Navy Training Safety:

High-Risk Training Can Be Safer

NSIAD-91-112: Published: Jun 26, 1991. Publicly Released: Jul 9, 1991.

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Pursuant to a congressional request, GAO reviewed selected Navy high-risk training courses, focusing on the Navy's efforts to improve training safety.

GAO found that: (1) although the Chief of Naval Education and Training (CNET) took a number of steps to improve internal controls after the death of an airman recruit during a high-risk training course, internal control weaknesses continued to exist in such courses; (2) significant weaknesses existed involving student and instructor screening, processing controls for students with medical problems, trainer evaluations, and the course critique system available to students; (3) most problems resulted from inadequate implementation of CNET policies, rather than inadequacies in such policies; (4) the Navy lacked adequate oversight of high-risk training to ensure student and instructor safety; (5) five of the eight training activities visited lacked adequate mishap reporting systems, and authorities responsible for analyzing such mishaps failed to do so; (6) while the Navy took steps to improve safety reviews and policies, it still conducted unsafe and unapproved training exercises; (7) the Navy established the Training Performance Evaluation Board to systematically monitor and evaluate all high-risk training; (8) the Navy shortened its curriculum at two surface rescue swimmer schools despite strong opposition and concerns that a shortened course would compromise safety and increase the risk of training injuries; and (9) the shortened course resulted in increased attrition due to more demanding schedules and reduced students' ability and proficiency in rescue techniques.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: CNET has made local commanders responsible for tracking student medical status and made it a specific inspection item for the Training Performance Evaluation Board (TPEB).

    Recommendation: The Chief of Naval Education and Training should enforce and monitor administrative processing controls aimed at ensuring that a student determined to be medically unqualified for high-risk training cannot reenter training until cleared by proper medical authorities.

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

  2. Status: Closed - Implemented

    Comments: CNET established a review of instructor evaluations as a TPEB inspection item and promulgated an instruction requiring corresponding coverage of non-classroom instruction in instructor evaluations.

    Recommendation: The Chief of Naval Education and Training should enforce compliance with CNET requirements to evaluate instructors of high-risk courses quarterly and require training commands to increase the coverage of their nonclassroom activities in their instructor evaluations.

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

  3. Status: Closed - Implemented

    Comments: CNET issued a new instruction (CNET Instruction 1540.6D) on student critiques.

    Recommendation: The Chief of Naval Education and Training should revise student critique form requirements to ensure that the forms used in all high-risk training courses are unbiased, ask specific rather than general questions, solicit student feedback on nonclassroom activities, individual instructors, and unsafe training conditions or practices, and can be completed anonymously.

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

  4. Status: Closed - Implemented

    Comments: The Chief of Naval Operations has redirected fleet commanders to ensure that all candidates for high-risk training meet all stated prerequisites, including true volunteer status if applicable.

    Recommendation: The Chief of Naval Operations should direct fleet commanders to adhere to the minimum requirements specified in the Catalogue of Navy Training Courses when sending personnel to high-risk training courses, and that they send only volunteers to those courses.

    Agency Affected: Department of Defense: Department of the Navy: Office of the Chief of Naval Operations

  5. Status: Closed - Implemented

    Comments: CNET Instruction 1500.2B now requires all training-related first-aid, medical treatment, and lost time mishaps to be reported. The Naval Safety Center now requires course identification numbers on training mishap reports to track and analyze trends.

    Recommendation: The Chief of Naval Operations should strengthen the role of the Naval Safety Center by requiring training commands to report all high-risk training mishaps that occur in individualized and specialized training and require any type of trained medical attention, regardless of training or work time lost, to the center.

    Agency Affected: Department of Defense: Department of the Navy: Office of the Chief of Naval Operations

  6. Status: Closed - Implemented

    Comments: The Naval Safety Center has devised a system allowing it to analyze training mishaps by course.

    Recommendation: The Chief of Naval Operations should strengthen the role of the Naval Safety Center by requiring the center to devise a system to analyze high-risk training mishaps for causes and trends and to share the results of those analyses on a regular basis with the Chief of Naval Education and Training.

    Agency Affected: Department of Defense: Department of the Navy: Office of the Chief of Naval Operations

  7. Status: Closed - Implemented

    Comments: Oversight of training mishap reporting has been increased. Training activities are now required to submit a quarterly report of reportable and recordable training-related illnesses and injuries.

    Recommendation: The Chief of Naval Education and Training should require subordinate commands to: (1) keep thorough and accurate records of all high-risk training mishaps; (2) evaluate them for trends that may indicate unsafe training policies, practices, or equipment; (3) initiate corrective actions when trends indicate they are warranted; and (4) regularly report results of mishap analyses and corrective actions to senior commands.

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

  8. Status: Closed - Implemented

    Comments: CNET directed diving experts to determine the reasons for the relatively high incidence of shallow-water blackout. Schools have been directed to discontinue all training that teaches hyperventilation as a means to decrease the urge to breathe.

    Recommendation: The Chief of Naval Education and Training should have the pool competency drill conducted in the SEAL training examined by medical diving experts to determine the reasons for the relatively high incidence of shallow-water blackouts and revise procedures to reduce the risk of those incidents.

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

  9. Status: Closed - Implemented

    Comments: CNET directed course curriculum model managers to review course exercises that involve high risk. CNET also reemphasized in Instruction 1500.20B that only the approved curriculum is to be conducted.

    Recommendation: The Chief of Naval Education and Training should direct that any exercises that do not contribute to training objectives, particularly those that appear to involve unacceptable risks, be discontinued, and that all high-risk training evolutions be included in the course curriculum and approved by higher authority before they are conducted.

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

  10. Status: Closed - Implemented

    Comments: The Navy has developed a screening instrument to be administered to instructors and students of high-risk training courses and has issued procedures for psychological screening.

    Recommendation: The Chief of Naval Education and Training should explore the development of psychological screening devices for all students and instructors in high-risk training to determine their suitability to participate in that training.

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

  11. Status: Closed - Implemented

    Comments: CNET reviewed the curriculum of the surface rescue swimmers training and it has been revised accordingly.

    Recommendation: The Chief of Naval Education and Training should reconsider the decision to shorten the surface rescue swimmer course.

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

 

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