source GAIA package: Origin key: Sx_MilitaryTimes_M6201310312030014 imported at Fri Jan 8 18:18:12 2016

Rules were broken, protocols ignored, and yawning holes in barracks security revealed.

In the wake of a crime-of-passion shooting aboard Marine Corps Base Quantico, Va., earlier this year that left three Marines dead, a new command investigation sheds light on the events surrounding the murders. But the question of who should take the blame for the tragedy remains in dispute.

Late at night on March 21, 2013, Sgt. Eusebio Lopez, 25, a tactics instructor at Quantico's Officer Candidates School, gunned down two fellow Marines: Lance Cpl. Sara Castromata, 19, a warehouse clerk, and Cpl. Jacob Wooley, 23, a field radio operator. Lopez then shot himself in the head. The investigation reveals that recommendations for improved practices were made for a number of commands in the aftermath of the shootings, but it's far from clear that any of these could have prevented the violence.

"We must recognize the significance of even the seemingly inconsequential details that effected or failed to prevent this incident," wrote the investigating officer, Marine Brig. Gen. Marcela Monahan. "In hindsight, some details now loom large."

But the investigation's endorsement by Lt. Gen. Richard Mills, former commander of Marine Corps Combat Development Command, challenges that conclusion.

"Notwithstanding the investigating officer's findings regarding the command climate, medical treatment, force preservation and command policies, the murder-suicide in this case was not reasonably foreseeable by any individual or command," he wrote. "This conclusion does not otherwise relieve anyone for individual or collective failings identified in the report, but it cannot be concluded from the facts and circumstances that any of the variables, together or separate, were a direct or indirect causal factor in this tragic event."

Col. Kris Stillings, commander of OCS, was the only officer relieved for cause following the shootings, said Marine Corps Combat Development Command spokesman Col. Sean Gibson. But 12 Marines, including three officers, have faced or will face administrative and nonjudicial proceedings in the wake of the incident, Gibson said.

Stillings' relief in April was considered shocking and controversial among those who knew him and his reputation. A command climate survey reviewed by Marine Corps Times found Stillings was "universally respected and seen as an engaging and caring leader." He had successfully worked to improve the school's reputation following a high-profile sex scandal among instructors that blew up in 2011 and sent 10 troops to courts-martial.

In a statement provided to Marine Corps Times on Nov. 29, Stillings said he took full responsibility for everything that occurred on his watch, but found the rule-breaking behavior of a small number of Marines not to be representative of the disciplinary atmosphere at OCS and certainly not an indicator of a causal relationship between the school's command climate and the shootings.

"For once, why don't we call it what it is," he wrote. "A young Marine murdered two people and killed himself. He is responsible.

"Yes, it is extremely sad and we must do everything we can to not let this happen again as three young people are dead, families in ruins and careers are destroyed. We have to learn what we can from this horrible event and institutionalize the lessons for the betterment of our Corps as this tragic event is a part of our society's larger problem of gun violence and mental health issues. But the continued public discourse on who is to blame now only hurts the families involved and the unit."

Stillings' full statement accompanies this story.

A troubled Marine

According to the July 12 investigation, obtained by Marine Corps Times through a Freedom of Information Act request, Lopez, a seven-year Marine from Pacifica, Calif., had deployed twice before, in 2007 to Iraq and in 2011 to Afghanistan. A close encounter with a pressure-plate improvised explosive device on his first deployment visibly altered his mood and demeanor. On the second, his vehicle struck a roadside bomb, leaving him with mild traumatic brain injury, persistent back pain and an even more altered and irritable personality.

Whatever the cause, there is plenty of evidence in retrospect that Lopez was troubled. In professional reviews from 1st Battalion, 9th Marines, his prior command at Camp Lejeune, N.C., regarding his performance downrange, Lopez is described as "absolutely awesome ... definitely able to multi-task." He "displayed strong initiative ... [and] significantly enabled the company's operations to thrive in the combat environment," according to the investigation.

But that changed after he returned from his second deployment.

In early 2012, Lopez's wife returned home from an outing to find him holding a knife. He told her she was lucky she didn't bring a man home with her, then told her he would use a shotgun on her if she ever cheated, the investigation found. It's not clear if she reported these threats when they happened.

"What consumes your mind controls your life," read one of his tattoos. Another featured a grim reaper.

Lopez's professional file contains a number of disciplinary records, including counseling for disrespect to his section leader.

While Lopez was treated for his head injuries, his care with the Marine and Sailor Concussion Recovery Center was concluded in May 2012, shortly before he transferred to Quantico's OCS on orders. A mental health summary from a TBI specialist, cited in the command investigation, reported: "Interview (with Lopez) completed 17 April 2012. He required no follow-up and was not referred for further mental health services."

The investigation found that there was no "conscientious and deliberate transfer" of Lopez's medical case from Lejeune to Quantico. Nevertheless, he was still suffering from his war injuries, with symptoms that included cognitive difficulty, emotional numbness and irritability, forgetfulness and difficulty concentrating, the investigation notes.

His leadership at OCS gave him faint praise, saying he lacked initiative and was not a multi-tasker, but displayed adequate professional behavior.

He had also been counseled to keep better professional boundaries between himself and the Marines he was supposed to lead. He was seeking a divorce from his wife, and had become involved in a romantic relationship with Castromata.

On Aug. 27, 2012, after Lopez had transferred to Quantico, he sent a series of text messages to a woman back in Jacksonville, N.C., expressing suicidal thoughts. Fearful for his safety, she contacted his command and reported her concerns. The OCS officer on duty reported the call up the chain of command, and the local sheriff's department was dispatched to Lopez's Stafford, Va., home.

But Lopez said the texts were taken out of context and convinced the officers that he was calm and stable. At OCS, Lopez's senior officers made sure someone was checking in on him and talking with him, but found he seemed to be all right and did no further follow-up work.

"No elevated risk assessment was made, and no further action was taken," the investigation found.

Breaches of security

The probe also found that Lopez was never asked about his personal weapons when he moved from off-base housing in Virginia to a barracks room in Quantico. In fact, no paperwork was found showing Lopez had permission to move into the Taylor Hall barracks at OCS as a geobachelor, a request that required the permission of a base or area commander, the report said.

Another Marine told investigators that Lopez kept a handgun in the nightstand next to his barracks bunk. Ammunition was later found in his car, also in violation of base policy. He never registered any weapons with the base, an installation requirement.

He was not alone. Investigators learned that a number of Marines, including one officer, were violating base weapons policy, despite receiving a brief about weapons regulations following the Sandy Hook, Conn., shootings in December 2012. Some Marines were keeping weapons in their cars to avoid checking them into the armory when they came on base. At an "amnesty hour" a few days after the shootings, OCS Marines surrendered unauthorized weapons including two pistols, two archery bows, and one knife.

The investigation also determined that Lopez never received a physical health assessment in 2013, which was supposed to be administered within 30 days of February, his birth month. Moreover, no force preservation councils, designed to evaluate at-risk personnel, met at OCS between April and August 2012, though they were supposed to meet every month.

The day before the shooting, Lopez brought a civilian friend into the barracks without signing her into the visitor's log and had sex with her in his room, both against barracks orders, the investigation states.

A deadly confrontation

On March 21, the day of the shooting, Lopez sent at least two dozen text messages with suicidal overtones to Castromata, who had ended their relationship weeks before. Lopez's staff NCO could not recall if he had ever counseled Lopez about inappropriate fraternization with Castromata, though someone had reported the relationship to him. The investigation showed that she told one other Marine she was concerned about Lopez, but nobody confronted him or reported the messages to his command.

By that time, Castromata had begun dating Wooley.

Just hours before pulling the trigger, Lopez went to the assistant to the barracks manager and said he had locked himself out of his room. The assistant gave Lopez the master key to the barracks, which was never supposed to leave his possession. Lopez returned moments later, but instead of giving him back the master key, he gave him the key to his own room. He used the master key to gain access to both Castromata and Wooley's rooms throughout the evening, although not during the actual shooting incident. The copy of the investigative report obtained by Marine Corps Times does not indicate what he was doing there.

Around 10 p.m., a Marine in his barracks room heard Wooley, who had emerged from Castromata's barracks room, verbally confront an unknown individual. He said he then heard five or six gunshots. Lopez shot Wooley 14 times, then entered Castromata's room and shot her six times.

When an individual, whose identity is redacted in the report, came near the scene of the murders, Lopez emerged from the room, waving a gun. "Go away, get out of here right now," he said.

He shot himself in Castromata's room soon afterward.

Investigators discovered that the OCS officer on duty had no specific instructions for dealing with an active-shooter incident. A military special response team, summoned by 911 calls following the gunshots, found Wooley's body right away, but it took nearly four hours for responders to discover the bodies of the other two Marines.

The aftermath

The investigation concluded with 32 recommendations, 12 of which are designed to help the Navy Bureau of Medicine and Surgery review possible systemic flaws that may have led to Lopez's breakdown, with the hope of preventing future incidents. The report also recommends that OCS review and update all orders, directives and procedures related to barracks management, weapons possession and storage, standing duty, alcohol possession and consumption, and barracks security, among other topics.

Lopez's alcohol consumption was determined to be a factor in the shooting.

Recommendations for MCCDC included directing subordinate commands to establish active-shooter response scenarios, ensuring all commands conduct force protection councils and physical health assessments as directed, and allow medical personnel to alert FPCs to elevated risk, within privacy standards, using a new system piloted by the 2nd Marine Regiment.

Gibson said MCCDC already ensures that commands adhere to the standards and that the command was enhancing its force protection efforts with beta testing of a new Defense Department system, since the regimental version proved not to be a viable option.

According to Gibson and 2nd Lt. Matthew Rojo, a spokesman for Quantico, one significant change since the tragedy is the amount of command attention devoted to active-shooter training and scenarios. Thirty "response to an active shooter" briefs have been conducted this year, they said. Of the three active-shooter exercises that have been conducted aboard the base since 2010, two took place this year.

A spokeswoman for BUMED, Navy Capt. Dora Lockwood, said Navy Medicine was already conducting reviews of the treatment and assessment of post-traumatic stress in cases of mild traumatic brain injury, as recommended in the investigation. Officials were also working to create guidelines for timely integration of medical records and reports into the Defense Department electronic record system, per recommendations.

In the wake of the shooting — and other incidents involving unauthorized use of personal weapons on base — the head of Marine Corps Installations Command, Maj. Gen. Juan Ayala, ordered a review of how personal weapons policies in the National Capital Region were enforced. And many of the tenets of Commandant Gen. Jim Amos's recent "reawakening" campaign pertain to barracks management and security, including more officers patrolling the barracks, fewer distractions for Marines standing duty and surveillance cameras at each facility.

For all the information unearthed by the investigation and all the command actions that followed, the horror and sadness of March 21 remains undimmed and the mystery of Lopez's actions untouched.

"Yes, something went wrong as no one commits an act like this without having issues. But the fact is that we will never know why; the truth went to the grave with him," Stillings said.

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