Navy Training: Safety Has Been Improved, but More Still Needs to Be Done: NSIAD-89-119

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.