An alignment of odd and ordinary circumstances within the 1st Battalion, 18th Infantry Regiment unwittingly aided Pvt. Jeremiah Carmack in his final mission, with disastrous results.

Following the battalion’s 15-month tour to Iraq, many soldiers, including several key leaders, were leaving for new assignments, according to an Army report. There were manpower shortages and information wasn’t flowing as smoothly as normal. There also were problems in the armory, mainly due to its personnel’s incomplete training.

And so Carmack’s litany of troubles came crashing together "at the apex of a perfect storm," said Lt. Col. Steven Miska, who took over as battalion commander in late January. Carmack was shot dead by German police March 13 after he smuggled an M-4 off a Schweinfurt post and took his ex-girlfriend hostage. The woman was unhurt.

"In the span of about a month, we had three different command teams," Miska said. Each command team — rear detachment, regular and incoming — "had a whole lot on their plate." It was a time of "high personnel turbulence."

The report the Army released Friday chronicled a series of procedural errors in the unit’s arms room as well as mistakes in the handling of critical information concerning Carmack, who had recently attempted suicide.

In the report, the investigating officer characterized the company arms room as "unorganized," inattentive, and "prone towards confusion and chaos." Carmack was able to exploit the situation due to his familiarity with the operations of an arms room from a previous enlistment.

Since the March incident, battalion and brigade officials have taken steps to improve the management of its arms rooms. While not going into detail, Miska said one change is the creation of a list of soldiers not authorized to draw weapons. A soldier undergoing mental health treatment would fall into this category.

Miska said the Army is now looking into giving units returning from Iraq or Afghanistan more time to get settled.

Carmack, 30, a logistics specialist, actually had been pitching in at the arms room, and his familiarity with the section afforded him the opportunity to secure a weapon during an Expert Infantry Badge event, even though he was not taking part. In fact, the soldier Carmack got the gun from soon left to take part in the drill himself.

The report wasn’t all negative.

A review of procedures at the qualification range found that it had "very good shakedown procedures for checking for brass and ammunition retention by soldiers," the report stated. Still, investigators believe Carmack obtained the 15 rounds and one magazine from the range three days before his death.

And that, Miska said, illustrates how difficult it can be to stop somebody bent on revenge, even with adequate safeguards.

Carmack, who had smacked a superior during a previous enlistment, was incensed when he learned his roommate and former girlfriend were dating.

Carmack’s checkered past and his December suicide attempt should have been caught by a physician assistant, Miska said, especially since Carmack was being considered for a job in the armory. But a shortage of physician assistants and their lack of access to all his medical files played roles in the oversight.

"There was a definite breakdown in information being passed (along)," Miska said. With all the red flags, communication between leaders "should have happened, but it didn’t."

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