The investigation was convened by Commander, Naval Education and Training Command and conducted by 11 members from various backgrounds of expertise, such as safety, medical, legal and Naval Special Warfare.

“At its core, the investigation finds that relentless and continuous self-assessment and self-correction within all departments of NSWC’s BTC is required,” said Rear Adm. Peter Garvin, commander, Naval Education and Training Command. “This investigation identifies risks that aggregated as the result of inadequate oversight, insufficient risk assessment, poor medical command and control, and undetected performance enhancing drug use; and also offers actionable solutions to mitigate those risks going forward.”

The investigation found that the BUD/S training program was operating with a previously unrecognized accumulation of risk across multiple systems.

Naval Special Warfare Command has already implemented many improvements to its training programs and policies, including but not limited to, greater instructor oversight and training; more thorough medical screenings for cardiac conditions; updated medical policies and standard operating procedures; and a new expanded authority to test NSW candidates for PEDs.

“I wish to extend my sincere gratitude to the Naval Education and Training Command investigation team for their insightful recommendations,” said Rear Adm. Keith Davids, commander, Naval Special Warfare Command. “Our effectiveness as the Navy's maritime special operations force necessitates demanding, high-risk training. While rigorous and intensely demanding, our training must be conducted with an unwavering commitment to safety and methodical precision. Therefore, in the wake of the tragic loss of Seaman Kyle Mullen, we have taken decisive steps to improve our policies and standard operating procedures. The insights gleaned from the NETC investigation will also further empower us to refine, enhance, and elevate our naval commando training.”

Davids said it remains a top priority for NSW and the Navy to learn from this tragedy and take the actions necessary to prevent it from happening again.

“We will honor Seaman Mullen's memory by ensuring that the legacy of our fallen teammate guides us towards the best training program possible for our future Navy SEALs.”

Investigation can be found:  https://www.netc.navy.mil/Resources/FOIA/FOIA-Reading-Room/