The following is the Feb. 21, 2020 command investigation into the fatal shooting into the Naval Air Station Pensacola, Fla., on Dec. 6, 2019. The report was released on Nov. 20, 2020.
Findings
The self-radicalization of 2nd Lt Al-Shamrani was the primary cause of this fatal attack. However, his actions and behaviors, along with the organizational environment inherent in the aviation pipeline, likely increased his probability of committing an insider attack. Military leaders, government employees, contracted employees, peers, and civilians knew of isolated events and indicators, but all remained unaware of a complete picture of 2nd Lt Al-Shamrani’s potential threat indicators. While these indicators are apparent in hindsight, they were not evident in aggregate before 6 December 2019. Based upon the information available at the time, no one person or organization knew or could have known 2nd Lt Al-Shamrani would attack active duty service members and civilians at NASC.
There are six primary reasons a complete picture of 2nd Lt Al-Shamrani’s path to radicalization was not recognized and interrupted. First, 2nd Lt Al-Shamrani performed adequately across the aviation pipeline and his record contained neither disciplinary nor significant performance issues. Second, during his time at NASP, he reported to five separate commands over an 18 month period, limiting oversight by individual commanders. Third, his weapon purchase and training remained unknown to U.S. military and civilian leadership. Fourth, his social media presence and radical posts remained unknown to U.S. military and civilian leadership. Fifth, his multiple instances of unauthorized travel within the United States remained unknown to U.S. military and civilian leadership. Finally, a documented equal opportunity complaint was considered closed 7 months before the attack, though likely not to the satisfaction of 2nd Lt Al Shamrani. Based on existing policies, programs, and procedures, the investigation team could not conclude anyone should have identified 2nd Lt Al-Shamrani as a threat.
Utilizing critical path analysis, the investigation team identified contributing factors potentially influencing 2nd Lt Al-Shamrani’s action. The presence, or in some cases absence, of these risk factors and organizational conditions may have influenced the sequence of events leading to the attack. These factors include:
- Adverse IMS microclimate at NASC
- Harassment by a Training Wing SIX (TW-6)-contracted instructor
- Perceived inadequacy of the resolution of an equal opportunity (EO) harassment complaint
- Inattention and absence of the RSAF country liaison officer (CLO), responsible for good order and discipline
- Perceived inadequacy of religious facilities by Kingdom of Saudi Arabia (KSA) IMS and RSAF leadership
- Reported noise infractions at his public-private venture (PPV) residence
- Observation of his attempted weapon purchase by a TW-6-contracted instructor
- Isolated, questionable interactions with instructors and international military student officers (IMSO)
- Self-isolation from other KSA IMS
- Unfulfilled verbal request to complete advanced Undergraduate Military Flight Officer (UMFO) training with his roommate
- Departure of his roommate on leave in November 2019
- Social media network risks
- Absence of a coordinated, risk assessment process
- Numerous instances of unauthorized leave and travel
In addition, 2nd Lt Al-Shamrani likely faced additional personal and professional stressors due to a language barrier, cultural differences, and the rigor of high-risk aviation training and academics. Mitigating these individual risk factors may not have stopped 2nd Lt Al-Shamrani from evolving into a hostile insider threat, yet they may have lessened his cumulative load of stress, pressure, and anger. Nonetheless, the majority of these risk factors and organizational conditions are not unique to 2nd Lt Al-Shamrani or IMS writ large. In the absence of proactive leadership, positive command climates, and personalized risk management, they may also apply equally to our own Sailors and civilian personnel.
The specific findings, opinions, and recommendations of the investigation team are included in Chapters 3 through 10 and Appendix B of this report. The findings are grouped into two general categories–potential contributing factors and noncontributing factors. Mitigation of potential contributing factors may have interrupted the critical path leading to the attack. Noncontributing factors did not directly impact the critical path, but should be addressed to prevent or mitigate future attacks, improve our readiness, and assure the safety of our force. In accordance with the convening order, the findings are categorized based on compliance with applicable law, regulation, programs, policies, and procedures; or deficiency in doctrine, organization, training, materiel, leadership and education, personnel, and facilities (DOTMLPF). All recommendations identify an actionable entity in alignment with its known authorities.
Download the report here.
