Pentagon reviews find Navy Yard shootings were preventable

Tuesday - 3/18/2014, 4:13pm EDT

Jared Serbu, DoD Reporter, Federal News Radio

Download mp3

Last September's mass killing at the Washington Navy Yard could and should have been prevented, according to an internal Navy investigation made public Tuesday. In response, the Pentagon said it is taking several measures to prevent a similar incident and to target other insider threats.

The Navy investigation was one of three parallel reviews the Defense Department ordered in the aftermath of the Sept. 16 tragedy in which Navy IT contractor Aaron Alexis fatally shot 12 people and wounded four others over the course of 23 minutes in the Navy Yard's Building 197.

It found serious failures throughout the Navy's own system of personnel and physical security, but investigators laid the most serious shortcomings at the feet of the contracting chain that employed Alexis: HP Enterprise Services and its subcontractor, The Experts, Inc.

"If the proper procedures had been followed, the chain of events that led up to the shooting on the 16th of September would have been interrupted," said Adm. John Richardson, who led the Navy investigation. "If those contractors observe behavior that raises questions about an employee's suitability for access to installations or information, those concerns should be identified to the Navy, and those requirements were not met. They did observe those behaviors and did not make those reports, and so it was impossible for the Navy to act on that information."

Company never reported erratic behavior

The 40-member Navy review team brought forward several instances in which Alexis' employers allegedly witnessed his unstable behavior, but did not report it to the Navy.

In one example just a month prior to the Navy Yard incident, investigators say police at Naval Station Newport, R.I., were called four times after The Experts' own travel coordinator reported that Alexis might try to harm himself or others. Police responding to his hotel room found he had disassembled his bed because he believed someone was hiding beneath it.

In another example the next day, Alexis asked to stay in the hotel room of an HP supervisor because he believed people were following him and had checked into the hotel room beneath his. He told police later that night that someone was sending vibrations into his body and speaking to him through the walls.

Neither those nor several other instances of aberrant behavior were reported to the Navy officials who supervise the contract nor those who would have been in a position to suspend Alexis' security clearance, according to investigators.

In a statement, HP officials emphasized that Alexis never worked directly for them, and said that they had fully cooperated with the Navy's investigation.

"As the report confirms, The Experts was aware of significant information about Aaron Alexis that was not known to HP. Yet, The Experts made a decision to send Alexis back to work after the incident in Newport, R.I. without sharing any of this information with HP or the government. Based on what we learned about The Experts' conduct, on Sept. 25 HP terminated its relationship," HP said in a statement.

The Experts did not immediately respond to an emailed request for comment.

Review cites 'troubling' gaps in DoD management

But the Navy report's critiques of the events leading up to Sept. 16 are by no means limited to the actions of the contractors.

For instance, the shootings might have been prevented were it not for serious shortcomings in the government's own background investigation process, as Defense Secretary Chuck Hagel acknowledged Tuesday.

"The reviews identified troubling gaps in DOD's ability to detect, prevent and respond to instances where someone working for us — a government employee, a member of our military or a contractor — decides to inflict harm on this institution and its people," he said.

For example, the reviews found that Alexis had been arrested numerous times, including two instances in which he had fired gunshots in anger. He was also disciplined for personal misconduct while he served as an active duty sailor, but none of that information found its way into the Joint Personnel Adjudication System (JPAS), DoD's centralized repository for managing security clearances.

Because none of what the Navy knew about Alexis was entered into JPAS, neither HP nor The Experts — which hired him based, in part, on his existing secret security clearance — had full knowledge of the extent of his troubled history before they hired him in the first place.

And when the Navy first issued Alexis his secret security clearance in 2008, while he was still serving on active duty, it warned him that it was a "conditional" clearance: he would have to make good on past debts, attend financial counseling and maintain financial solvency. But there is no evidence that anyone in the Navy followed up to make sure he did any of those things, nor that the Navy had systems in place to require such a follow-up.