Report: Shipyard shooter’s history of mental health issues failed to raise alarms

HONOLULU, Hawaii (HawaiiNewsNow) - An inquiry into the December 2019 shooting at the Pearl Harbor Naval Shipyard that left two civilians dead has highlighted a series of failures that allowed the gunman access to military firearms despite a history of worrisome incidents and mental health issues.

The investigation, completed in July, could not determine gunman Gabriel Romero’s motive and stressed that even when his history, personal issues and grievances are considered “no one could have reasonably predicted” that he would kill two people and wound a third before fatally shooting himself.

But the inquiry did raise serious concerns about how Romero was handled, saying that military mental health professionals under-diagnosed him and failed to provide an adequate level of care, and his superiors responded to his unsuitability for service by assigning him to armed guard duty.

The shooting happened on Dec. 4, 2019, shortly after Romero started his shift on the USS Columbia submarine as an armed watchstander. Investigators say Romero told the petty officer of the deck, “I’ll be back” before walking to dry dock 2 and firing on civilians. “While the victims lay on the ground, and before first responders were on the scene, Romero used his M-9 pistol to shoot himself,” the report said.

It added, “The shooting only lasted a few seconds from beginning to end.”

Romero died at the scene while two of the civilians — Vincent Kapoi, Jr., a 30-year-old metal inspector apprentice, and Roldan Agustin, a 40-year-old shop planner and veteran — where rushed to area hospitals, where they succumbed to their injuries. A third civilian was injured by the gunfire.

What led up to the shooting? While investigators don’t know why Romero opened fire, they did identify “potential contributing factors” that if acted on could have prevented the deadly incident.

Investigators said:

• A submarine-embedded mental health provider failed to properly manage Romero’s mental health condition during eight visits to a clinic at Pearl Harbor between September and November 2019. He was diagnosed only with “phase of life problems” and an “unspecified” psychosocial disorder when he showed signs that “likely would have disqualified him from submarine duty," the report said.
• The mental health clinic also did not come up with a plan for handling Romero’s mental health treatment. They kept concerns about his behavior confidential rather than prompting a discussion that “may have led USS Columbia’s chain of command to question his fitness for duty.”
• His chain of command and medical representative did not share information on his disciplinary issues, medical and mental condition and family situation effectively. Collaboration and information sharing, investigators said, could have led the chain of command to take “more intrusive actions to direct additional mental health evaluation or remove Romero from armed watchstanding.”
• Some of Romero’s worrisome behaviors exhibited to shipmates were never reported to supervisors. Actions like punching a locker in anger, yelling at a shipmate and complaining he was tired of work.

“The investigation team determined Romero had long-developing problems that in aggregate should have raised concerns about his mental condition, and his maturity, stability, and dependability,” the inquiry said. “If these risk factors would have been shared among medical providers and the USS Columbia chain of command ... the Navy may have interrupted the chain of events that led to this tragedy.”

Investigators noted Romero had failed attempts to earn his submarine qualifications so the only watches he was qualified to stand on were non-technical armed watches. “However, armed watches should not be treated as a menial task for deficient performers,” the inquiry said.

Romero was first seen by a mental health professional at the Tripler Army Medical Center emergency room in March 2019. He said he’d had difficulty focusing at a traffic court hearing that day and was referred to the mental health program. He was not seen again by a mental health professional until September.

His fellow shipmates also reported that Romero grew increasingly “isolated and withdrawn.”

In November 2019, the USS Columbia held a disciplinary review board to look at his repeated tardiness and qualification delinquency. The report says Romero would cry when he received counseling for poor performance, but never expressed suicide or threats of violence toward others in clinic visits.

David Hendrickson, who was a marine infantryman and an Army lawyer, reviewed the report and noted Romero was not only under disciplinary inquiry the day before the fatal shooting, but missed a safety briefing before standing armed watch. “Those members of the command could’ve evaluated his demeanor and his temperament and maybe discovered somethings is not right,” he said.

“There were a lot of indicators to show that he was disturbed and a problem."

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