ProPublica

This is the USS John S. McCain being towed after it crashed in the summer of 2017, killing 10 sailors. One sailor had warned superiors: “It’s only a matter of time before a major incident occurs.”

This is the USS Fitzgerald, which crashed nine weeks earlier, killing seven sailors. An officer had told his bosses that his shipmates might die without changes.

Years of Warnings, Then Death and Disaster

How the Navy failed its sailors.

By Robert Faturechi, Megan Rose and T. Christian Miller

Design by Xaquín G.V.

The Asahi Shimbun via Getty Images

When Vice Adm. Joseph Aucoin was elevated to lead the vaunted 7th Fleet in 2015, he expected it to be the pinnacle of his nearly four-decade Navy career. The fleet was the largest and most powerful in the world, and its role as one of America’s great protectors had new urgency. China was expanding into disputed waters. And Kim Jong-un was testing ballistic missiles in North Korea.

Aucoin was bred on such challenges. As a Navy aviator, he’d led the “Black Aces,” a squadron of F-14 Tomcats that in the late 1990s bombed targets in Kosovo.

But what he found with the 7th Fleet alarmed and angered him.

The fleet was short of sailors, and those it had were often poorly trained and worked to exhaustion. Its warships were falling apart, and a bruising, ceaseless pace of operations meant there was little chance to get necessary repairs done. The very top of the Navy was consumed with buying new, more sophisticated ships, even as its sailors struggled to master and hold together those they had. The Pentagon, half a world away, was signing off on requests for ships to carry out more and more missions.

The risks were obvious, and Aucoin repeatedly warned his superiors about them. During video conferences, he detailed his fleet’s pressing needs and the hazards of not addressing them. He compiled data showing that the unrelenting demands on his ships and sailors were unsustainable. He pleaded with his bosses to acknowledge the vulnerability of the 7th Fleet.

Aucoin recalled the response: “Crickets.” If he wasn’t ignored, he was put off — told to calm down and get the job done.

On June 17, 2017, shortly after 1:30 a.m., the USS Fitzgerald, a $1.8 billion destroyer belonging to the 7th Fleet, collided with a giant cargo ship off the coast of Japan. Seven sailors drowned in their sleeping quarters. It was the deadliest naval disaster in four decades.

Barely two months later, it happened again. The USS John S. McCain, its poorly trained crew fumbling with its controls, turned directly in front of a 30,000-ton oil tanker. Ten more sailors died.

The Navy, embarrassed and scrambling to explain to Congress and America’s allies how such seemingly inexplicable disasters could have happened, moved quickly to prosecute members of ship crews it declared all but incompetent and to strip senior officers of their commands.

But the swift, seemingly decisive action masked a much more damning story of failure by the Navy’s top command and the Pentagon. Aucoin had hardly been the only one detailing the once-proud 7th Fleet’s perilous condition. The alarms had been sounded up and down the chain of command, by young, overmatched sailors, by veteran captains and commanders, and by some of the most respected Navy officials in Washington.

Two three-star admirals told ProPublica they had explicitly notified superiors of the growing dangers. The two people who served successive terms as undersecretary of the Navy, the No. 2 position in the civilian command, said they had, too. They produced memos, reports and contemporaneous notes capturing their warnings and the silence or indifference with which they were met. Now, frustrated by what they regard as the Navy and Pentagon’s papering over of their culpability for the twin tragedies, these officials and others have broken with Navy custom and are speaking candidly, naming names and raising concern that the Navy could well repeat its mistakes.

Mounting Alarms

Sec. of Defense

Ash Carter

Deputy Sec. of Defense

William Lynn III

Sec. of the Navy

Ray Mabus

Under Sec. of the Navy

Robert Work

Chief of Naval Operations

Gary Roughead

Pacific Fleet

Patrick Walsh

US Fleet Forces

John Harvey, Jr.

7th Fleet Commander

John Bird

Naval Surface Forces

D.C. Curtis

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February 2010The Navy tasked retired three-star Adm. Phillip Balisle to assess surface force readiness. His report finds that the Navy’s attempts to create efficiencies had instead harmed the fleet, resulting in cuts to staffing, training and maintenance.

Around 2012Navy Undersecretary Robert Work tried to convince Deputy Defense Secretary Ash Carter that the pace of operations being demanded of Navy ships was overtaxing the fleet. In response to one operation request, he presented rounds of data proving his case. “And he would send us back and say, ‘I don't believe the data,’” Work recalled. “We'd come back with more data. He'd say, ‘I still don't believe it.’”

January 2013 Three-star Adm. Thomas Copeman speaks at the Surface Navy Association Symposium, warning that readiness was headed toward a “downward spiral”: “It’s getting harder and harder I think for us to look the troops in the eye.” That same day, Copeman started getting calls from representatives of the chief of naval operations chastising him: “How could you possibly do this to CNO?”

Mid-2013Copeman said that a few months after his speech drawing attention to the Navy’s readiness problems, Chief of Naval Operations Jonathan Greenert asked him to retire early.

August 2013Copeman authors a memo forwarded to the chief of naval operations warning about the confusion created when the same systems have different interfaces on each ship. Copeman said the memo, which is particularly prophetic about problems that contributed to the McCain collision, received no response from Greenert.

April 2014Work becomes deputy secretary of defense.

May 2014Copeman writes another memo to Greenert warning of the continued shortage of trained and experienced sailors: “If we continue to invest in the latest and greatest equipment and the most capable weapon systems without making an equivalent investment in our workforce, we will move further away from being a ready force.” Copeman said he saw no action taken in response.

August 2014Copeman retires and Thomas Rowden takes over his position.

March 2016In her first months in office, Navy Undersecretary Janine Davidson becomes convinced that the Navy was devoting too many resources to buying new ships and weapons systems and dangerously neglecting readiness. She expresses her concerns to Secretary Ray Mabus, who refused to act. Going to the Hill wasn’t an option. Mabus’ chief of staff had told Davidson, she said, to stop talking to Congress.

February 2017Three-star Adm. Joseph Aucoin provides four-star Adm. Scott Swift data showing readiness is suffering because his fleet was being assigned too many operations. Swift replies that he will assign a deputy to look into it, but Aucoin never heard back. This is one of several instances Aucoin said he raised alarms but received little or no assistance from his boss.

August 2017After the McCain collision, Aucoin said Swift fired him, saying that he had to get rid of him, “Otherwise they’d be looking at me.”

Three-star Adm. Thomas Copeman, who from 2012 to 2014 was in charge of the fitness of the Navy’s ships for combat, had made clear to his superiors in 2013 that it was getting harder to “look the troops in the eye and say, ‘Hey, just do it.’”

Copeman said he was pushed out of his job after he spoke out. But he doesn’t regret it.

“If you're an admiral in the Navy,” he said, “you may have to make that decision to send people into combat, and you better not have blood on your hands the rest of your life because you didn't do everything you could in peacetime to make them ready.”

These firsthand accounts by Aucoin, Copeman and others are supported by thousands of pages of internal Navy records, public reports and confidential investigations obtained by ProPublica: a 2010 report that all but predicted the accidents; data kept by admirals vividly demonstrating how thin the 7th Fleet was stretched; a 13,000-page investigation that lays bare the extraordinary risks commanders were willing to have their sailors face.

Those records include the account of a sailor on the McCain who warned superiors before the collision: “It’s only a matter of time before a major incident occurs.” The account of another sailor on the ship suggested why: “Incompetence is the standard.” An officer on the Fitzgerald told ProPublica he warned his bosses people could die without changes.

At the Pentagon, Navy Undersecretary Janine Davidson repeatedly told her boss, Navy Secretary Ray Mabus, that the Navy was plowing money into buying new ships while its current fleet was falling dangerously into disrepair. His expanded fleet would take years, even decades to build; the risks were immediate. Mabus, appointed in 2009, served the entire two terms of the Obama administration, leaving just months before the crashes.

“His priority was shipbuilding. He made it very clear,” Davidson said of Mabus, whom she accused of blocking her from speaking to Congress about her concerns. “Anybody who had a different opinion was shut down.”

Robert Work, Davidson’s predecessor, informed senior officials at the Pentagon that the Navy’s fleet was being overtaxed by missions that were of limited value. Work, who went on to be the deputy secretary of defense, said the Pentagon repeatedly rejected his analysis.

Despite the stresses on the 7th Fleet, Navy leaders were reluctant to push back on the relentless requests from Pentagon commanders to send the fleet’s ships on missions, even those that the Navy’s own admirals and ship captains considered of questionable value.

Mabus said Davidson, once considered a possible successor, was angling to boost her political profile when she raised alarms. He readily acknowledged that he had been committed to building a stronger Navy through buying new ships.

“Quantity has a quality all of its own,” Mabus liked to say.

Magnifying the 7th Fleet’s troubles, and the Navy’s broader state of decline, were brutal and sudden budget cuts during the Obama administration by a Congress riven by continued partisan enmity.

ProPublica, months ago, asked to discuss its findings with the current Navy leadership and sent detailed questions about the 7th Fleet, including charges from former commanders that the American public had not heard the full story behind the deadly crashes in the Pacific. The Navy responded with a statement saying it had committed to reforms that included improved training and better staffing of its warships.

“We have implemented several changes over the past year and a half to ensure we meet the high standards of performance that the American people must expect from us,” Adm. John Richardson, the Navy’s top military officer, said in the statement.

But the fleet’s relentless pace still forces crews to work 100-hour weeks or more. And the Government Accountability Office, Congress’s watchdog, reported in December that the Navy “continues to struggle” with fixing its ships and putting enough sailors on them.

“The men and women of the Navy deserve better,” Aucoin said. “The truth needs to come out to prevent this kind of tragedy from ever happening again.”

Chapter 1

“Only a Nitwit of the Highest Order ...”

There’s no disputing that Mabus — the onetime governor of Mississippi and a politician admired for his savvy — faced daunting challenges when President Barack Obama named him Navy secretary in 2009.

The Navy had seen its budget cut by almost 25 percent in real dollars in the 1990s, after the Cold War ended. The 600 ships the Navy boasted in the late 1980s would shrink by half. Then, the administration of George W. Bush committed America to two long and frustrating land wars.

Tens of thousands of sailors were dispatched to relieve ground troops in Afghanistan and Iraq, reducing crew sizes on ships and depriving the ships of sailors with specialized skills. Between 2006 and 2009 alone, more than 1,200 sailors were taken off cruisers and destroyers like the Fitzgerald and the McCain and sent to the Middle East.

In the early 2000s, the Navy embarked on a quest for so-called efficiencies. Vern Clark, the Navy’s top military officer during much of the Bush era, brought an MBA to the job and pitched his cuts to the force using the jargon of corporate downsizing. Smaller crews were “optimal” crews. Relying on new technologies to do the work sailors once did was described as “capital-for-labor substitutions.”

Promising a “workforce for the 21st century,” Clark’s team tried out new training and staffing ideas, including a decision that officers no longer needed to attend months of classroom training to learn the intricacies of operating billion-dollar warships. Instead, aspiring Surface Warfare Officers, charged with everything from driving ships to launching missiles, could learn mostly at sea with the help of packets of CDs. The program was widely derided by sailors as “SWOS in a Box.”

The efficiencies even included eliminating a requirement for ship captains to post lookouts on both sides of ships, a cut that would later prove crucial when the Fitzgerald’s crew failed to see a fast-closing cargo ship until it was too late.

In an interview with ProPublica, Clark said these reforms were intended as experiments for a more streamlined and ready Navy and should have been regularly re-assessed.

“Only a nitwit of the highest order would continue down this path without seeing if it’s working,” he said.

Mabus, taking on a downsized, marginalized Navy, wasn’t ambiguous about what needed to be done: replenish the fleet’s number of ships. The worldwide fleet had fallen to just 278 ships before Mabus was sworn into office.

His plan made strategic sense. The world’s oceans were a re-emerging battleground. China was expanding its Navy, and it routinely patrols contested waters around the South China Sea to assert its dominion. Russia has become newly assertive in the waters off its coasts, especially in the Arctic. And North Korea’s aim of building missiles to reach mainland America is best contained by a robust Navy presence offshore.

To maintain control of the world’s oceans, military and congressional leaders have determined that the Navy has to build new ships to meet new threats. Projecting American power and values across the globe required gray hulls on the horizon.

Mabus, a Democrat, meant for a restocked fleet to be his lasting legacy. Over his nearly eight years in office, the longest tenure of any Navy secretary in a century, he boasted the Navy signed contracts to build 86 ships — twice the total as had been approved in the prior seven years under the Bush administration. When he left office in 2017, Mabus said the Navy was set to have 308 ships by 2021.

For Clark, by then retired, it was a surprising use of the Navy’s limited budget.

“When I looked at the shipbuilding, I couldn’t believe my eyes,” he said. “I knew how much money we had.”

Chapter 2

“We’re Using the Fleet Too Much"

About the same time Mabus took charge, the full impact of Clark’s cuts were becoming obvious in the fleet. Building ships was fine, even necessary, but some military professionals thought the priority should have been fixing the dangerous shortcomings with the current fleet.

The Navy called three-star Adm. Phillip Balisle out of retirement to investigate the state of its operations. The fleet was in decline, with two warships so neglected they were unfit for combat. He delivered a sobering assessment.

In 2009, Balisle and a team of investigators had traveled to the Navy’s power centers, in Norfolk, Virginia; Hawaii and San Diego, interviewing senior enlisted sailors, private contractors and officers up and down the chain of command. They toured ships, gathered data and received briefings from senior officials in Washington.

They were alarmed by what they saw. Clark’s “optimal manning” had reduced crew sizes for warships. Destroyer crews had shrunk on average from 317 sailors a decade earlier to 254. Then the Navy shorted the ships even further, exacerbating what was already a critical situation. Ships had roughly 60 percent of the enlisted leaders needed to mentor and train young sailors. And to make up for the short-staffing, the Navy simply extended the crews’ workweeks.

Balisle’s team determined the Navy’s 283 surface ships needed 4,500 more sailors to be staffed to recommended levels.

The condition of those ships was also declining as the Navy reduced time devoted to maintenance. Ships that once docked for 15 weeks for repairs were sent to sea after just nine weeks. The effects were dramatic; destroyers the Navy hoped would last for 40 years were hanging on for just 25. Reports of problems with certain radar systems were up, and sailors were increasingly unable to make fixes on their own.

A legion of poorly trained junior officers aboard the ships were being promoted, Balisle warned, creating a generation of unprepared leaders.

Balisle’s report, dated February 2010, was delivered to Mabus and to Congress.

"It appears the effort to derive efficiencies has overtaken our culture of effectiveness," Balisle said in the report. He then took aim at the “downward spiral” of the Navy’s culture, in which a commitment to excellence had been badly eroded.

"From the most senior officers to the most junior petty officer, the culture reveals itself in personal attitudes ranging from resignation to frustration to toleration,” he wrote. “While the severity of current culture climate may be debated, its decline cannot."

The report left Work, then the undersecretary of the Navy and Mabus’ No. 2, shaken. He decided to act.

Work, a widely respected figure at the Pentagon, said he began using his monthly meetings with then Deputy Secretary of Defense Ash Carter and his counterparts at the Army, Marines and Air Force to detail the stress on the Navy’s ships. The Navy was being asked to conduct too many operations, Work told them, some of debatable merit. The problems were real, he said, and the risks to readiness considerable.

“We’re using the fleet too much," Work told the Pentagon. “We have to say ‘no’ more often.”

Work said he brought Carter round after round of data showing the demands on the fleet were degrading its readiness to counter threats.

Specifically, Work recalled raising concerns about a request around 2011 to have two of the Navy’s 11 aircraft carriers — and their escort ships — in the Persian Gulf at all times, an unusual demand that would require putting off repairs and training.

The request came from the commander of CENTCOM, the uniformed officer responsible for all operations in the Middle East. In the military, the wishes of what are known as combatant commanders are all but paramount. They are often dealing with issues of utmost national security: the war in Afghanistan, the development of nuclear weapons in North Korea, ISIS fighters in the Middle East, Al Shabab terrorists in the Horn of Africa, the expansionist aims of China and Russia.

Individual combatant commanders, who report to the secretary of defense, are in charge of military operations inside six global regions, no matter which branch of the military is conducting the operation. The leaders of the Navy, Army and Air Force are responsible for delivering trained and equipped troops. They can lobby the Pentagon against an operation they feel is ill-advised, but the final say goes to the defense secretary, and ultimately the president.

Navy officials — from captains helming ships to three-star admirals — told ProPublica that many commanders’ operations seemed unnecessary, such as shows of force requested by allies, joint-training exercises with foreign militaries or so-called presence missions in non-contentious parts of the world. As Aucoin struggled to find ships to patrol off nuclear-armed North Korea, his superiors sent a destroyer to help the small Pacific islands of Tuvalu and Nauru enforce their fisheries laws.

Some extolled such operations as key to maintaining so-called soft power — keeping allies happy, telegraphing might without direct military force. But others saw them as a luxury a strapped Navy could no longer support. When the Navy had 600 ships, about 100 were at sea at any given time. With half as many ships, the Navy still keeps about 100 at sea. In other words, as the Navy shrunk its fleet, it increased the workload on its sailors.

The commanders “would ask for ships, they would ask for airplanes, they would ask for troops,” Work said. “And it was very, very difficult for the Department of Defense to say no because almost every single request that came in was judged as high risk if not approved.”

Work said Carter dismissed his concerns and even questioned the analyses done by Work’s aides. “He would send us back and say, ‘I don't believe the data,’” Work recalled. “We'd come back with more data. He'd say, ‘I still don't believe it.’”

Carter did not respond to emailed questions from ProPublica.

Work, who would later serve as deputy secretary of defense from 2014 to 2017, also could not expect much backup from his boss. For Mabus, the incessant demands on his aging fleet helped justify buying more ships.

“From Secretary Mabus’ perspective, the more ships in the fleet, the better,” Work said. “And the more ships that were out and about, the better.”

In an interview, Mabus, in fact, said he didn’t recall the Balisle report that had so worried his deputy.

“I'm sure I knew about it when it came out,” he said.

Chapter 3

A “Hollow” Navy

Three-star Adm. Thomas Copeman wore a smile as he approached the lectern at an annual Navy symposium at the Hyatt hotel in Arlington, Virginia. A stack of notecards in hand, he cracked a few jokes about the Navy officials in attendance being distracted by their dinner plans or their BlackBerrys.

It was January 2013, and it had been almost three years since the Balisle report. Copeman had been nursing a host of frustrations.

Officers on the decks of ships were telling him they needed more sailors, and better trained ones, to operate and maintain their equipment, he told the crowd. Commanders were robbing specialists from some ships to make the crews of other ships whole, a Band-Aid solution. The workweek had been extended, vessels were degraded, parts were breaking and increasingly ships lacked the spares to replace them.

Readiness was supposed to be his job, but he’d had trouble getting it done. Echoing the words of Balisle three years earlier, he said, the Navy was headed toward a “downward spiral.”

The Navy’s surface forces needed $3.5 billion, he said, just to fix what was wrong with training alone.  

Copeman raised the specter of a “hollow” Navy.

“I can’t tell you whether we’ve gotten to that point,” he said. “But I will tell you that we’re getting closer to it.”

The path forward was for the Navy’s civilian leadership to determine, Copeman told the assembled Navy officers. He would salute and follow orders no matter what. But the obvious solution was to stop building new ships and start taking care of the current fleet.

Copeman knew as he said it that his solution stood in stark contrast to the agenda set out by Mabus.

“I heard him and his immediate staff state more than once that they can ‘catch up with readiness in a year or two, but you couldn’t do the same with ships,’” Copeman told ProPublica.

The blowback to Copeman’s public airing was swift.

Within hours of leaving the stage, the calls began. Within a few days, he was contacted by four different representatives for Mabus and for Chief of Naval Operations Jonathan Greenert. A Mabus representative told Copeman it was extremely disappointing he was not supporting the secretary’s shipbuilding agenda. A Greenert aide asked how he could have betrayed Greenert.

Mabus and Greenert said they had no knowledge of the calls.

Greenert later summoned Copeman and asked him to submit his retirement papers early. The decision, Greenert told ProPublica, wasn’t due to Copeman’s public criticisms but “was associated with the availability of the best and fully qualified successor for the position.”

Copeman said in an interview he didn’t second-guess his decision to be frank.

“It'd be tough to look in a mirror if I'd stayed silent,” Copeman said.

Still, he believes the order to retire may have had a chilling effect on other top commanders speaking out.

“I think that many flag officers took notice,” he said.

A third-generation Navy officer, Copeman fired off a couple more memos before retiring, hoping he might at last get the leadership’s attention.

The first warned of the fleet’s increasing “configuration variance” problem: The same systems operated in dozens of different ways on different ships, confusing sailors as the Navy shifted them from one vessel to another.

“I liken it to this,” Copeman told ProPublica. “You have a car with a steering wheel and a gas pedal and one day you walk out and get in your car and an iPad sits were your steering wheel used to be and the gas pedal is no longer there.”

Copeman enlisted a four-star admiral, Bill Gortney, to sign the memo and distribute it in the upper echelons of the Navy. His memo would prove prescient. Four years later, confusion over the McCain’s new steering system caused the ship to turn in front of an oil tanker.

Finally, three months before retiring, Copeman issued a dire warning about the lack of trained sailors.

“If we continue to invest in the latest and greatest equipment and the most capable weapon systems without making an equivalent investment in our workforce, we will move further away from being a ready force,” the memo read.

A staffer thanked Copeman for his input, but Copeman never saw any changes. (Greenert said both memos contributed to reforms.)

Around that time, Congress compounded the Navy’s problems.

Facing a budget impasse over the conservative Tea Party’s demands for deficit reductions, Democrats and Republicans agreed to allow a supercommittee composed of a dozen members from each party to come up with a compromise. If they failed, more than $1 trillion in cuts would hit military and domestic programs, wonkily known as sequestration. It was a scenario designed to be so catastrophic that it would guarantee a deal got done.

Navy officials warned Congress that the sudden drastic cut would be disastrous — and many lawmakers echoed that concern.

“The feeling was this won't happen,” Greenert said. 

It did.

In 2013, the Navy got $9 billion less than it had budgeted for, its penalty under budget sequestration. Even advocates for slashing defense spending considered the cut reckless.

The Navy trimmed its budget in part by cutting software and computer upgrades planned for DDG-class destroyers — including the Fitzgerald, the McCain and several other destroyers based in the 7th Fleet.

“Before we went to sequestration we were planning to do a bunch of stuff for the DDGs. Sequestration happened. Plans changed,” Dave McFarland, the Pentagon’s deputy for surface ship warfare, told a reporter in 2014.

Three years later, the Fitzgerald would set sail with many of its computers and software out of date. For instance, its primary navigation system, known as the Voyage Management System, was running on Windows 2000 — the oldest version among ships based in Japan. Sailors would say that the navigation system would wrongly plot their position or the position of other ships.

After the cuts, Greenert warned Congress, “Unless this nation envisions a significantly diminished global security role for its military, we must address the growing mismatch in ends, ways and means.”

The Navy propped up its budget for ship maintenance with special funding designated for the war on terror. This led to unpredictable funding and hasty spending, according to a former Navy official who worked on budgetary matters. And when the anticipated funding fell short, maintenance simply didn’t get done.

Even more damaging was the reliance by Congress on stopgap budget fixes known as continuing resolutions, which kept funding at the level of the previous year until lawmakers passed a new budget. The measures kept the money flowing but restricted how it was used, blocking the Navy from launching new projects and changing spending priorities as its needs changed.

“They were killers for us,” Mabus said.

A former ship captain recalled getting to shore during one continuing resolution with a long list of urgent maintenance needs: “They come back to me and say: ‘There's no way we can afford that. Tell me what you're not going to do.’”

He asked to skip their planned weapons modernizations and instead take care of some of the more pressing maintenance projects. But he was told he couldn't cut the weapons modernizations because they were already in the base budget.

“What you're talking about is analogous to taking a big 55-inch TV,” he said, “and putting it in a leaky shack. How long do you think that's going to last?"

Chapter 4

“Sleepwalking” Into Risk

Shortly after Janine Davidson took over as undersecretary of the Navy in the spring of 2016, she began touring shipyards in San Diego, Seattle and Norfolk and visiting the decks of ships at sea.

The evidence of neglect was everywhere. The previous May, the GAO, recalling the warnings of Balisle and Copeman, had told Congress that the Navy had a serious readiness problem in the Pacific. Many crew certifications — proof of competency in such things as navigation and ballistic missile defense — were expired. And the Japan-based ships were deteriorating.

In response, the Pentagon told the GAO the Navy was “well aware of the risks” and accepted them as the cost of increasing its presence in the region. Navy and Pentagon leaders promised to ease the pace, but they instead ramped up operations. When the GAO reviewed the certifications again after the crashes of the Fitzgerald and McCain, it found that the lapses of certifications had increased more than fivefold since 2015.

As Davidson was digging, Thomas Rowden, the three-star admiral who had succeeded Copeman in overseeing surface ship readiness, began confiding in her that problems were getting worse.

To Davidson, it was clear: “It’s sleepwalking into a level of risk you don’t realize you have,” she said of the Navy in 2016.

The shortcomings, she found, extended beyond the Navy’s ships. Pilot training was down, and the backlog for fighter jet repairs was growing. From 2013 to 2015, aviation mishaps went up by almost 50 percent. In 2016, two Super Hornets collided during a training mission off the coast of North Carolina. Davidson said the final straw was discovering the Navy’s budget for ship maintenance was $800 million short.

“I was like: ‘What? How does that happen?’” Davidson said.

Davidson had joined the Air Force in 1988, becoming the first woman to fly the C-130, a military transport aircraft. As a civilian, she turned her focus to military operations, later serving as a deputy assistant secretary of defense from 2009 to 2012, overseeing military war plans.

As Mabus’ undersecretary, she said, “My role was to probe.”

When Mabus wasn’t traveling, she’d join him and other senior officials, including Thomas Oppel, his chief of staff, around a Pentagon conference table. There, she’d make her case for dedicating money and energy to shoring up the Navy’s beleaguered and overmatched men and women and ships.

Mabus refused to budge.

A former Navy official recalled Mabus’ blunt response: “We’re building ships. I’m not going to move more money.”

The room, in those moments, would fall silent. The conversation was over.

Taking her concerns to Congress wasn’t an option for Davidson. Oppel — who served as the enforcer for his more genteel boss — had told her to stop talking to lawmakers when she was first beginning to poke around on readiness shortfalls, before she realized the true extent of the problem.  

“They didn’t want me going up there,” Davidson said.

Mabus didn’t dispute Davidson’s account, and he defended his decision to stop her from talking to Congress.

“If you've got concerns, great. Bring them to me,” he said. “But if you're a political appointee, we got to have one message. Particularly going to Congress.”

Oppel insisted that requiring Davidson to do so was not an effort to silence her.

“There was never an attempt to muzzle anybody,” Oppel said.

Mabus said the issues Davidson brought to him were motivated by careerism. Her priority was becoming the next secretary of the Navy, he said, and to make herself stand out, she purposely staked out positions that differed from his. Davidson denied this was her motivation.

“I'm not sure she, regardless of what my agenda had been, she would have agreed with it,” he said.

Rep. Adam Smith, the chairman of House Armed Services Committee, told ProPublica he was alarmed to learn that an undersecretary of the Navy was dissuaded from bringing her concerns to Congress.

“Hearing that leadership at the Pentagon actively worked to withhold information from us is deeply troubling,” Smith said. “Especially when that information could have helped us better fund readiness accounts critical to helping prevent accidents like the ones that cost the lives of 17 sailors.”

Chapter 5

“Calm Down, Joey”

Almost from the moment he took over the 7th Fleet, Aucoin was on collision course with his boss, four-star Adm. Scott Swift.

Aucoin led with an understated, reserved style; even his personal call sign, typically a self-deprecating or derogatory joke, was an uninspired “Joey.”

Swift was garrulous and politically adroit, with eyes on ultimately being elevated to the combatant commander for the Pacific region — considered one of the choicest jobs in the military. To do that, he needed to impress his superiors with “can do” volume and no complaints.

Ironically, Swift’s boss, Adm. Harry Harris, who was then the Pacific combatant commander, had once had Swift’s job, and during his tenure there in 2014, Harris’ staff complained to the GAO that the pace of operations demanded from the 7th Fleet was unsustainable. But when he was promoted in 2015, Harris, too, ramped up the demands.

Harris could not be reached for comment.

Aucoin said Swift relentlessly ordered his fleet out on ballistic missile defense and other missions — including some Aucoin believed were unnecessary. Breaks between deployments were so short there often wasn’t time for the crew to do basic training.

That breakneck “operations tempo,’’ as the Navy calls it, left Aucoin worried about mistakes. “If we cannot get peacetime navigation” right, Aucoin wrote in his 2016 message to his commanders, “we will face real risk when we enter the fog of war.”

At one point, he had four assignments and just two ships available. He had to ask the Japanese to fill in and escort an American aircraft carrier for him. At one point, Aucoin recalled, he begged Swift to borrow a couple of ships from the Navy’s San Diego-based 3rd Fleet and was denied.

In January 2017, Swift had ordered that the USS Curtis D. Wilbur, a destroyer, be pulled out of maintenance early for an intelligence mission. The voyage did not strike Aucoin as urgent, and the ship needed repairs.

“In my 38 years of doing this kind of stuff,” Aucoin said, “I did not deem it worth the squeeze to have this ship go out.”

Aucoin thought at the time he had a solid case. Swift overruled him yet again.

“It’s like a broken record. It keeps on happening over and over again,” Aucoin told ProPublica. “It’s running our fleet ragged.”

Aucoin only recalled rare instances when Swift would accede to one of his requests, in one case agreeing to ease up the fleet’s responsibilities in the South China Sea.

Then, in January 2017, the USS Antietam, a guided missile cruiser on loan from the 3rd Fleet, ran aground on a shoal in the Tokyo Bay, in part because its skipper was in a rush that morning to get underway. No one was injured, but the ship gushed hundreds of gallons of hydraulic oil into the sea.  

The commanders in Aucoin’s 7th Fleet were worried.

They put together a troubling statistical picture: The fleet’s pace of operations was the highest in the Navy. Training was down. Certifications, which crews received after proving they were prepared to handle crucial warfighting duties, had dropped from 93 percent completed in 2014 to 62 percent in 2016. That year, only two of the fleet’s 11 destroyers and cruisers received all recommended maintenance. One ship only got a quarter of its scheduled upkeep.

In February, Aucoin decided to send the data to Swift, thinking perhaps that would persuade him to ease up.

“Excellent work,” Swift emailed the next day, according to Aucoin. Swift promised that his deputy, three-star Adm. Phillip Sawyer, would “look at the need to reduce Operations to match the fleet assigned.”

The pace of operations did not let up. Aucoin said he never heard another word.

But he was copied on many of Swift’s regular updates to his bosses: Harris and Adm. John Richardson, the head of the Navy. The emails typically began with a rosy refrain such as, “I have no issues requiring your assistance at this time.”

Swift declined to discuss Aucoin’s allegations or whether he took any actions as a result of the warnings. In a brief email, he said that readiness funding is not a new problem for the Navy and that it is a “much more systemic issue than any one individual.” After the crashes, the Navy accurately detailed weaknesses, he said, and is now fixing them.

Aucoin had directed an aide to monitor manpower in the fleet, coding vessels green if they had enough sailors; those with fewer than needed, yellow; and those where the situation was dire, red. For months, much of the 7th Fleet had been red and yellow. Frustrated, he asked to see the same chart for U.S.-based ships. They were all green.

In 2014, the Navy had moved to ensure fully trained sailors filled every post — but only on U.S.-based ships. Those ships were also given dedicated time just for training, but ships in the 7th Fleet had to squeeze it in at sea between missions.

Based in Yokosuka, Japan, the fleet is the Navy’s largest overseas installation, encompassing about 20,000 sailors and up to 70 ships and submarines. As its commander, Aucoin was responsible for an area with 36 countries and half the world’s population.

Why, then, were the U.S.-based ships better taken care of? Aucoin made clear his upset and worry to Swift.

“Calm down, Joey, we’ll take a look at this,” Aucoin recalled Swift saying.

Aucoin didn’t get a critical influx of sailors, ideally a group of senior chief petty officers who could help train his greener crews. But he got Swift, and Navy policymakers in Washington, to agree to come to Yokosuka for a conference where Aucoin could show them the problems firsthand.

As Aucoin’s concerns over the fleet’s readiness grew, its success, always crucial to American interests, was becoming even more important as the war of words between President Donald Trump and Kim Jong-un intensified. North Korean state media was saber-rattling about launching nuclear missiles at Guam and California. In April 2017, Trump threatened to send “an armada, very powerful.”

But in the Pacific, one of Aucoin’s subordinates Capt. Jeffrey Bennett, who was in charge of the squadron of ships that included the Fitzgerald and the McCain, knew that power had been diluted.

He ran around the Yokosuka ship repair facility trying to triage repairs. The ships were grossly undermanned. His direct commander, one-star Adm. Charles Williams, would call him on short notice and order him to send ships out, sometimes within hours. If he couldn’t find one, Williams ordered him to recommend a “ship based on the least impact to training and maintenance schedules,” he wrote.

Williams declined to answer questions.

Bennett called it “forced to source” — he was ordered to provide a ship to fulfill a mission, even when he objected. All his concerns were sent regularly through the ranks to Aucoin and then Swift.

“My Chain of Command was fully informed,” Bennett later wrote in a letter to a military judge after he’d been sanctioned for his role in the collisions.

Bennett’s predecessor had also specifically warned “senior leadership” in a July 2016 memo about the wholesale risks “currently being taken regarding navigation and operations.”

By 2017, 11 of the 7th Fleet’s cruisers and destroyers were, on average, short five operations specialists and at half capacity for deck seamen, the grunts essential for ships to run. Forty-nine sailors were temporarily shifted to other ships to fill gaps, strapping their home ships and at times requiring them to operate systems they’d never been trained on. Almost half the ships lacked a senior quartermaster, one of the most important navigational posts, including the Fitzgerald, which investigators later found contributed to the crash.

It's hardly the picture the Navy’s top command presented to Congress. Indeed, on Feb. 7, 2017, four-star Adm. William Moran, vice chief of naval operations, testified before the House Committee on Armed Services. The Navy was in top shape, he testified.

Overseas fleets, including the 7th, he said, were “operationally ready to respond to any challenge … and they have the training and resources they need to win any fight that might arise.”

Chapter 6

“In No Way … Prepared for an Actual Real-World Emergency”

At 1:30 a.m. on June 17, 2017, the USS Fitzgerald collided with a container ship off the coast of Japan. Ocean water flooded in through a gaping hole, killing seven sailors in the room where they slept and temporarily trapping the ship’s commander in his bunk.

Standing with the families of the ship’s crew, Aucoin and his wife watched from the pier as the disabled Fitzgerald limped back to port. Navy divers plunged into the ship’s depths to recover the bodies of the young sailors, one by one.

Aucoin said the crash seemed to jolt Swift into action. He sent Aucoin a draft of a white paper he was preparing for his superiors on cruiser and destroyer readiness in the fleet. The data it relied on, Aucoin said, was the same data he’d sent Swift in February.

Aucoin found it hard to be gracious: “I honestly feel that leadership failed to heed my recommendations” about the unrelenting pace of operations, he said he wrote back to Swift, “and its negative impact on training and maintenance.” He recommended that Swift stop pulling his ships away from their most significant training exercises for missions.

Swift, he said, did not reply. The Navy did not halt operations in the 7th Fleet to determine what had gone wrong with the Fitzgerald.

On Aug. 21, 2017, Aucoin got the call that another of his destroyers was involved in an avoidable crash. This one was worse than the last. Ten sailors dead.

Aucoin phoned Swift that Monday to tell him he was heading to Singapore, where the mangled USS McCain was to pull in.

"No, you stay,” Aucoin said Swift told him. “I want to see you in Japan on Wednesday."

"We’re using the fleet too much. We have to say ‘no’ more often.” — Robert Work, former Deputy Secretary of Defense.

“It’s getting harder and harder I think for us to look the troops in the eye.” — Three-star Adm. Thomas Copeman, former head of Navy's surface fleet.

"It's sleepwalking into a level of risk you don't realize you have." — Janine Davidson, former undersecretary of the Navy.

Roslan Rahman/AFP/Getty Images, U.S. Navy, and The Asahi Shimbun via Getty Images

The subsequent internal investigation of the McCain crash, obtained by ProPublica, unspools an almost inconceivable collection of lapses and blunders. Many were foreshadowed during the previous seven years, from the Balisle report in 2010 through Aucoin’s pleas for help.

According to the investigative report, the McCain was steaming through the crowded Singapore Strait en route to a shipyard on the country’s northern coast, when the captain noticed that one of his sailors was having difficulty staying on course and maintaining the ship’s speed at the same time.

The captain ordered a second crew member at a different computer console to take control of the speed, but that only led to more confusion and eventually panic. No one fully understood how to use the new touchscreen navigation system. For several minutes, the crew mistakenly thought it had lost control of the steering. Then they accidentally slowed the propeller on only one side, forcing the McCain to turn sharply left.

The errors led the McCain to careen into the path of a oil tanker more than three times its size. The impact ripped a giant hole in the McCain’s side, flooding a sleeping area, and much like it had with the Fitzgerald, trapping and drowning the sailors inside. Only two of the 12 men in the room escaped.

The initial investigation chronicled a familiar list of deficiencies: The ship had too few sailors, and those it did have were getting just four to five hours of sleep a day. The chief petty officer in charge of teaching the sailors how to use the new steering system had received less than an hour of instruction.

In a survey of the crew the year before, sailors had alerted their leaders about their lack of training on the ship’s new systems.

“Many sailors commented they were doing maintenance without fully understanding what they were doing,” the investigation found. Meanwhile, the fixes for major system failures and deterioration were described as “putting a Band-Aid on equipment to make senior leadership happy."

"We may be able to pass certifications but in no way be prepared for an actual real-world emergency or casualty," one sailor said.

Chapter 7

“You Choose Your Battles”

Two days after the McCain crashed, Aucoin sat in the front row of the base movie theater in Yokosuka, the same place the Navy had memorialized the Fitzgerald sailors just nine weeks earlier. He had gathered hundreds of top officers and enlisted sailors for what the military calls a “safety stand down.” Operations stop for a day and the focus is turned to discussing what went wrong.

Back in Washington, members of Congress were demanding action after a second historically deadly Navy accident in as many months.

In the theater, Aucoin’s assistant got his attention. He needed to check The Wall Street Journal.

“Vice Adm. Joseph Aucoin, the three-star commander of the U.S. Seventh Fleet in Yokosuka, Japan, will be relieved of command on Wednesday…,” the story read.

Aucoin knew Swift was scheduled to arrive in about 90 minutes. He rushed from the theater and fired off a blunt email to the Navy’s top military leader: His warnings had been routinely ignored, and he didn’t appreciate learning from a newspaper that he was to be fired.  

When Swift arrived at Aucoin’s office, he sank into the couch. Both men began crying, Aucoin recalled. Swift told him that if he hadn’t fired Aucoin, he’d have been the one under fire.

“They should be looking at you,” Aucoin said he responded.

No commanders ranked higher than Aucoin were fired.

Swift did not get a promotion and retired. He is now a visiting scholar at the Massachusetts Institute of Technology.

Swift’s deputy, Sawyer, who Aucoin said did not respond to his warnings, took over Aucoin’s command.

Rowden, who succeeded Copeman and worried aloud to Janine Davidson, was forced to retire at a lower rank.

The four-star admiral in charge of setting the ships’ manpower levels, Phil Davidson, was allowed to write the Navy’s report on the systemic problems that contributed to the collisions. He was then promoted.

Sawyer and Phil Davidson did not respond to requests for interviews.

Janine Davidson became president of Metropolitan State University of Denver. As a Democrat, she was expected to stay on in a Hillary Clinton administration, potentially taking over as Navy secretary. When Mabus shut down her readiness complaints, she backed down, expecting she’d have another run at it the following year, after the election.

“You choose your battles,” she said. “It was a ‘We’ll get at it next year’ kind of thing.”

As for Mabus, the Navy secretary departed before the crashes and started his own consulting firm. His office, high above K Street in Washington, is decorated with his old campaign memorabilia and Navy honors. Oppel, his former aide, joined him there. In his interview with ProPublica, Mabus assumed no responsibility for either collision. He called the Navy’s two deadliest accidents in decades coming within weeks of each other “a coincidence.”

“Both of them were failures on those ships,” he said.

On Sept. 7, 2017, the House Committee on Armed Services called Moran, the second-highest ranking Navy officer, back to account for his reassurances before the collisions that the 7th Fleet was ready for any challenge.  

“I personally made the assumption, and I have made the assumption for many, many years that our forward-deployed Naval force in Japan was the most proficient, well-trained, most experienced force we had, because they're operating all the time,” said Moran, who is reportedly next in line to become the Navy’s top commander.

“I've made the assumption. It was a wrong assumption, in hindsight.”

Read More: How We Investigated the Navy’s Twin Disasters in the Pacific →

The following people contributed to our reporting: Robi Bean, Sophie Chou, Jeff Ernsthausen, Stefan Fichtel, Xaquín G.V., Joshua Hunt, Ian MacDougall, Claire Perlman, Gabriel Sandoval, Ann Schneider, Nate Schweber, Lucy Sexton, Ginger Thompson and Lucas Waldron.

Additional design and development by Al Shaw and Ken Schwencke.

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Robert Faturechi is a reporter at ProPublica covering money in politics. Before joining ProPublica, he was a reporter at The Los Angeles Times, where his work exposed inmate abuse, cronyism, secret cop cliques and wrongful jailings at the Los Angeles County Sheriff’s Department.

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Megan Rose, formerly Megan McCloskey, covers criminal justice for ProPublica. Previously she covered the military, investigating such issues as the billions of dollars wasted by the U.S. government in Afghanistan and how the Pentagon was failing in its efforts to find and identify missing service members from past wars.

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T. Christian Miller is a senior reporter for ProPublica. In more than 20 years as a professional journalist and foreign correspondent, Miller has covered four wars, a presidential campaign and reported from more than two dozen countries. He has won numerous accolades for his work in the U.S. and abroad, including the 2016 Pulitzer Prize for Explanatory Reporting.