 May 20
197
Crozier, B. CAPT Statement dtd 15 May 20
198
Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20
199
Crozier, B. CAPT Statement dtd 15 May 20; TR CMC Statement dtd 17 May 20

50

  

 

Figure 11: Cot Setup

51

FOR OFFICIAL USE ONLY

Figure 12: Gym Cot Setup

Figure 13: Guam Expeditionary Medical Facility (EMF)

52

 FOR OFFICIAL USE ONLY

Figure 14: Guam EMF

When the Government of Guam issued a state of public health emergency on March
14th, Naval Base Guam set Health Protection Condition Level (HPCON) C+. Th is
HPCON significantly limited personnel on and transit with in the base. Additionally, the
pier area around TR had been designated a Force Health Protection Boundary (FHPB),
restricting movement for TR's Sailors off the pier.

Delays in Disembarking Crew
C?F said he believed that the TR CO and CSG-9 were resisting sending the crew
ashore because available facil ities were not fully CDC compl iant. 200 Some of the
spaces available are pictured in Figures 15 and 16 below.

200

C7F COS Statement dtd 21 May 20

53

 FOR OFFI CIAL USE ONLY

I

Figure 15: USS Theodore Roosevelt (CVN 71) Sailors quarantined in gym (US Navy Photo)

Figure 16: USS Theodore Roosevelt (CVN 71) Sailors quarantined in facility on Guam (US Navy Photo)

54

 FOR OFFICIAL USE ONLY
On March 28th, TR XO emailed TR CO, copying TR’s Command Master Chief (CMC)
and TR SMO, regarding TR’s inability to comply with CDC or Navy guidelines aboard
the ship. Estimates of “close contact” Sailors ranged from 1,400-2,000. TR XO
recommended moving as many Sailors as possible off the ship into lodging. TR XO
stood up the Emergency Command Center (ECC) onboard the TR and placed the
Combat Direction Center Officer (CDCO) in charge on the first full day pierside in Guam
(March 28th). TR XO suggested that the ECC data demonstrated the ship's segregated
berthing plan was making the rate of transmission worse.201 According to email updates
sent to CCSG-9 from the TR SMO, tested positive cases were 44 at midday on March
28th,202 46 in the evening of March 28th,203 50 at midday on March 29th,204 and 53 in the
evening of March 29th.205 The SMO stated to CCSG-9 in an email, “we have lost”
against COVID-19 on TR.206 This conclusion was incorrect, as those in segregated
berthing had been placed there due to close contact tracing, and had a higher likelihood
of showing symptoms. A higher rate of COVID cases in quarantine areas should have
been expected.
Prior to the hotels becoming available, the testing requirement for Sailors going ashore
was not completely understood by TR CO, TR XO, and TR SMO. In his interview
statement, the C7F COS stated that 100 percent testing was not required and that
message was clearly communicated, however, on March 28th, he told the CSG-9 COS
that TR was not following “protocol” because Sailors were going into quarantine without
batch tests to determine if the virus was present.207 In their interview statements, TR
CO stated that testing was required, XO stated that 100 percent testing was not being
conducted, and TR SMO stated that he was confused over testing requirements but did
not agree with 100 percent testing.208 Supervisors, to include the TR CO and CCSG-9,
were unaware of this confusion and the associated delays. Contributing to this, the TR
SMO did not consistently attend or send a representative to the daily C7F medical
synchronization meetings because the medical staff was heavily loaded with patient
care and testing.209 As a result, this issue was never brought to the attention of C7F for
resolution until the preliminary inquiry identified it.
By March 29th, the testing rates for TR were up to 120 per day and there were 4,389
crew remaining to be tested, which would take 37 more days at that rate.210 The ship
                                                            
201

TR XO Statement dtd 16 May 20
Email – TR SMO to CCSG-9 – COVID-19 update 28 March - Mid-day update dtd 28 Mar 20
203
Email – TR SMO to CCSG-9 – RE COVID -19 update 29 March – Evening update dtd 28 Mar 20
204
Email – TR SMO to CCSG-9 – COVID-19 update 29 March - Mid-day update 29 Mar 20
205
Email – TR SMO to CCSG-9 – COVID-19 update 29 March - Evening update dtd 29 Mar 20
206
Email - TR SMO to C7F and CPF Surgeons – Reality dtd 28 Mar 20
207
Email (SIPR) – COS C7F to COS CSG-9 – Triage and procedure dtd 28 Mar 20
208
C7F COS Statement dtd 21 May 20; Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; TR SMO
Statement dtd 17 May 20
209
CPF Surgeon Statement dtd 19 May 20
210
Email (SIPR) – C7F COS – Numbers dtd 29 Mar 20
202

55

 FOR OFFICIAL USE ONLY
was down to the last 100 test swabs. More swabs were inbound, but not expected to be
delivered until after April 2nd .

Alternate Housing Options Discussed
During planning sessions on March 27th, Ill MEF and C?F refined Okinawa's available
capacity to approximately 3,000 rooms. Atsugi was also expected to have 400-600
rooms. However, the C?F planning diagram 211 was distributed showing rooms on
Guam as available that were not yet ready. Further, rooms on Okinawa were listed as
"White Beach : 5,700 and Commander, Fleet Activity Okinawa (CFAO): O." Although
CFAO owns White Beach, Ill MEF billeting is not located at White Beach (see Figure
17). C?F had arranged for Ill MEF to vacate their barracks in Oki nawa located at
MCAS Futenma, MCB Butler and outlying camps. This would have made 5,700 rooms
available on the Marine Corps bases, not Wh ite Beach that CFAO had cognizance over.
The TR CO and CSG-9 Warfare Commanders stated that they were unaware of this
intended movement of Il l MEF.

.. ,,..
o i..,

(AST CI UNA SCA
Okuma

(il Camp Courtney
@ Camp Foator/Butlor

0 Camp Hansen
(:) Camp Lester
C} Camp Kinser
() Camp Schwab

PACIFIC OC(AN

C7F listed 5,700
beds at White

Up to 5,000 beds at Ill MEF
locations (MCAS Futenma,
MCB Butler, and outlying

Beach

<amps)

E) Camp Shields
~ Torti StaUon

0
0
0

Kadena Air Base

White Beach Naval Facility
NCAS Futenma
C, Camp McTureous
G> Camp Gon salves

Figure 17. Location of beds in Okinawa.

211

(S) C7F TR COVID Placemat 29 Mar - DRAFT

56

 FOR OFFICIAL USE ONLY
On March 28th, CCSG-9 and TR were tasked to develop plans to airlift crew members to
Okinawa. After hours of work towards this task, the TR CO emailed an acquaintance, a
Navy Captain at Kadena Air Force Base on Okinawa, to confirm the availability of
appropriate and sufficient berthing and was told there were insufficient bunks
available.212 The TR CO discussed this with the TR XO and senior Warfare
Commanders. They said they believed the C7F staff had wasted their time on a nonviable COA. The TR CO did not attempt to verify the accuracy of this information up the
chain of command.213 The same day, initial discussions about increasing capacity via
hotels occurred between CJRM and his Chief of Staff.214
CJRM began consulting with the Government of Guam on March 28th215 to obtain hotel
rooms, independent and without any knowledge of the ship's expectations. While the
TR CO and CSG-9 Warfare Commanders indicated they were not fully aware of the
details regarding the Guam hotel COA,216 CCSG-9 was aware of ongoing efforts by
higher headquarters to negotiate for the use of hotels on Guam. TR CO was also
aware that higher headquarters were working toward securing hotels on Guam.217
From the onset of the first MEDEVAC flights on March 25th218 from TR, JRM and TR
received support from the people and Government of Guam led by Governor Leon
Guerrero. Following CJRM’s notifications of the first three MEDEVAC patients on
March 25th and 21 more COVID-positive patients on March 26th, communications
between JRM and the Government of Guam significantly increased.219
Following the initial CJRM calls on March 28th, during which the Governor pledged her
assistance saying that “we (Guam) need to support the people who defend us. This is
the humanitarian thing to do.”220 JRM staff quickly began identifying the scope and
requirements for support. The Governor's COS provided an initial referral to the
President of the Guam Hotel and Restaurant Association (GHRA) on March 29th. The
detailed, immediate planning was led by COS, JRM and the President of GHRA, in
conjunction with TR leadership between March 30th and April 1st. As this delicate
coordination was taking place, the President of the GHRA passed along a string of
emails where an unknown person from the TR was looking to book hundreds of rooms
                                                            
212

Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20
CCSG-9 Statement dtd 15 May 20; Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20
214
Email - CJRM – Follow Up to 13 May 20 Phone Call
215
Email - CJRM – Follow Up to 13 May 20 Phone Call; C7F COS statement dtd 21 May 20
216
Crozier, B. CAPT Statement dtd 15 May 20; CVW-11 CAG Statement dtd 19 May 20; CDS-23 Statement dtd 19 May 20; CSG-9
COS Statement dtd 18 May 20
217
C7F Statement dtd 18 May 20
218
Email – TR SMO to CCSG-9 – COVID-19 update 25 Mar - End of Day testing results dtd 25 Mar 20
219
Email - CJRM – Follow Up to 13 May 20 Phone Call
220
Email - CJRM – Follow Up to 13 May 20 Phone Call
213

57

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in Guam for the TR.221 When informed of this, TR XO emailed all leadership on TR to
ask personnel to stop, as this was “counterproductive” as Guam political leaders were
“under tremendous pressure from their constituents to contain [the TR COVID cases] to
the base” and noted that currently there was “little local support for moving” TR Sailors
into hotels on the island.222 After the initial concept of operations was developed and
GHRA identified the first hotels, a unified "walkthrough" of partner hotels was arranged
on April 1st and 2nd at various sites.223
On March 29th, TR had 53 positive cases with at least seven showing symptoms.224
CPF directed that no Navy personnel leave Guam until he personally reviewed and
approved that plan, effectively putting a hold on the Okinawa COA.225 The TR SMO
assessed that up to half of the ship was a close contact making the continued use of the
quarantine areas aboard as ineffective.226 The TR XO considered that conditions in the
aft quarantine area were creating “human suffering” and that the large number of Sailors
in the aft quarantine area was unmanageable.227
The same day, with an estimated total exceeding 1,000 Sailors in quarantine, the TR
CO released these Sailors in aft quarantine based on the recommendation of the TR
SMO and TR XO.228 Additionally, there were large numbers of Sailors in quarantine and
the TR XO considered the spaces to which they were confined to be very crowded.229
The TR CO made the decision without consulting CCSG-9 but later informed him of his
decision.230 The CO, NBG and C7F COS believed that if they could not achieve more
social distancing ashore, more Sailors would develop the virus.231 C7F and CPF were
neither informed nor consulted on this critical decision.232
The CSG-9 Warfare Commanders, TR CO and TR XO developed an information paper
which would later inform a COA development discussion with CCSG-9.233
The Warfare Commanders’ email and attached information paper stated that testing
cannot determine who does not have the virus, it can only confirm who does, and
further stressed that TR could not become a “clean” ship leveraging testing alone.
                                                            
221

Email – TR PAO to JRM PAO et al. – RE: IMMEDIATE AWARENESS” >> Fwd: 400 Rooms checking in ASAP dtd 31 Mar 20
Email - TR XO - Hotel Room inquires dtd 31 Mar 0202
223
Email - CJRM – Follow Up to 13 May 20 Phone Call
224
Email – TR SMO to CCSG-9 – COVID-19 update 29 March - Evening update dtd 29 Mar 20
225
Email (SIPR) – CPF to C7F – RE (S) C7F COVID-19 Update 29 Mar CORRECT COPY!!! dtd 29 Mar 20
226
TR SMO Statement dtd 17 May 20
227
TR XO Statement dtd 16 May 20
228
Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20
229
TR XO Statement dtd 16 May 20; Crozier, B. CAPT Statement dtd 15 May 20
230
CCSG-9 Statement dtd 15 May 20; Crozier, B. CAPT Statement dtd 15 May 20
231
Email (SIPR) - NBG CO to C7F COS - Quarantine - Social Distancing - getting to 4,000 dtd 29 Mar 20
232
CPF Surgeon Statement dtd 19 May 20, C7F Statement dtd 18 May 20
233
Crozier, B. CAPT Statement dtd 15 May 20; TR XO Statement dtd 16 May 20; CVW-11 CAG Statement dtd 19 May 20; CDS-23
Statement dtd 19 May 20
222

58

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Applying their interpretation of lessons learned from the cruise ship Diamond Princess
to the TR situation, the paper concluded that 1) 500 additional infections occurred due
to quarantine aboard versus isolation ashore and 2) 47 percent of positives were initially
asymptomatic. By this reasoning, Sailors initially thought to be safe, were not. The
letter stated the absence of symptoms did not indicate lack of infection much like
negative test results do not indicate lack of infection. This paper, which the CVW-11
CAG emailed to CCSG-9 on March 29th, would later form the basis of the CO's letter.
CCSG-9 concurred with the recommendation and proposed the Guam hotel COA to
C7F the next day (March 30th), and while acknowledging the request and knowing that
CCSG-9 was aware of ongoing negotiations for the hotel rooms, C7F directed him to
continue to focus on Okinawa as the primary COA. Bringing TR to NBG had been
predicated by a guarantee from CPF to the Government of Guam that no support would
be required from them.234 C7F 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.235 The longer-term solution would be Okinawa or
Guam hotels.
Ultimately, on March 29th, CPF was not ready to approve C7F’s plan for moving the TR
crew to Okinawa based on the risk of accelerating infection spread on the aircraft during
the 9-hour flight to that island, and complications with the government of Japan.236 At
the time, there were 1,167 beds available on Guam, of which 535 were occupied.237
As mentioned earlier, prior to TR’s arrival in Guam, CSG-9 COS emailed C7F COS to
relay the recommendation from TR CO and TR SMO that 4,000 hotel rooms should be
obtained in Guam.238 C7F, CCSG-9, CJRM and TR 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).

Days Leading to Relief of TR CO
By this point, the TR CO, TR XO and CSG-9 Warfare Commanders were frustrated.
They felt they had been distracted by numerous RFIs from higher headquarters, and by
working COAs that they did not believe in, and that in the end, they were going to be
made to stay in the makeshift berthing on Guam, long-term, which they viewed as
                                                            
234

UPDATED: USS Theodore Roosevelt Quarantines Sailors on Guam as Coronavirus Outbreak Spreads, USNI News (26 Mar 20)
C7F Statement dtd 18 May 20
236
Email (SIPR) – CPF to C7F – Evening Ops Update and COVID 29 Mar dtd 29 Mar 20
237
Email - CJRM – Follow Up to 13 May 20 Phone Call
238
Email (SIPR) – CSG-9 COS to C7F COS – (U) HOTEL OPTION dtd 25 Mar 20
235

59

 FOR OFFICIAL USE ONLY
worse than the ship. Further, they considered that available rooms on Okinawa never
existed, and that the whole event had been a distraction. This was compounded by the
continued increase in number of COVID-19 positive Sailors and the worst-case
narrative of TR fatalities that continued to be pressed forward by the TR SMO and
championed by key TR and CSG-9 leadership.
None of these leaders took action to openly communicate these concerns directly with
C7F, VADM Merz, although they had a voice at the daily briefs.
Believing that the C7F staff was not seriously entertaining or working towards obtaining
CDC compliant hotel rooms in Guam for crew isolation and quarantine, the TR CO and
TR SMO elected to bypass their chains of command, and took parallel actions to take
matters into their own hands, described in Chapter 4 below.
On March 28th, a JRM COS telephone call with the Governor of Guam COS revealed
positive indications on the hotel option, and that the Governor required a formal request
from CPF or INDOPACOM.239 That same day, the TR SMO wrote an email to C7F and
PACFLT Surgeons stating the need to get 4,500 personnel into individual berthing with
single heads.240 On March 31st, with 1,450 Sailors aboard TR in quarantine or isolation,
CPF formally requested Guam hotel options and negotiations commenced for an
undetermined number of hotel rooms.241 Also that day, the TR SMO sent an email to the
Navy Surgeon General, restating the need to get at least 4,500 personnel off the ship
and into single berthing.242
NBG, C7F, and TR agreed to the egress strategy and its prioritization of categories of
Sailors. Dissatisfied with the pace of egress, C7F repeatedly prompted CCSG-9 for
TR's plan to utilize the isolation and quarantine quarters available. With no plan in hand
four days after the ship's arrival, and with hundreds of temporary quarantine bunks
remaining unused, C7F issued “C7F TASKORD for Recovery of USS Theodore
Roosevelt from COVID-19 Infection” on April 1st, formally requiring development of this
plan, the same day the San Francisco Chronicle published a copy of the TR CO’s
memo.
On April 2nd, the TR CO sent letters to family members regarding the memo stating, “It
was never my intention to have the letter made public.” The CO's letter to the families
stated that every Sailor would be tested for COVID-19 and those with negative test
results would be moved to individual rooms off base for 14 days, while those who tested
                                                            
239

C7F Statement dtd 18 May 20; Email - CJRM – Follow Up to 13 May 20 Phone Call
Email - TR SMO - Reality dtd 28 Mar 20
241
C7F Statement dtd 18 May 20
242
Email – TR SMO to Navy Surgeon General – Situation on the Ground dtd 30 Mar 20
240

60

 FOR OFFICIAL USE ONLY
positive would be housed on base in individual rooms. The letter indicated that some
Sailors would remain aboard to clean the ship before moving off to complete their 14day isolation.
TR Sailors began occupying Guam hotels on the morning of April 2nd. Of the 2,343
isolation and quarantine beds available on NBG, 1,283 remained vacant when the CO
was relieved later that day.243
Following the A-SN’s April 2nd (D.C. date) public announcement of his direction to
relieve TR CO, CCSG-9 relieved the TR CO on April 3rd (Guam date). Prior to the
former TR CO’s departure, TR XO made notification to TR heads of department (HODs)
of the former CO’s departure from the ship.244 As former TR CO departed the ship
through the hangar bay and via the officer’s brow to the pier, hundreds of Sailors
gathered to witness the former CO’s departure. In multiple open-source videos, the
Sailors are seen amassing and then cheering and chanting his name with only a small
number wearing masks and with no social distancing (see Figure 18 below). Most of
the videos taken and then shared on social media, online video sharing sites, and with
news outlets, were taken by Sailors.

                                                            
243
244

C7F Statement dtd 18 May 20; Email - CJRM – Follow Up to 13 May 20 Phone Call
CCSG-9 Statement dtd 15 May 20

61

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Figure 18. TR crew cheers former TR CO as he departs the ship after being relieved of command on April 3, 2020
(https:llnypost.com/2020/04/03/capt-brett-crozier-gets-dramatic-send-off-from-sailors/)

In his testimony to the investigation team, CCSG-9 recalled the former TR CO's
departure and his reaction to the event. He stated that when he witnessed the videos,
he immediately contacted TR XO and asked for an explanation to which the TR XO
stated that he had alerted the HODs of the former TR CO's departure but had no reply
to CCSG-9 regarding the ensuing mass of Sailors in close proximity in the hangar bay
still not practicing social distancing. CCSG-9 further stated that he assessed the crew
had an understand ing of COVID-19 at the time but did not appreciate the
seriousness.245 In his testimony to the investigative team, C7F recounted the signifi cant
concerns he had following his viewing of the videos and restated his comment to the
Sailors aboard TR that ''our job just got a lot harder." 246

245
246

CCSG-9 Statement dtd 15 May 20
C7F Statement dtd 18 May 20

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Chapter 4 – Development of and Response to USS Theodore Roosevelt (CVN 71)
Commanding Officer Letter of March 30, 2020
This chapter addresses the preparation and email delivery of the former commanding
officer’s letter dated March 30, 2020, further handling of that email, and response to the
email and letter by the chain of command. This chapter refers to transcripts and
summaries of public statements made by Department of the Navy officials related to the
relief of the former commanding officer.

Preparations for Arrival in Guam
Prior to TR’s arrival on March 27th, the CO, NBG and staff addressed berthing
arrangements needed for COVID patients from TR. Upon TR’s arrival in Guam, TR CO
requested to CO, NBG berthing arrangements for the ship’s crew that centered upon
fully meeting the requirements of CDC Guidance and Navy guidance247 were prioritized.
From March 25th onward, TR and CCSG-9 recommended 4,000 beds as the preferred
COA, using hotels in Guam as well as potentially alternate locations including Okinawa
and Atsugi.248
NBG provided a laydown of alternative berthing arrangements prior to arrival and during
the port visit that met many but not all of the parameters TR CO and TR XO believed
Navy guidance required.249 The ship did not have a means of tracking where the crew
members were going until the TR XO activated the Emergency Command Center (ECC)
on March 28th to centralize requests and information flow. The ECC operated out of the
TR XO conference room principally to answer RFIs.250

Warfare Commanders White Paper for CCSG-9
The TR CO, TR XO and TR SMO all stated they collectively believed that by TR’s fourth
day in Guam there were no clear plans to move 4,000 personnel off the ship into
isolation and quarantine in CDC compliant facilities in which each person would have
their own room and bathroom and be supplied with appropriate food, ventilation and air
conditioning.
247

NAVADMIN 083/20 Restriction of Movement (ROM) Guidance dtd 23 Mar 20
Email (SIPR) – CSG-9 COS to C7F COS – (U) HOTEL OPTION dtd 25 Mar 20
249
The TR CO and TR XO interviews cite NAVADMIN 083/20: “For transient personnel and those residing in close quarters such as
unaccompanied housing or ships, temporary lodging meeting CDC guidance of separate sleeping and bathroom facilities shall be
arranged, when available”
250
TR XO Statement dtd 16 May 20; CDCO Statement dtd 18 May 20 (digitally signed)
248

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On March 29th, the CVW-11 CAG sent a white paper presenting a COVID-19 analysis
and suggested COAs to CCSG-9. The white paper was produced in collaboration with
Warfare Commanders and TR senior leadership. The goal was to provide options for
CCSG-9 to bring to C7F to spur action toward a safer situation for the crew of TR. After
receiving the white paper, CCSG-9 directed the Warfare Commanders to distill it into
four executable COAs. CVW-11 CAG sent the “Warfare Commander’s Courses of
Action”251 white paper which outlined the following possible avenues to address the
growing outbreak on the ship:
1. 4,500 Sailor individual isolation; 500 remain to run ship; swap & deploy
2. 2,500 in individual isolation / 2,500 on board TR and in group berthing off-ship
3. Status Quo – group berthing off-ship using available NBG facilities
4. Immediately get underway
CVW-11 CAG stated that the COAs were designed to minimize the number of Sailors
exposed to COVID-19 and regain warfighting readiness as soon as possible. The
Warfare Commanders met with CCSG-9 to discuss the options available to combat the
growing crisis. CCSG-9 listened to the counsel of his subordinates before explaining
that there was a desire to keep the solution to the problem within Navy channels and
that the hotel issue needed to be resolved with the Governor of Guam. CVW-11 CAG
stated that the paper and subsequent COA development prompted CCSG-9 to keep
pressing C7F for solutions to individual isolation challenges.252
The CSG-9 COS stated he believed the Warfare Commanders provided CCSG-9 with
the white paper because they were frustrated with the way ahead and wanted CCSG-9
to “jump the chain of command” to CPF for additional emphasis.253
CCSG-9 requested 4,000 CDC compliant rooms on March 25th with higher
headquarters.254 However, according to CCSG-9, the feedback he received was that
the Guam hotels were really not an option because the A-SN had said publicly that the
U.S. Government would not use the resources of Guam.255 Specifically, A-SN stated
during a press conference on March 26th that, “[t]he ship [TR] is pulling into Guam; it will
be pierside, no one on the crew will be allowed to leave anywhere into Guam other than
251
Email - CVW-11 CAG – Four COAs – WARFARE COMMANDER DEVELOPED PROs & CONs / RISK TO MISSION & RISK TO
FORCE dtd 29 Mar 20
252
CVW-11 CAG Statement dtd 19 May 20
253
CSG-9 COS Statement dtd 18 May 20
254
CCSG-9 Statement dtd 15 May 20
255
CCSG-9 Statement dtd 15 May 20

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on pierside. And we are already starting the process of testing 100 percent of the crew
to ensure that we’ve got that contained.”256 Despite this public statement from A-SN,
CCSG-9 did not believe using the local resources of Guam was completely off the
table.257 However, C7F and CPF were, in fact sensitive to making the request, as the
Navy had promised to not impose upon the Government of Guam, who was dealing with
its own public health emergency.258 In addition, on the morning of March 30th, CCSG-9
recommended to C7F (via video-teleconference) removal of 4,500 Sailors to individual
isolation rooms based on both the white paper and COAs in development by the
Warfare Commanders. C7F acknowledged the recommendation but directed to
continue batch testing, identification of “clean” groups, and development of plan to get a
“clean” ship.259
TR CO stated that he was unaware of any promises the U.S. Government had made to
Guam about the use of local resources to aid in the care of Navy Sailors.260 He did,
however, acknowledge that the A-SN’s COS had understood they needed more cots on
base and attributed the acceleration of that delivery to his interaction. Subsequent
information provided by A-SN’s COS indicated that he did not specifically direct any
additional resources as he was informed CPF and TR’s chain of command were
addressing all needed support.261
CVW-11 CAG outlined that while the NBG facilities were appreciated, they were not
sufficiently isolating personnel per the TR SMO’s guidance. He stated they “knew that
securing hotels for the entire TR crew was impractical upon arrival and were careful to
ask for isolation, not specifically hotel rooms.”262

Development of the TR CO Letter and Email
The TR XO indicated that the TR CO’s letter was an abridged version of the white paper
to which all CSG-9 Warfare Commanders had contributed. The TR XO said CCSG-9
and C7F were concerned why more available berthing on Guam was not occupied. He
explained the growing sense of frustration present on board as they (TR CO, TR XO
and Warfare Commanders) started to hear and note positive tests of Sailors in the open
256

Transcript: Marine Corps Officials Hold a Defense Department News Briefing on COVID-19 Efforts dtd 26 Mar 20
https://www.defense.gov/Newsroom/Transcripts/Transcript/Article/2127585/marine-corps-officials-hold-a-defense-department-newsbriefing-on-covid-19-effo/
257
CCSG-9 Statement dtd 15 May 20
258
CPF Statement dtd 17 May 20; C7F Statement dtd 18 May 20; Email - CJRM – Follow Up to 13 May 20 Phone Call
259
CVW-11 CAG Statement dtd 19 May 20
260
Crozier, B. CAPT Statement dtd 15 May 20
261
Email - A-SN COS to DNS – RE: Support Requirements dtd 30 Mar 20
262
CVW-11 CAG Statement dtd 19 May 20

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bay gym settings (the open bay areas were notionally for “clean crew” who would make
up critical watchstanders needed to get the ship underway). He further 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 social media and
to families in San Diego. Additionally, the TR XO stated that he was frustrated with
discussion over COAs that could not fully comply with NAVADMIN guidance.263
While the TR CO and TR XO waited for a possible phone call they believed would be
coming from the CNO264 on the morning of March 30th, the TR CO asked TR XO to
shorten and simplify the much longer Warfare Commanders’ information paper. The
investigation found that the CNO had not planned to call the TR CO. The anticipated
call was confused with another request from the CNO’s Battle Watch Captain (BWC)
calling TR to ask if the previous A-SN COS call had been completed.265 The TR XO
stressed that neither he nor TR CO knew at this time of any momentum or desire to
obtain individual isolation rooms for Sailors on Guam (i.e., the hotel options). The TR
XO sat at the large table in the TR CO’s In-Port Cabin and worked on this project with
pen and ink. The TR XO did not know to whom the TR CO meant to address the letter,
so he it left that section blank. The TR CO simultaneously composed the email cover
letter. The TR XO presented his notes to the TR CO and then used the Ship's
Secretary’s computer to turn the notes into a four page memo (CO’s Letter). The TR
CO made edits to the opening and closing paragraphs while the TR XO proof-read the
email the TR CO had written. Once the TR CO was satisfied with both documents, he
signed and scanned the four page memo, attached it to his email and sent it to CPF,
CNAP and CCSG-9. The TR XO estimated both documents were written in two to three
hours. The only individuals involved in drafting those documents were the TR CO and
TR XO with administrative support from the Ship’s Secretary.266
The TR CO received calls and emails from A-SN’s COS on March 30th at 0525 and the
evening of March 30th to address a visit by the Secretary on April 1st and voice support
for, as well as assistance to, TR. CPF had also called the TR CO on March 29th to
notify him that A-SN would be calling (which ended up being the A-SN COS). CPF
asked if any additional assistance was required, and the TR CO indicated he was
getting what he needed.267 The TR CO did not specify an immediate need for 4,000
263

TR XO Statement dtd 16 May 20; Email - TR XO to TR CO - Memo for Record - Failure to comply with NAVADMIN 083_20 dtd
28 Mar 20
264
Email - CNO Former EA to TR CI Senior Legal Advisor – TR Investigation dtd 20 May 20 (noting CNO was not requested, nor did
he intend, to contact TR CO by phone directly at any time relevant to this investigation instead trusting “the leadership in [the TR]
Chain of Command to discuss the immediate issues of the ship with” the TR CO).
265
Email CNO ABWC PTGN to BWC PTGN RE: Hot RFI.THEODORE ROOSEVELT RFI dtd 30 Mar 20; email CNO EA to BWC
PTGN FW: TR dtd 29 Mar 20; Email - CNO Former EA to TR CI Senior Legal Advisor – TR Investigation dtd 20 May 20
266
TR XO Statement dtd 16 May 20; TR RO Statement dtd 18 May 20; CVW-11 CAG Statement dtd 19 May 20
267
CPF Statement dtd 17 May 20

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beds fully in compliance with CDC and Navy guidelines in those conversations and did
not specify that the current plans were not acceptable.268
On March 30th at 1348, the TR CO sent an email containing the letter drafted by TR XO
to ten recipients: addressed to CPF, CNAP, CSG-9, and copied to CVW-11 CAG, TR
XO, CVW-11 Deputy CAG, CDS 23, TR SMO, CPF COS, and CNAP COS.
In the attached paper (“Request for Assistance in Response to COVID-19 Pandemic,”
dated March 30th), the TR CO specifically requested “all available resources to find
NAVADMIN and CDC compliant quarantine rooms for my entire crew as soon as
possible.”269 This was the only specific resource request outlined and did not specify
what command was responsible for delivery of these rooms nor did it indicate how many
rooms or beds required, were currently available and in use. He stated that his letter
“was designed to bring a sense of urgency to what we thought was a growing
tragedy.”270 He “wanted to stop the administrative bureaucracy” and “bring focus back
to what we thought was the best course of action to get people off the ship.”271
The TR CO used unclassified email to send the email and letter instead of a classified
network. In addition, he anticipated that the style and method would be more urgent
and quicker to read on mobile devices and that he wanted a timely response.272 TR CO
mentioned that the majority of work and updates regarding the ship was conducted on
the unclassified network (daily COVID-19 reports on the number of positive cases). He
stated that he did not foresee a leak to the press nor did he anticipate any difficulties the
letter would generate with the negotiations with the Governor of Guam.
One key aspect of the TR CO’s letter attached to the email is the sense of urgency tied
the consequences of inaction. “Sailors do not need to die” and “If we do not act now,
we are failing to properly take care of our most trusted asset – our Sailors” reflect the
underlying theme of both the email and letter.273

Reactor Department Email
The TR Reactor Officer (RO) expressed concern about the ability to keep the Reactor
Department watch supervisors safely isolated so they could perform their jobs as
268

Crozier, B. CAPT Statement dtd 15 May 20; CPF Statement dtd 17 May 20
TR CO Email and Ltr - Request for Assistance in Response to COVID-19 Pandemic dtd 30 Mar 20
270
Crozier, B. CAPT Statement dtd 15 May 20
271
Crozier, B. CAPT Statement dtd 15 May 20
272
Crozier, B. CAPT Statement dtd 15 May 20
273
TR CO Email and Ltr - Request for Assistance in Response to COVID-19 Pandemic dtd 30 Mar 20
269

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required. The TR RO’s Sailors were going to the gym. This was a problem because
the gym was getting one or two positive hits a day for COVID. The TR RO went to talk
to the TR CO who showed her the letter that he and the TR XO were drafting with some
assistance from the Ship's Secretary. The TR RO mentioned that she had a very good
relationship with Naval Reactors (NR) and stressed that as an RO she may speak to the
Admiral directly with any concerns. On March 26th, the TR RO sent an email to CNAP
and NR via the classified network that outlined the current situation and way ahead for
operations.274 On March 30th, after observing that several Sailors were testing positive
in the gyms (ostensibly a segregated zone for “clean” COVID-negative critical
watchstanders), she became concerned about the lodging situation of her Sailors and
was worried about her ability to re-man the department in a timely manner. After
consulting with TR CO and seeing the email and memo that TR XO and TR CO were
drafting, she drafted a classified email which the TR CO subsequently sent to CNAP on
March 30th at 1938 with the subject line: “COVID-19 Pandemic – TR request for
assistance.”275 This email was very similar to the chain of command email and voiced
concerns about manning watch teams and outlined the need to house Sailors “off ship
in true isolation rooms with separate bathroom facilities.” However, not enough time
would have passed for Sailors who tested positive or were showing symptoms while
being assigned to common areas like a gym to have actually become infected while
assigned there; instead, given the timing, any Sailors showing symptoms at this time
would have had to become infected earlier while aboard the ship. To the degree
anyone may have believed that Sailors had become infected in such a common area,
their analysis was actually flawed due to the timing.

Medical Department Letter
On March 28th, the TR SMO sent an email to the CPF, C7F and CNAP Surgeons
stating, “We have lost,” and declaring the “‘quarantine’ measures on the ship are a
sham.”276 The TR SMO also noted that TR was “failing to comply with any sort of
[testing guidelines] . . . or guidelines on quarantine” and needed “to implement
appropriate quarantine measures . . . which will involve getting 4,500 people off the ship
into individual berthing with single heads.”277 The TR SMO also communicated to
CCSG-9 his opinions that the testing required to allow Sailors to move ashore was “a
waste of time.” The TR SMO felt that testing would not prove whether or not a Sailor
274

Email (SIPR) – TR RO to NR, CNAP RO – FW: CVN-71 COVID-19 Roll Up and Way Ahead dtd 26 Mar 20
Email (SIPR) – TR CO to CNAP RO – (C) COVID-19 Pandemic – TR Request for Assistance dtd 30 Mar 20
276
Email - TR SMO to C7F and CPF Surgeons – Reality dtd 28 Mar 20
277
Email - TR SMO to C7F and CPF Surgeons – Reality dtd 28 Mar 20
275

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had the virus. He did not believe that if an individual “pops negative” it did not mean
that the person was “clean.” He believed it to be “a waste of his resources and time to
test everyone on the ship” and repeated to CCSG-9 that “you can't test your way out of
this virus.”278
The TR SMO also sent an email to the Surgeon General of the Navy on March 31st,
copying the CPF and C7F Surgeons along with a small group of other senior leaders in
Navy medicine. The TR SMO’s email contained a letter signed by the TR SMO and four
other members of the medical staff aboard.279 This letter did not outline specific
requests but relayed a sense of urgency about the situation aboard TR at the time and
lamented the lack of action to treat Sailors in accordance with CDC and NAVADMIN
083/20 guidance. It also stressed the high likelihood of casualties and asserted they
could have up to 50 deaths onboard based on their assessment of published fatality
estimates at the time. Lastly the letter states, “Our intent is to submit this letter to the
public to demonstrate our concerns for the safety of our patients and your Sailors.”280
Although the TR SMO initially emailed the medical letter to eight people, the Surgeon
General of the Navy and seven others, approximately three minutes later, the TR SMO
further emailed the letter to over 160 additional medical community members. None of
these additional addressees were in the TR operational or administrative chains of
command.
The medical team presented their letter to the TR XO at a meeting where he showed
them a hard copy of the TR CO’s email and letter. TR XO recommended that the
medical team not send their letter and not go to the press because the TR CO just
talked to leadership. He told them, “not to send the letter and that it was not helpful,
and the tone was unprofessional and overly combative.”281
This letter was subsequently presented to the TR CO at a meeting with the TR SMO
and other medical staff who had signed the letter. The TR CO asked the medical team
not to send their letter because he had sent an email up his chain of command and “I
can’t tell you not to send it if you have a moral imperative – but ask you not to send it. I
think my letter will address your concerns.”282
Certain members of the Medical Department did not sign the letter. This appears to be
due to concerns about potential professional repercussions. The TR Nurse, for
278

CCSG-9 Statement dtd 15 May 20
Email - TR SMO to Navy Surgeon General - Letter from Medical Department on USS Theodore Roosevelt dtd 31 Mar 20
Medical Department letter dtd 31 Mar 20
281
TR XO Statement dtd 16 May 20
282
Crozier, B. CAPT Statement dtd 15 May 20
279
280

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example, stated that although she agreed with the content of the letter and level of
concern, she did not sign it because she was afraid it would “affect her career.”283 The
letter states it is the Medical Department’s “intent . . . to submit this letter to the public to
demonstrate our concerns for the safety of our patients and your Sailors.”284 However,
signers of the letter indicated they had no intent to release the letter publicly, but instead
wanted to “generate aggressive action to move Sailors.”285

Chain of Command Response to the Email and Letter
The response to the TR CO’s March 30th email, with his letter attached, was swift from
the chain of command. CPF and CNAP responded as soon as they received the
email.286 CNAP responded thanking TR CO “for the red flare” and offered his help,287
also looping in C7F and CJRM who were not on the initial communication from the TR
CO. CPF responded to TR CO and CCSG-9 to “call [him] ASAP.”288 CPF subsequently
spoke with CCSG-9 and TR CO on the speaker phone together following his receipt of
the email and asked what he and TR wanted him to be doing that he was not already
doing.289 CNAP also spoke with TR CO following his email to provide mentorship and
counsel and to gain insight into why he sent the email and letter.290 TR CO confirmed
the relationship with C7F and CCSG-9 were “healthy, with good communications in both
directions, and plenty of communication opportunities. He also noted VADM Merz
(C7F) was particularly engaged, holding multiple VTCs each day regarding the situation
on the TR.”291 When he asked the TR CO why he sent the letter, the TR CO replied he
“did not feel the response was moving fast enough.”292
The TR XO stated he felt the email and letter were effective as he believed they saw
“good initial movement after the email.”293 In addition to speaking with CNAP and CPF,
the TR CO also received communications from CJRM offering assistance as a result of
CNAP looping CJRM into the email string.294 Specifically, CJRM responded to that
email offering his, NBG, and AAFB continued support and to house what they could
283

TR Nurse Statement dtd 18 May 20
Medical Department letter dtd 31 Mar 20
285
See e.g., TR Surgeon Statement dtd 18 May 20
286
See Email - CNAP to TR CO - RE: TR request for assistance dtd 30 Mar 20; Email - CPF to TR CO and CCSG-9 - RE: TR
request for assistance dtd 30 Mar 20
287
CNAP to TR CO - RE: TR request for assistance dtd 30 Mar 20
288
Email - CPF to TR CO and CCSG-9 - RE: TR request for assistance dtd 30 Mar 20
289
CPF Statement dtd 17 May 20; CCSG-9 Statement dtd 15 May 20
290
CNAP Statement dtd 13 May 20
291
CNAP Statement dtd 13 May 20
292
CNAP Statement dtd 13 May 20
293
TR XO Statement dtd 16 May 20
294
Email - CJRM – Follow Up to 13 May 20 Phone Call
284

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“within [their] fence lines as well as transport Sailors to Anderson Air Force Base for
further transfer off island should that be the COA selected.”295 CJRM also advised that
he was “working the local solution to lodging outside the fence line but [was] treading
lightly as that solution will be in direct opposition to the stated Navy position296 not to
place the burden on Guam’s resources to solve our issue.”297
On the other hand, CCSG-9 believed the letter did not need to be sent as all aspects of
the TR-desired COA were in works and he expressed his surprise and anger upon
learning that the TR CO sent the letter.298 CCSG-9 and the TR CO discussed the letter
together, with others present,299 and also took the call from CPF about it. CPF
confirmed that no new actions were taken as a result of TR CO’s email and letter. He
had already addressed specific requests through CJRM for hotel space in Guam. He
did call the Governor of Guam on Tuesday to request rooms be made available to
Sailors who were not COVID-positive.300
In addition, comments from CJRM, C7F and CPF also indicated the letter created
significant challenges negotiating hotels with the Governor of Guam.

Publication of Letter in San Francisco Chronicle
On March 31st at 0911, a reporter from the San Francisco Chronicle contacted the
Pentagon Press Operations Duty Officer via email stating he had “obtained a copy of a
four-page letter sent from [TR CO] pleading for help from the U.S. Navy brass to bring
equipment to allow isolated quarantines for his entire crew.”301 This media inquiry was
forwarded to CPF public affairs and eventually on to TR’s PAO at 1323.302 A story from
the San Francisco Chronicle, dated March 31st and entitled “Exclusive: Captain of
aircraft carrier with growing coronavirus outbreak pleads for help from Navy” was posted
on their website on April 1st at 0400 initially without comment from the Navy.303 The TR
CO stated he did not send the letter outside Navy channels.304 The memorandum from
295

Email - CJRM to TR CO - RE: TR request for assistance dtd 30 Mar 20
UPDATED: USS Theodore Roosevelt Quarantines Sailors on Guam as Coronavirus Outbreak Spreads, USNI News (26 Mar 20)
https://news.usni.org/2020/03/26/coronavirus-outbreak-sidelines-aircraft-carrier-uss-theodore-roosevelt
297
Email - CJRM to TR CO - RE: TR request for assistance dtd 30 Mar 20
298
CCSG-9 Statement dtd 15 May 20
299
TR OPSO Statement dtd 18 May 20
300
CPF Statement dtd 17 May 2020
301
Email - TR PAO - dtd 31 Mar 20
302
Email - TR PAO - dtd 31 Mar 20
303
“Exclusive: Captain of aircraft carrier with growing coronavirus outbreak pleads for help from Navy” SF Chronicle (31 Mar 20)
https://www.sfchronicle.com/bayarea/article/Exclusive-Captain-of-aircraft-carrier-with-15167883.php, accessed May 8, 2020
304
Crozier, B. CAPT Statement dtd 15 May 20; See also, TR OPSO Statement dtd 18 May 20 (“I was there when the CO realized
the letter was leaked; he had the news up on his computer. The CO commented that they sent the letter to his hometown paper,
stating, "They're going to think I did this, but I didn't do it.")
296

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the TR CO was included in this article without the accompanying email. The San
Francisco Chronicle article was later updated to include public comments A-SN made
during an interview with CNN where he stated the Navy had “been working actually the
last seven days to move those Sailors off the ship and get them into accommodations in
Guam” and that they were “very engaged in this, . . . very concerned about it and . . .
taking all the appropriate steps.”305
In addition, CCSG-9 stated that the publication of the letter in the San Francisco
Chronicle created additional tension between with the Navy and the Government of
Guam as there had been negotiations to utilize hotels in Guam.306 Not only did the TR
CO claim he did “not expect to see [the letter] in the open press, he also did not
anticipate his letter would create difficulties with the Governor of Guam.307
Stories pertaining to the TR CO letter rapidly gained traction in the press and it was
widely reported in print, television, and various internet news outlets.308

Impact on Discussions with Government of Guam
While the article did not change the Governor’s support for TR, according to testimony
provided by CJRM, it affected her team's opportunity to shape the public narrative for
the partnership. Eight community groups in Guam had sent a letter to the Governor of
Guam urging the military to keep patients at bases until COVID-19 was eradicated.309
The Governor had intended to voice her support during a press conference on April 1st,
in order to convey the well-managed and thoughtful civil-military response to the
situation on the ship.310 The San Francisco Chronicle article and TR CO’s
memorandum changed the narrative from a measured response to a reactive one. The
305
“Exclusive: Captain of aircraft carrier with growing coronavirus outbreak pleads for help from Navy” SF Chronicle (31 Mar 20)
https://www.sfchronicle.com/bayarea/article/Exclusive-Captain-of-aircraft-carrier-with-15167883.php, accessed May 8, 2020
306
CCSG-9 Statement dtd 15 May 20
307
Crozier, B. CAPT Statement dtd 15 May 20
308
"Captain of Aircraft Carrier Pleads for Help as Virus Cases Increase Onboard" NY Times (31 Mar 20)
https://www.nytimes.com/2020/03/31/us/politics/coronavirus-aircraft-carrier-theodore-roosevelt.html; "Battling an outbreak, captain
of aircraft carrier asks Navy to evacuate crew" Washington Post (31 Mar 20) https://www.washingtonpost.com/nationalsecurity/battling-an-outbreak-captain-of-aircraft-carrier-asks-navy-to-evacuate-crew/2020/03/31/cfa57e1c-7363-11ea-ae507148009252e3_story.html; "‘Sailors do not need to die,’ warns captain of coronarvirus-hit U.S. aircraft carrier" Reuters (31 Mar 20)
https://www.reuters.com/article/us-health-coronavirus-usa-navy/sailors-do-not-need-to-die-warns-captain-of-coronavirus-hit-u-saircraft-carrier-idUSKBN21I2SV; "Coronavirus: US Navy captain pleads for help over outbreak" BBC (31 Mar 20)
https://www.bbc.com/news/world-us-canada-52110298; "Theodore Roosevelt captain makes urgent plea for individual quarantine
sites as COVID-18 cases multiply" Military Times (31 Mar 20) https://www.militarytimes.com/news/your-navy/2020/03/31/theodoreroosevelt-captain-makes-urgent-plea-for-individual-quarantine-sites-as-covid-19-cases-multiply/
309
"Governor: 'One Guam' approach needed to defeat virus" Pacific Daily News (31 Mar 20)
https://www.guampdn.com/story/news/local/2020/03/31/governor-one-guam-approach-needed-defeat-virus/2938329001/
310
Email - CJRM – Follow Up to 13 May 20 Phone Call

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Governor’s staff was concerned that the “dire situation” the TR CO described in his
memorandum would result in increased public health concern among the community.311
CJRM outlined that the concerns included the potential for more vocal opposition from
anti-military activists and a negative impact on GHRA’s support of the hotel COA resulting in the loss of critical capacity to house Sailors. Ultimately, a plan to quarantine
and isolate Sailors went forward, but the opportunity for a coordinated messaging
initiative was lost.312

Preliminary Inquiry and Relief of TR CO
On April 2nd, 2020, the CNO ordered a preliminary inquiry into the events surrounding
the disembarkation of Sailors from TR in Guam, in response to cases of COVID-19.313
While this preliminary inquiry was pending, A-SN decided to relieve the TR CO and
announced his decision in a press conference with CNO where he stated that “at [his]
direction, the CO of [TR] . . . was relieved by [CCSG-9].”314 A-SN subsequently traveled
to Guam where he spoke with members of the TR crew via the public address system
(1MC) and met with the former CO who was at the time in quarantine as a result of his
positive test for COVID-19.315 A-SN’s remarks over the 1MC were recorded by
members of the crew and released to the press by means of a written transcript
followed by the actual audio recording.316 The transcript released on the internet
through various news sources appears to be a true and accurate representation of ASN’s comments as heard on the recording. These remarks were also widely
reported.317
This investigation was not directed to evaluate the A-SN’s decision to fire the TR CO,
and in fact, in briefing, the investigating team was counselled to specifically stay away
from this topic. However, we were asked to identify statements by Department of the
Navy officials on the relief of the CO that may have been in error. Where appropriate,
we have identified those errors.
In A-SN’s public remarks concerning the email and letter sent by TR CO, he appears to
conflate a number of facts with those from the letter generated by the TR Medical
311

Email - CJRM – Follow Up to 13 May 20 Phone Call
Email - CJRM – Follow Up to 13 May 20 Phone Call
313
CNO Ltr Ser 5800 dtd 2 Apr 20
314
Transcript: DON Press Briefing with Acting Secretary of the Navy Thomas B. Modly and CNO Admiral Gilday dtd 2 Apr 20
315
Crozier, B. CAPT Statement dtd 15 May 20
316
How a Ship’s Coronavirus Outbreak Became a Moral Crisis for the Military, NY Times (6 Apr 20)
317
Transcript: Acting Navy Secretary Thomas Modly addresses USS Theodore Roosevelt crew about "stupid" ousted captain CNN
(6 Apr 20) https://www.cnn.com/2020/04/06/politics/thomas-modly-transcript/index.html
312

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Department. Specifically, in response to a question at his April 2nd press conference, ASN stated “I think you raise a particular level of alarm when you say that 50 people on
the - on the crew are going to die, OK?” This appears to be a reference to a comment
in the March 31st letter signed by members of the TR Medical Department in which they
conclude that they stood “the potential to have 50 or more fatal cases”318 aboard TR if
their expected case fatality rate remained constant, as the TR CO’s March 30th letter
makes no such mention of numbers of potential fatalities.319 Similarly, A-SN stated at
the same press conference that the TR CO’s email and letter was “sent and copied to a
broad array of other people . . . [and] outside of the chain of command.”320 In fact, the
email was sent to 10 recipients, all of whom were either in TR’s direct operational chain
of command (CPF and CCSG-9) or administrative chain of command (CNAP).321 It did,
however, omit C7F, who was in his chain of command. There is no indication from the
evidence available during this investigation that TR CO forwarded this letter beyond that
initial group. However, the letter from the TR Medical Department was widely
distributed via email to a broad array of people from across the Navy medical
community by the TR SMO.322 Of note, SMO’s email with a copy of the Medical
Department letter was sent to over 160 recipients, all of which were outside the
administrative and operational chains of command of TR.

Resignation of A-SN
Following his remarks aboard TR and subsequent calls for his resignation, including
from House Armed Services Committee Chairman Adam Smith (D-WA),323 A-SN
offered his resignation to the Secretary of Defense on April 7, 2020324 and his
resignation was accepted that same day.325 In his final “Vector” to the Department, ASN acknowledged his “poor use of words”326 on the TR and separately offered a public
statement “to apologize to the Navy” for his comments to the crew of the TR.327
The initial report of the preliminary inquiry into the events surrounding the
disembarkation of Sailors from TR in Guam, in response to cases of COVID-19, was
318

Medical Department Letter dtd 31 Mar 20
TR CO Email and Ltr - Request for Assistance in Response to COVID-19 Pandemic dtd 30 Mar 20
320
Transcript: DON Press Briefing with Acting Secretary of the Navy Thomas B. Modly and CNO Admiral Gilday dtd 2 Apr 20
321
TR CO Email and Ltr - Request for Assistance in Response to COVID-19 Pandemic dtd 30 Mar 20
322
Email – TR SMO - Medical Dept Letter dtd 30Mar 20; Email – TR SMO – FWD: Medical Dept Letter dtd 30 Mar 20
323
Press Release: "Smith Calls for Modly's Removal After Mishandling U.S.S. Theodore Roosevelt COVID-19 Outbreak" dtd 6 Apr
20
324
A-SN Ltr of 7 Apr 20
325
SECDEF Ltr of 7 Apr 20
326
A-SN Ltr of 7 Apr 20 Final Vector SECNAV Final Vector
327
UPDATED: Modly Resigns Amidst Carrier Roosevelt Controversy; Army Undersecretary to Serve as Acting SECNAV USNI
News (7 Apr 20) https://news.usni.org/2020/04/07/modly-offers-resignation-amidst-carrier-roosevelt-controversy
319

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completed on April 7th, prior to the A-SN’s resignation. An addendum to the report was
provided on April 14th at CNO’s request to conduct additional interviews to clarify the
timing of conversations between the TR CO and members of his operational and
administrative chains of command, as well as whether there were observations of
concern during the CSG-9 training cycle prior to deployment. This evaluation revealed
that CSG-9 had completed all deployment preparations and certifications with high
marks, including having a strong leadership team with disciplined, effective battle
rhythm and planning processes.328
 
 

 

                                                            
328

Email (SIPR) - VADM Conn to ADM Burke – “FW: (U) Updated CSG-15 CTX Brief to C3F for 17 December” dtd 13 Apr 20,
CSG15 TR C2X Debrief, dtd 20 Dec 19

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Chapter 5 - Opinions and Recommendations

Summary of Opinions
The following 18 key opinions were derived from this investigation into the COVID-19
outbreak aboard TR:
1. Based upon the pre-event risk analysis, the decision to execute the Da
Nang port visit was appropriate. The visit was executed with sensible
precautions, based on the world’s understanding of COVID-19 at the time.
2. The former TR CO initially responded appropriately by quarantining 39
Sailors following the Da Nang port visit. However, after three Sailors tested
positive for COVID-19 aboard TR on March 24, 2020, the former TR CO
failed to put adequate additional measures in place for the rest of the crew
to further slow the spread of COVID-19 throughout the ship.
3. The TR SMO’s recommendation and the resulting release by the former TR
CO of crewmembers in quarantine from the aft portion of the ship on March
29, 2020 likely resulted in infection to a larger portion of the crew.
4. The embarked CSG-9 Warfare Commanders (WCs) (TR CO, CAG CVW-11,
DESRON Commodore) and the TR SMO displayed an abundance of
concern for the safety of the crew as their primary focus, yet they were
unable to develop COAs prior to or even by four days after arrival in Guam
that provided for the short-term safety of the crew. Instead, they focused
efforts on the most constrained and least executable COA (at the time),
while taking insufficient parallel steps that would have resulted in more
immediate segregation, quarantine and isolation of the crew. As a result,
efforts to move the crew off the ship were uncoordinated, unsupervised
and slow. The extended time Sailors remained on the ship, while no longer
segregated, likely increased the number of infections.
5. CCSG-9, the embarked CSG-9 WCs, and the former TR CO and TR SMO did
not demonstrate effective leadership when they initially took few actions to
overcome obstacles to aggressively utilize the approximately 2,300 beds
that were made available by Naval Base Guam, likely resulting in infection
to a larger portion of the crew.
6. C7F’s early focus on the Okinawa option over the Guam hotel option
resulted in the TR Strike Group key Captains (CSG-9 COS, former TR CO,
TR XO, TR SMO and CVW-11 CAG) believing that C7F did not feel their
same sense of urgency for providing proper long term quarantine and
isolation quarters. This led these Captains to distrust the C7F staff and
hampered their ability to deal with the crisis with the resources that were
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available, or develop alternate courses of action other than the request for
4,000 CDC compliant rooms, which at the time was the most constrained
and least likely COA.
7. The former TR CO did not demonstrate forceful backup, effective
communication or adequately communicate with his Immediate Superior in
Command (CCSG-9, embarked in TR) in that he did not discuss his concern
with the lack urgency he perceived from C7F and CCSG-9 on the Guam
Hotel option being pursued, prior to sending his letter.
8. CCSG-9 did not provide effective leadership to the former TR CO and the
embarked CSG-9 WCs in that he did not effectively address and correct a
growing, divisive and counterproductive narrative among his senior
officers regarding distrust of C7F or any course of action that did not fit
their immediate sense of urgency. Additionally, he did not direct decisive
action to ensure prompt execution of the egress of the TR crew. Finally, it
is not clear that he effectively advocated for TR’s needs to higher
headquarters or provided clear feedback to his team when those needs
could not meet TR leadership’s timeline.
9. The TR SMO developed a flawed, worst-case crew casualty narrative that
the CAG CVW-11 reinforced and frequently amplified at Warfare
Commander Boards, and that had an impact on the mindset of the former
TR CO and TR XO. The TR SMO fostered distrust of HHQ actions, and put
his leadership in an untenable situation.
10. The TR CO sent his email and letter as a genuine plea for help from CPF
and CNAP. Each leader received and acted upon it as such, responding via
phone and email, respectively, within minutes of receipt, with CNAP also
ensuring C7F and CJRM were made aware of the request. Further, CPF
considered the matter of sending the letter closed after his conversation
with both CCSG-9 and TR CO.
11. When asked to sign a letter that contained a flawed, worst-case crew
casualty narrative as well as an ultimatum concerning an intent to submit
the letter to the public, the TR SMO missed a leadership opportunity to
correct subordinates. Instead, he signed the letter, and transmitted it
outside the chain of command, essentially endorsing the effort to
undermine Navy leadership.
12. The former TR CO intended for his email to be a “red flare” to accelerate
needed support and ensure attention to what he believed to be insufficient
courses of action. The former TR CO wrote his email to break down
communication barriers on plans, resources and support, and did not
intend for it to be released to the public. However, he did not personally
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inform his Immediate Superior in Command, CCSG-9, of the letter and
instead transmitted information of a very sensitive nature about a capital
warship on an unclassified network.
13. The exclusion of C7F on the former TR CO’s email, as well as the lack of
advanced coordination by the former TR CO with CCSG-9 and others,
bypassed the operational chain of command and demonstrated poor
judgment.
14. The former TR CO’s email and the attached letter of March 30, 2020 were
unnecessary, and had no positive impact on actions already being
aggressively pursued by higher headquarters (CJRM, C7F, and CPF).
15. Release of the former TR CO’s letter to the San Francisco Chronicle
complicated the Navy’s negotiations with the Government of Guam for use
of hotel rooms in Guam.
16. Detailed patient history analysis of the 29 personnel received aboard TR via
COD following the Da Nang port visit concluded that CODs were not the
likely source for the COVID-19 outbreak. Although the pre-event risk
analysis for the Da Nang port visit was assessed as sufficiently thorough
and the decision to the execute the port visit was appropriate at the time,
the Da Nang port visit was found to be the most likely source of the
outbreak on TR.
17. Detailed analysis of TR sick call logs revealed that COVID-19 was likely
present, yet undetected, as early as March 11, 2020.
18. The use of personal protective equipment (PPE) and employment of tactics,
techniques, and procedures (TTP) by the TR Medical Department were
likely effective, as there was only one COVID-19 infection among TR
Medical Department personnel.

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Recommendations
The following nine recommendations resulted from this investigation into the COVID-19
outbreak aboard TR:
1. The former TR CO should not be reassigned to command afloat or ashore.
2. Consider appropriate administrative measures for the former TR CO, TR
SMO, CAG CVW-11, and CCSG-9. For the TR SMO specifically, a
detachment for cause due to substandard performance is recommended.
3. OPNAV perform a study to determine which, if any, coastal states have not
been transparent about the number of their COVID-19 cases; port visit
approval authorities use the results of the transparency study as an
additional factor to weigh when acting upon potential port visits in the
future.
4. BUMED coordinate with Naval Warfare Development Command (NWDC) to
update to NTRP 4-02.10 in light of the COVID-19 outbreak; OPNAV issue
clear requirements concerning minimum precautions and tiered responses
for each specific class of ship and submarine that shall occur following
potential exposure to a highly transmissible infectious disease.
5. Naval Safety Center lead Cultural Workshops for TR and CSG-9 to identify
hazards that result from cultural behaviors associated with poor
communication, lack of trust, and integrity.
6. BUMED debrief TR Medical Department to determine what specific personal
exposure precautions were taken in the Medical Department and, if
appropriate, publish best practices guidance throughout the Navy’s
medical community and the fleet.
7. Navy leadership use this case study to emphasize the Navy's recent lesson
learned from the USS Fitzgerald (DDG 62) and USS John S. McCain (DDG
56) collisions of 2017, in that Navy leaders are willing to listen when
commanding officers have concerns about mission readiness or need
additional assistance. CPF spoke with CCSG-9 and the TR CO on the
phone immediately after the CO's email was sent. In this call, CPF laid out
all the actions in progress, and at the end of the conversation, asked
CCSG-9 and the TR CO what else they needed. With no additional requests
made, CPF considered the matter closed. CPF did not make any
notifications up to the CNO/VCNO level until some 30 hours later when it
became apparent media had a copy of the letter, and that a story based on
the letter, which contained inaccuracies, would soon follow. CNAP's
immediate response was “thank you for the red flare… we'll escalate
work... immediately.”
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The lessons should also reinforce that although the TR CO's intentions
were pure, his method of transmitting his concerns did not display good
judgment. Further, the lesson should emphasize some fundamental points
if in the position of needing to bypass your immediate superior(s) in
command:
a. First, review your actions and check your facts. The Navy's culture
prides itself on an open and candid exchange between seniors and
subordinates. Look at yourself with a critical eye and make sure you
are not missing some key information.
b. Ask yourself why you are there - have you done all you can to
communicate your case in clear and unambiguous terms? Just as
you would do for a subordinate, you owe that senior an opportunity
to correct the situation. Talking to the senior's staff is not a
substitute for addressing them directly. A staff representative may
not be capable of relaying your case with the detail, rigor or passion
that only you can provide.
c. Finally, if you must bypass that senior, recognize this should be
considered a last resort. Use a private means of conveying those
concerns, such as a phone call or an in-person office call with the
next superior, if possible. This allows face-saving opportunities on
both sides. The boss's boss may have key information or context
that makes you realize you had it wrong.
8. CNO, in coordination with 4-star Fleet Commanders, conduct a review of
the existing formal course of training for Strike Group Commanders. This
review should specifically address the sufficiency of the training
curriculum and make recommendations for the mandatory completion of
priority training events prior to assumption of Strike Group
command. Additionally, this review should make recommendations for the
addition of training events focused on developing critical thinking and
problem solving during nontraditional operations and unpredictable crisis
event response.
9. USFFC, in coordination with CPF, propose to CNO how future CSG training
and certification events will evaluate the ability of commanders and Strike
Group Staffs to deal with “off-script” events in the face of battle, such as
the curve-ball thrown by COVID-19. As we go forward, we need Strike
Group Commanders, and their supporting staffs, who will not flinch in the
face of a distraction like COVID-19 while fully engaged in combat
operations.

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Status of Recommendations from the Preliminary Inquiry

a. Issue revised Navy-wide COVID-19 guidance to address the magnitude of the
problem on TR and strategies for triaging crew members to limited numbers of
makeshift quarantine and isolation facilities both aboard the ship and at remote
shore locations. Complete.
Conduct war games and table-top exercises to optimize various scenarios and
conduct shipboard training/exercises. In progress.
b. Using the TR case history, develop warship-specific COVID-19 infection spread
models. In progress.
c. Examine the impact of the ship’s decision to release personnel from isolation on
March 29th and use this to inform the infection spread model recommended in
recommendation b. In progress.
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. Complete.
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. In progress.

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