More than a year after a submariner died of an apparent self-inflicted gunshot wound while on guard duty at Pearl Harbor Naval Shipyard, a Navy report on its investigation into the command climate aboard the USS Charlotte shines a light on the toxic work environment he and his crewmates endured in the months leading up to his death.

The Navy report, obtained by the Honolulu Star-Advertiser through the Freedom of Information Act, tells a story with troubling parallels to the deadly 2019 shooting at the shipyard in which two civilian workers were killed by a USS Columbia submariner.

Petty Officer 3rd Class Manuel Julian, a 23-year-old torpedoman’s mate, was found dead at the shipyard on March 15, 2021, while on duty as an armed “watch stander” for the Charlotte. A Navy investigation “revealed leadership and command climate problems” that led to “a loss of confidence” in the Charlotte’s commanding officer, Cmdr. Joseph Lau­tenslager, who was relieved of command on April 28, 2021.

Julian was the third watch stander over a three-year period known to have died on duty guarding a submarine undergoing maintenance at the shipyard.

In December 2019, Seaman Gabriel Romero, a submariner assigned to the USS Columbia, killed two civilian workers and wounded another with a rifle before killing himself with his sidearm while on guard duty. Shortly after, Hawaii News Now reported that a watch stander guarding the USS Chicago had taken his own life on duty just weeks before Romero.

The Naval Criminal Investigation Service’s probe into Julian’s death remains ongoing. NCIS spokesperson Jeff Houston said, however, that the investigation “is nearing completion. Out of respect for the investigative process, we cannot comment further while the investigation continues.”

Congress has pressed the Navy to act on military suicides. In 2021 it passed the Brandon Act, named for Navy Petty Officer 3rd Class Brandon Caserta, which aims to reduce the stigma around reporting mental health issues. The 21-year-old aviation electrician killed himself in 2018 by lunging into the rotor blades of a helicopter after repeated bullying and hazing.

The legislation named after him calls for service members to be able to seek help confidentially, including outside their chain of command if they choose. It also requires a mental health evaluation as soon as a serv­ice member self-reports.

Caserta’s father, Patrick Caserta, a Navy veteran who pushed for passage of the bill and is one of the founders of the Brandon Caserta Foundation, said the military needs to take a proactive approach to helping service members in crisis.

“That’s what the Brandon Act does,” he said. “Of course, if it’s ever implemented.”

Caserta said the deaths of the Pearl Harbor watch standers at the same facility in such a short time should be a “red flag” to Navy officials.

“All toxic abusive commands and leadership have common themes,” he said.

While the NCIS probe of Julian’s death remains open, the author of the investigation into the command climate aboard the USS Charlotte wrote, “All of the sailors that I spoke with felt that the command does not have their interest at heart. Almost entirely across the board sailors had little to no trust that their concerns were being heard.”

The investigator noted complaints about poor management, exhausted crew, allegations of racism and suspected alcoholism, and alluded to a sailor pulling a gun on a crew mate — all of which occurred before Julian’s death.

The Navy released its investigation into the deadly December 2019 shipyard shooting to the public with minimal redactions. After that incident, Navy officials promised reforms, including improved mental health care, better training and more accountability for leaders.

The report into the Charlotte command climate included portions evaluating how the Pacific Submarine Force had gone about incorporating lessons from the 2019 tragedy, but those portions were redacted and cited documents not included. The Navy redacted all portions related to the investigator’s recommendations in the version of the document released to the Star-Advertiser, and officials have not provided information on the nature of the recommendations after repeated inquiries.

The Navy also did not answer questions about whether it has made any changes to guard duty or weapons handling procedures in light of the recent deaths.

However, the unredacted portions of the investigation show parallels between the circumstances leading up to the December 2019 shooting at Columbia’s dry dock and Julian’s death, namely a disorganized leadership overseeing a submarine under maintenance with a demoralized and angry crew.

The author of the investigation into the Charlotte wrote that “junior sailors do not feel that there is a consolidated message of what their purpose is or what the priorities are for them” and that “sailors do not feel valued or included in the workplace on board.”

The investigator noted that members of the Charlotte’s crew were “extremely frustrated that they have no plan and their workday normally will not start until late in the afternoon,” and “all sailors I spoke to said they never know what time they are going home when they come in at the beginning of the day.”

The investigator said the leadership style aboard the Charlotte left sailors “little flexibility to conduct work or maintenance planning on their own” and noted that “this was personally observed during the investigation.”

The investigator also raised concerns that leadership essentially trapped crew members aboard the Charlotte, giving them little guidance as to what they were expected to do.

“A significant number of personnel that I spoke with have been denied leave and told ‘there’s no time,’” the investigator wrote. “The (Engineering Department Master Chief) has been referenced several times as the source for saying leave will not be allowed.”

Pointing out common denominators, Caserta said, “When you are in a command who clearly doesn’t care about the crew, no one wants to be there. You think of ways to take leave or transfer out of there. The chain of command blocks your way out, and the under-crew issue is their created problem. … This is people in a corner. They have no way out.”

The findings on the USS Charlotte mirror the issues aboard the USS Columbia in 2019, where sailors across the crew had complained of unpredictable schedules, a lack of planning, late working hours and last-minute tasks. The investigation of the 2019 shooting found that “the organizational culture tolerated a below-average command climate because USS Columbia was in an industrial environment.”

In a survey before the deadly December 2019 incident, an anonymous Columbia crew member wrote, “Not having a purpose and just being here to clean, we work in an industrial environment, you can only sweep the decks so much … often times I considering (sic) putting my pistol in my mouth and ending it all or just throwing myself into the dry dock basin.”

The Pacific Fleet’s investigation of the Columbia incident also concluded that Navy psychologists might feel pressured to underdiagnose mental issues among submariners to keep them on duty.

The 2021 investigation of the Charlotte criticized the leaders on that submarine for their attitude toward the health, safety and mental well-being of the crew.

The investigator noted a situation in which a sailor pointed a gun at another sailor “was never adequately addressed with the crew.”

The version of the report released to the Star-Advertiser offered no other details on the incident. The report also noted that “specifically, racism and discrimination comments have not been addressed,” but did not elaborate.

The report singled out a lack of communication, noting that “this is a pervasive problem that spans all ranks within the command and includes communication internally and externally with outside agencies,” and that “sailors felt they do not get a clear message of what’s going on at any time.”

The investigation said junior officers and department heads on the submarine “specifically identified that was at its worst” in the periods immediately after the deaths of two individuals, whose names the Navy redacted in the version of the report it released.

“The command triad was completely ‘closed door’ during that timeframe,” the investigator wrote. “No direction was given from (Lautenslager) at that time to the officers, chiefs, or the crew.”

Almost a month after Julian’s death, Lt. Cmdr. Russell Cruz, a supply officer assigned to the Naval Submarine Support Center at Pearl Harbor, took his own life during a standoff with police at the Kahala Hotel & Resort. The deaths of so many submarine force sailors in Hawaii over a relatively short period of time was noted in news coverage at the time.

A report released in April by the Government Accountability Office concluded that service members stationed in places like Hawaii and Alaska, as well as several overseas installations defined as “remote,” appeared to be at greater risk of attempting suicide than those stationed on the mainland.

But troops on the mainland are not immune, particularly those working in shipyards.

The Navy has struggled to maintain its fleets — which have been pushed to their limits as the Navy conducts global operations — with its aging shipyards. Keeping ships and subs running on a near-constant basis has also pushed sailors to the limit as they attempt to meet those demands and struggle with maintenance backlogs.

In 2019 three sailors working aboard the aircraft carrier USS George H.W. Bush died by suicide while it was undergoing an overhaul at the Norfolk Naval Shipyard in Virginia. In late April the Navy acknowledged it is probing seven suicide deaths — four this year and three from 2019 and 2020 — of sailors assigned to the carrier USS George Washington, which has been undergoing its own years-long overhaul in Newport News, Va.

Master Chief Petty Officer of the Navy Russell Smith recently visited the crew of the George Washington for a question-and-answer session. According to a transcript released by the Navy, when a sailor asserted that crews working on vessel maintenance have higher rates of suicides and mental health issues, Smith replied, “I would tell you anecdotally, I believe the same thing, I can’t tell you if there’s quantification of that, but it feels that way to me, too.”