Navy Training:

Safety Has Been Improved, but More Still Needs to Be Done

NSIAD-89-119: Published: Mar 7, 1989. Publicly Released: Mar 7, 1989.

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Pursuant to a congressional request, GAO investigated the circumstances surrounding the death of a Navy enlistee during swimming training, focusing on: (1) how and why the incident occurred; (2) the Navy's actions to prevent a recurrence; (3) the adequacy of an investigation into the enlistee's death; and (4) whether safety problems have contributed to other Navy training deaths since January 1986.

GAO found that: (1) command pressure to produce more graduates, an intimidating atmosphere, and inadequate internal controls were factors that contributed to the enlistee's death; (2) the Navy school did not adequately supervise and train its instructors, lacked an adequate student feedback system, improperly screened students, and did not have a system to alert instructors to student problems; (3) the Navy school's high-level command did not pay sufficient attention to high attrition and rollback rates, follow up on injury incidents, establish safety audit or inspection responsibilities, or review its curriculum; (4) the Navy's initial investigation was flawed and hasty and did not thoroughly analyze the circumstances of the incident; (5) although the investigation resulted in procedural changes, additional changes were necessary to clarify policies, eliminate coercion, improve instructor selection and training, and improve internal controls; and (6) safety problems were responsible for 16 other training-related deaths, some of which the Navy did not properly investigate.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: New Navy policy prohibits negative sanctions and regular safety reviews will check on implementation.

    Recommendation: The Chief of Naval Education and Training should eliminate the negative sanctions imposed on those who drop out of voluntary training programs because of safety concerns.

    Agency Affected: Department of Defense: Department of the Navy: Naval Education and Training Command

  2. Status: Closed - Implemented

    Comments: The ASW contract has been revised to provide a better description of the type of training.

    Recommendation: The Chief of Naval Education and Training should clarify the aviation anti-submarine warfare (ASW) operator enlistment contract to include a better description of the kind of training that is required.

    Agency Affected: Department of Defense: Department of the Navy: Naval Education and Training Command

  3. Status: Closed - Implemented

    Comments: Commanders are now required to investigate and report all training-related injuries. Since September 1989, each high-risk course was required to be assigned a safety officer to conduct independent investigations.

    Recommendation: The Chief of Naval Education and Training should ensure that schools comply with requirements to submit accident or injury reports and safety officers perform independent safety investigations of those incidents.

    Agency Affected: Department of Defense: Department of the Navy: Naval Education and Training Command

  4. Status: Closed - Implemented

    Comments: Policies have been revised to require that attrition and accident/injury information goes to course curriculum model managers.

    Recommendation: The Chief of Naval Education and Training should ensure that training course model managers receive information on attrition and accidents or injuries.

    Agency Affected: Department of Defense: Department of the Navy: Naval Education and Training Command

  5. Status: Closed - Implemented

    Comments: Student critique system policies have been revised to require critiques from attrited students also. Compliance will be monitored in high-risk course reviews.

    Recommendation: The Chief of Naval Education and Training should improve the student critique system to ensure that information is also gathered from students who do not complete training courses and that the student evaluation forms are redesigned to provide useful assessments.

    Agency Affected: Department of Defense: Department of the Navy: Naval Education and Training Command

  6. Status: Closed - Implemented

    Comments: Policies have been revised to require review of personnel and medical records. If any questions emerge from this review, the commander can request formal medical or psychological screening. The Navy is also working on developing additional screening devices.

    Recommendation: The Chief of Naval Education and Training should ensure that the selection process for instructors of high-risk courses includes an assessment of their suitability for that kind of environment and that instructor training for those courses includes preparation on how to deal with students in a high-stress or high-risk environment.

    Agency Affected: Department of Defense: Department of the Navy: Naval Education and Training Command

  7. Status: Closed - Implemented

    Comments: With improved safeguards for DOR and TTO and increased instructor training and screening, the Navy believes student screening can safely occur during training.

    Recommendation: The Chief of Naval Education and Training should ensure that the student selection process also includes some psychological screening of their suitability for high-risk occupations.

    Agency Affected: Department of Defense: Department of the Navy: Naval Education and Training Command

  8. Status: Closed - Implemented

    Comments: CNET safety review teams now contain members with safety expertise.

    Recommendation: The Chief of Naval Education and Training should ensure that course safety review teams include personnel with safety expertise.

    Agency Affected: Department of Defense: Department of the Navy: Naval Education and Training Command

  9. Status: Closed - Implemented

    Comments: Policies have been revised to task local commanders with responsibility for ensuring accurate knowledge of student status changes. Safety reviews will monitor for compliance.

    Recommendation: The Chief of Naval Education and Training should ensure that controls on student status changes are sufficient to provide supervisors with a clear indication of what status changes have been made.

    Agency Affected: Department of Defense: Department of the Navy: Naval Education and Training Command

  10. Status: Closed - Implemented

    Comments: The Navy disagreed with the recommendation to retain investigator notes and intends to take no action. This issue will be re-examined by GAO in a current assignment on Department of Defense Training Safety.

    Recommendation: The Secretary of the Navy should require that investigator notes be retained with the Judge Advocate General Manual investigation file.

    Agency Affected: Department of Defense: Department of the Navy

  11. Status: Closed - Implemented

    Comments: Policy has been revised to require documentation of legal opinions in the case file.

    Recommendation: The Secretary of the Navy should direct that any legal opinions that affect the course of an investigation be documented and made a part of the case file.

    Agency Affected: Department of Defense: Department of the Navy

  12. Status: Closed - Implemented

    Comments: All CNET high-risk courses now have incorporated DOR and TTO policies into their programs with standardized signalling.

    Recommendation: The Chief of Naval Education and Training should clarify the way the drop-on-request (DOR) and training-time-out (TTO) policies are communicated to the students and staff and how students are to signal that they are invoking the policies.

    Agency Affected: Department of Defense: Department of the Navy: Naval Education and Training Command

  13. Status: Closed - Implemented

    Comments: The Navy has reviewed its regulations and policies and clarified the circumstances under which investigations are to be made, who should perform them, and how their results should be disseminated.

    Recommendation: The Secretary of the Navy should review the regulations and procedures applicable to death investigations to clarify under what circumstances investigations should be performed, who should perform them, how investigative authorities are informed that death has occurred, and how the findings of death investigations should be disseminated.

    Agency Affected: Department of Defense: Department of the Navy

 

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