SEAL Drowning Investigation

UNITED STATES CENTRAL COMMAND
OFFICE OF THE COMMANDER

7115 SOUTH BOUNDARY BOULEVARD.
MACDILLAIR FORCE BASE, FLORIDA 13621-5101
6 September 2024
MEMORANDUM FOR COMMANDER, U.S. NAVAL FORCES CENTRAL COMMAND
(NAVCENT)
SUBJECT: Command Investigation Into the Facts and Circumstances Surrounding the Loss at Sea of
Two Task Force Three Personnel On Or About || January 2024
1. 1 have reviewed the above subject investigation and concur with the findingsof fact, opinions, and
recommendations, as modified, withthe excepion of Recommendations, paragraph 13.
2. 1 modify the Command Investigation, Recommendations, paragraph 13 to read as follows:
£66 RECOMMEND COMNAVSPECWARCOM evaluate and implement accountability based
‘on community experience and the findingsof this report. This incident, marked by systematic issues, was
preveniable. Neither the mission as asigned, the Command and Control (C2) structure, th “near or at
threshold" environmental conditions, or the acceleration to pull execution twelve hours earlier were
causalto this tragic mishap. Despite conflictingguidance as buoyancy standards, no guidance suggests
negative buoyancy for VBSS missions. This negative buoyancy was therootcauseofthese deaths. In the
ioe oEU—————. 1 it() GdKnow hey wer cgatively boyan (3s 10
buoyancy tests occurred in th first monthsof hei deployment), or (5) acknowledged yet disregarded
the negative buoyancy, expecting they would be "OK* afer shedding tactical gear andor supplementing
withthe TFSS. The TTP for boarding vessels recognize that oneof the most hazardous phasesofthe
operation isthe boarding teas embarkation ont the suspect vessel. However, layered defense of
personal responsibility, properly maintained and functional equipment, and process and procedures
safeguard against such hazard. Other ayersofdefense, such as pre-mission buddy checks or buoyancy
tests, help provide forceful bockup inthe instance when individual responsibilty misses the mark. In this
‘mishap, tha forceful backup may have fallen short ofNSW expectations. As such, NSW commanders arc
best suited to determine what degreeofresponsibilty to assign othe leadership echelonsaboveBEN
LT
3. [direct NAVCENT and the Investigating Office tobriefme on the findings and recommendations
within the next 30 days
4. 1 direct Fleet Master Chie ERS rior Enlisted Leader, USCENTCOM to be present
for NAVCENT's investigation briefing.
5. The pointof contac for this memorandum is Major Genera!SESS. Chi ofS1aT,
USCENTCOM whocanbereached by telephone ofSERRE 0 by electronic mail st
LLL —
MICHAEL E. Ki
Genel, US. Amy
or
®
USDEPARTMENT OFTHE NAVY
NAVAL FORCESCRNTRA
FSC BOK | LCOMMAND.
FOAE Sa!
5830
Ser Now/123
1Aug24
SECOND ENDORSEMENT on RDML DeVore lr 5830 of 28 Jun 24
From: Commander, U.S. Naval Forces Central Command
To: Commander, U.S. Central Command
Subj: COMMAND INVESTIGATIONINTO THE FACTS AND CIRCUMSTANCES
SURROUNDING THE LOSS AT SEA OF TWO TASKFORCETHREE PERSONNEL
ON OR ABOUT 11 JANUARY 2024
1. (66h Readdressed and forwarded.
2.4688 have reviewed the investigation and concur with he findings of fact, opinions, and
recommendations, 0 include Opinion 3 as modified by Commander, Naval Special Warfare
Command, in par. Recommend the following change:
a. 64 Modify opinion 3 to read:
“This incident, marked by systemic issues, was preventable. The“nearor at threshold”
cnvironmental conditions were not causal 10 his terrible mishap, but were a contributing factor,
‘The findings of fact do not support acausal nexus between the mishapand the mission as
assigned, the acceleration to pull execution twelve hours easlier, or the Command and Control
(C2) structure. [FoF 3, 5, 60, 65-68, 74-75, 78-79, 81-82, 84-93, 90-94, 96.97, 119, 148-150,
157,360-362, 377, 379-380, 408]
<5 WIKOFF
Conrolled by: CUSNC.

Caniroled by NOIY
CUI Category: etpmaves
RE
Dutrbo N
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btn
a.
& DEPARTMENT OF THE
NAVAL SPECIAL WARFARE NAVY
COMMAND
SANDIA S000TROENT WAY 4890
CALIORAS188
830
SerNoan12
30Jul24
FIRST ENDORSEMENT on RDML Michacl B. DeVore, USN tr of28 Jun 24
From: Commander, Naval Special Warfare Command
To: Commander, US.NavalForcesCentral Command
Subj: COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES
SURROUNDING THELOSS AT SEA TWO TASKFORCE THREE PERSONNEL ONOR
ABOUT 11 JANUARY 2024
1.{GU} |carefullyreviewedthe ubiget inert meticulously reconsruciedtheevents leading
up 10andfollowingtherage1oss of copy of
thisinvestigationwill beretainedbytheForce JudgeAdvocatesOfficein accordancewith § 0209 of
reference (8), andbymy Learningt0 ActionBoardforcontinuedcorrectiveaction.
2. 841 concur withth findings, opinions, and recommendations
oftheinvestigatingofficer, with the
following recommended change:
3.66h Inresponse to this AWARCOMvillmest urdutyand obligation to learn

lessonsfromthetragicdeathsof [Topreventsimilarincidents, actions
related to the following recommendations are already in progres
2. (U)Recommendation 2iiprogress. The FRMhasbeenrevised intotheForce Training and
Readiness Manual (FTRM). TheFTRM is a final rafavakingsignature. Changes weremadetothe
FTRM maritime.related Training Evens (ks), to include requirements for addressing pre-mission checks,
buoyancy checks, PFD maintenance, and donning,
b. (1) Recommendation is in progress. Command Training Detachments (TRADET) curently
useSOPsandLesson TrainingGuides (LTGs)whichaddressthedetailed buoyancyproceduresfobeused
daring training and execution ofthe evolutions. COMNAVSPECWARCOM isconsidering development of
a forccewide policy to address water safty during maritime operations. This policy would tsk all NSW
commands © ensure standardized documented procedures are In place for buoyancy requirements,
Controlled by: CNSWC.
Controlled by: NOOS
CUI Category: GupmBRE-pRYEY
DistributionDissemination: FEDCON
95 FOC
Smo
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Subj:
CRROUNDING THE LOSS ATSEATWOTASK FORCETHREEPERSONNEL
COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES
ABOUT I ANOARY 324 ON OR
c. (U) Recommendation 4 is in progress. NSWG-4 iscurrentlyrefiningman overboard

(MOB)
willbepart ofall NSWsurfacecraft
NSWcrat. The procedures
procedures forALLpersonnelonboard
‘safety briefs givenpriortoany evolution. The procedures will provide clear guidance regarding
theactions
for MOBs and will be formalized and promulgated to the Force.
4d. (G4)Recommendation § is in progress. COMNAVSPECWARCOMisdrafting a force wide

policy to address water safety during maritime operations. This policy would task all NSW commands to
Fe andycized docamested praedares 375 ym plea or DUOYANGY qian, SUIpIAOT! Chek,
te So
©. (U) Recommendation6 is in progress. TRADET SOPs aeinplace requiringbuoyancy checks
eons EE
Fardeen. i
oe PLAS ea
wlhe
De
FodnbBcRy alm
(1) Recommendation? fn progr. COMNAYSPECWARCOM
rn sinh process
Se
8 (U) Recommendation 8 is in progress. An industry survey and analysisofakematives to
‘provide operators ameansof fiksafe buoyancy is underway.
bh. (1) Recommenduion? sinprogress. COMNAVSPECWARGRU FOUR i conducting8
‘reviewofequipment changes that will work within the current craft configurations.
(0) Recommendation isin progres. COMNAVSPECWARCOM ildet afysan

‘down, once Naval Safety Command has completed the safety investigation Further,
'COMNAVSPECWARCOM is working with TRADET on changes to policies and procedures.
4 (ounTepainti omwh
‘Accordingly,| will doggedly pursue the implementationo ve
recommendations in order to improve the safety of our Force as we continue to meet our global mission.
Tr aay pararrome
era] kp u Seiin atin
SD.
Coronas
comm
SECRETINOFORN
5830
281 24
From: RDML Michael B. DeVore, USN
To: Commander, U.S. Naval Forces Central Command
Via: Commander, U.S. Naval Special Warfare Command
SURROUNDING THE LOSS AT SEA OF TWO TASK FORCE THREE PERSONNEL.
ON OR ABOUT 11 JANUARY 2024
Ref: See Appendix A
Encl: See Appendix B
EXECUTIVE SUMMARY
1. Summary of Findings Overview
a. (€6H) On the cvening on |1 January 2024, a deployed team of Naval Special Warfare
(NSW) operators from Sea Air Land (SEAL) Team THREE. TWO Troop. Chaslie Platoon (C-
Platoon) and Special Boat Team TWENTY (SBT 20), conducted a nighttime boarding ofa
stateless dow with suspected ties to the smuggling of Advanced Conventional Weapons (ACW)
from Iran into Yemen. During the early moments of the boarding, the dhow’smariners left their
wheelhouse in order 10 join their fellow crewmembers who were being gathered in one location
for the SEAL Team's security and safcty. This act changed the ship handling dynamics as the
vessel stopped transiting forward. As aresult, the sea sate intensificd the roll of the dhow as the
boardingprogressed, such that the combatant craft- assault (CCA) vesselcarrying the assault
teamreset twice during the action (0 beter reposition alongside the dhow.
b. (€6h Whit climbing from the CCA up to the howsdeck,(EHHN
USN, the Leading PettyOfficer (LPO)of t ofthe dhowinto the
water. siruggling, USN, jumped into the
water 10 render, assistance. Ythe woight ofeach individual's gear,
neither their physical capably nor emcrgency supplemental lotation devices, if activated, were
sufficient to keep themat the surface was only intermittently at the surfuce in
the subscquent twenty-six (26) seconds siter his Tal | was only int
surface in the thiny-(wo (32) scconds following his entry to attempt a rescue of
“The entire tragic cvent elapsed in just forty-seven (47) seconds, and two NSW WRITIOr Were
tothe sea
€. (84 The rool causeof these drownings was a lackof afailsafe and layered defense to
provide buoyancy (expounded in this report), whether (0 overcome the weighiofcquipment,
utigue from extreme physical exertion and resultant inability to read water, or an injury suffered
during the boarding process.
SECRETANOFORN
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SURROUNDING THE LOSS AT SEA OF TWO TASK FORCE THREE PERSONNEL
ON OR ABOUT 11 JAUARY2024
d. (4h This forward-deployed eam was generally manned, trained,and equipped to be
ready for operations, receiving its full and complete pre-deployment training requirement. They
were aware that Maritime Interception Operations (MIO) would be their primary deployment
focus, and concentrated their pre-deployment training preparations accordingly. However, the
following findings emerged in our study of this fatal mishap:
(1) 6644Eailureto recognizerisks(0 buoyancyandtheroleemergency flotationdevices
‘andsupplementalbuovantmaterialshould playinachievingbuoyancy. The Naval Special
Warfare Force Readiness Manual (FRM) implies the importance of buoyancy in mitigating risk
through regimented rehearsals in controlled environmentsby the number of times it prescribes
“buoyancy test personnel and gear" in training scenarios. However, i prescribes no specific
instruction or guidance on what an effective buoyancy fest entails, when “neutral” of “positive”
buoyancy should be obtained, nor does it outline the role emergency devices and supplemental
buoyant material added 10 various wom equipment plays in achieving an effective buoyancy test
- creating questions whether emergency floation devices alonc should keep an individual afloat
in addition totheirgear orifsupplemental buoyant material to their equipment is required. The
manufacturer of the flotation devices provides general guidance and limitations, but similarly
does not provide specific information on the roleofsupplemental flotation matcrial or how much
additional weight it can compensate on (0p of assisting an individual in siaying afloat
(2) (€4 Failure10complete buoyancytestsonce deployed. C-Platoon performed
buoyancy tests during their Interdeployment Training Cycle (IDTC), but under different mission
sets and in different environmental conditions (San Diego, CA, late winter /early spring in
wetsuits) than the conditions of this mishap (a maritime interdiction in the Middle East in water
temperatures of eighty (80) degrees Fahrenheit). Because this lest was performed in different
‘operating environment with different gear and equipment, it did not effectively provide a
buoyancy test thal would translate 0 the current operations in the Middle Eas!
(3) (€6hInsufficient caningspecificallywith theTacticalFlotationSupportSystem
(TESS).Operatorswere not well-practiced in using their emergency gear, with manynoting they
had only operated the Tactical Flotation Support System (TESS)devicesonce in their career. and
some could not recall activating them at all. The fact that operators conducted buoyancy tests
ducing thir pre-deployment training did not necessarity mean they activated theit TESS since
effective buoyancy could be achieved when supplemental buoyant material is added to individual
gear.
(4) (4)Conflicting guidanceand lackofimplementationof buoyancy requirements
‘While a baseline Navy reference highlighis the need for “positive” buoyancy for boarding team
members, others, including the training materials provided to the mishap platoon duting the
Interdeployment Training Cycle (IDTC) highlighicd the need for “neutral” buoyancy. Post
LL A
incident i th teammates revealed shock and disbelief thal an operator (and in this
10 maintain themselves at the surface, especially when supplemented with an emergency
2
REE
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ON OR AROUT I1 JAUARY 2024
Notation device. The conflicting guidance and lackof implementation of any buoyancy
fequiremen ultimately placed responsibility upon individual members o determine what type of
buoyancy was required and to configure themsel ves, possibly leading 0 confusion and
ineffective execution.
(5) (4) Themishapplatoon’s TFSSmainenance practicesdidnotmeet Navy
Maintenance undMaterialManagement(31 cacking
standards. It cannot be ruled out tha either, and documentation
heir emergency devices, yet they somehow Ta i templed o activate
vale. This could
operator's erro, poor gear “hygiene to ensure the safely devices were unobstructed be a result of the
‘equipment, materia failure, an capired shelf life, and/or poor maintenance processes by(0ensu olher
re
the device's proper operation. Peformance of NAVSEA maintenance, if performed to 1 Planne
Maintenance System or the manufacturers standard, did not follow the formality of maintenanced
scheduling, tracking, and documentation of tc Navy Maintenance and Material Management
(OM) system. As a result, there is variance in maintenance documentation across the teamsand
checks were not consistently documented and/or missing informa tion. No records of
Mmainenance checks were available for ST-3 C-Plutoon pre-incident. While it is possible the
TFSS failed to activate due (0 operator error or being obstructed by other equipment, i cannot be
ruled out hat the TFSS simply failed to function properly either from defect or the lack of proper
preventative maintenance.
©. (E44) Man overbourd (MOB) procedures we dh
{alling into the water. Upon determination that both
water, the Ground Force Commander, . proviized (he personnel
recovery (PR)us the primary missionof on-scene available assets. MOB procedures were
appropriate, prompt, and in accordance with prescribed guidance. Comman der, U.S. Naval
Forces Ce IAVCENT) committed extcrsi ve resourc es io the search in the
chance A al the surface. On 21 January 2024, the
search and rescue concluded aficr en(10) days and encompassed a search area of approximately
48.600 square nautical miles. Followi ng the intensive ten day long search and rescue effort, and
in accordance with established Navy policy, recovery and
recognized usa fit and inal resting place for the remains ofsalvage was not pursued as the sea is
members of he Naval Service
1. (654) During the course of ths investigation, NCIS reccived an anonymous complaint
alleging misconduct violations by various membersof C-Platoon. Thedy<1
<umption of alcohol aboard USS LEWIS B. PULLER b
CR om 05
having suggerp outside the knowle dge and care of U.S. Navy medicine; iia
investigation cam believes th allegations raised in the complaint were no root causes of the el
operational decisiontoconduct the boardin g operation, the tactical execution ofthe operation, or
the lossof life during the operation.
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[ p———
Subj: COMMANDINVESTIGATION INTOTHE FACTSANDCIRCUMSTANCES
SURRTHELOSSAT OUNDSEAOFTWO ING TASKFORCETHREEPERSONNEL
ONORABOUT 11JAUARY 2024.
2. Concl andRecommendat
usion ions
s
8.(CU)TheNSWtrainings,tactics,andproceduresforboardingvesselscontemplatesthat
“onsofthemosthazardousphasesoftheoperationistheboarding team'sembarkationontothe
‘suspect'svessel.” Thereis no doubtthe act of boarding a suspected smugglingvesselis
dangerousand canclovateinriskdependingonthefuctorsofthemission. However,
deficiencgapsandinconsiste
ies, nciesin doctrine,tactics,techniquesandprocedurescreated
missedopportunitiesforsafeguardsthatcouldhavedecrease thelikelihoodforthis incident.
Thesegapsincludedconflictingguidanceon buoyancyrequirements,issueswithmaintenanceof
‘emergencybuoyancyequipment,fiiluretorecognizeriskstobuoyancyandtheroleemergency
flotationdevicesand supplemental buoyantmaterial should play inachievingbuoyancy,and
insufficient training specifically withtheTFSSemergencyflotationdevice.
b. (CUB-Thus, key recommendations to actionthesosystemicissues Include:
(1) CU Formalization ofbuoyancyrequirementsformissions; eliminate ambiguity in
guidingreferences;
(2)(CUH)Oulinsthe role that emergency flotationdevicesplay in achieving buoyancy;
(3) (CUDAssesstheneedforafail-safemeansofemergeacy flotation,to include a
roview ofwhethersomesystem of sulomatically- devicesareoperatio
activatnallyfeasibleand
ed
desirable in NSWmissions;
(4)(CUB-Conductmareperiodicandrigorousemergencytrainingundtesting,
specifically Water Survival Training,undercontrolled conditions to develop proficiency in
‘operntinglifesaving devicesunderduress;
(5)(CU)Considerformalizingpre-missioncheckrequirements. Exhaustivechecks
alreadyoccur indiving aodparachuting. Thismayprovide a templateforan appropriately
scaled pre-mission formal inspectionof gearbydesignated experts;
(6)(CUS)Enforceformalmaintcoancestandardsforemergencylifesavingdevices.
‘While NSWoperareresponsible
ators for significant numbersofequipment to executadiverse
e
rangeofmissions,somepiecesofgearwarrant aformal,tracked,andfocusedmaintenance
effort. Recommend 8reviewof the critical istandensuethatanauditablemaintenancehistory
exists.
M.B. DEVORE
4
mi
EE 1 oven
SURROUNDING THE LOSS AT SEA OFTWO TASK FORCE THREE PERSONNEL
ONORABOUT 11 JAUARY 2024
TABLE OF CONTENTS
1. Executive Summary
SummaryofFindings Overview
Conclusions and Recommendations
2. Introduction
Overview
Scope of Investigation
Investigation Team Background
Report Structure
Personally deaifisble Information
3. Findings of Fact
Chapter 1. Overview
4. SEALTeam THREE and Tusk Force THREE
b. Overview of Maritime Intrdiction Operaions (MIO)
c. SEAL Team THREE/Task Force Three Roles and Responsibilities
Chapter If. Maritime lnterdiction Operation
a. Boardings One andTwo (December 2023)
b. Boarding Three Target Development (05.10 January2024)
Chapter IIL Boarding Three (11 January 2024)
a Morning: Gear Checks, Preparations, Review
b. Aftemoon: Team OPORDBriefand ROC Drill; CUSNC directiontoaccelerate
Revised Mission Planningand Pre Execution- Vessel of Interest (VOI)
a. pre-Mission Conditions-[I v<<irc
©. VBSS Mission to VOI
5
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(1) Approach #1 First three Assaulters
(2) Approach #2 - Second three Assauliers
(3) Approach #3 - Man Overboard
Chapter IV. Search and Rescue Events
a. On Scenc Rescue Efforts
b. USS. Naval Forces Central Command (Manama, Bahrain) Rescue Efforts
c. Recovery Considerations
Chapter V. Safety and Equipment
a. Equipping a SEAL Team unit for Boarding Team operations
b. Pre-Mission Safety Check or “Buddy Check of Equipment”
¢. General Maintenance Standards of Equipment
d. United States Coast Guard Boarding Incident (2011)
Chapter VI. Anonymous Complaint Alleging Misconduct by TF-3 Charlie Platoon
a. Allegations i Alcohol Abuse and Use Aboard USS LEWIS B.

PULLER
vo. Ategationso[RI veovthorized Mecca procedure

<. Attegationsof[NU of Performance Enhancing Drugs
a. Aiegasionso | INI +c o Pormance Enhancing Drugs
Chapter VII. Mission, Training,Equipment, and Risk Management Standards
a. Authorities and Command and Control
b. Command and Control Structure of ST-3
c. Capabilities ofa NSW Boarding Team
EERE,
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Suit COMMAND INVESTIGATION
SURKOUNDING THE INTOTHE FACTS AND CIRCUMSTANCES
LOSS ATSEN
ON OK ABOUT 1 IAUARY 202 OF THOTASKFORCE THRFF PERSONNEL
d. Taaining
a SEAL Team Unit for Deployed Boarding Team Operations
Mision Guidsnc 0 SEAL Team Uni for Bowring patios
{. Mitigating Risk during SEAL Missions
&. C-Platoon Interdeployment Training CycleExecution

h. Buoyancy Checks During Pre-Deployment Training
i. Bouyancy Checks: Neutral Versus Positive Buoyancy and Conflicting Guidance
I 75
+ rs
1 Sosa Bos Team Guido nd MOB Prose
4. Opinions
a. Opinions Specific Id
bh. Onions Spec
c. Opinions Commonto Bott
4. Search nd Rescue Efors
e. Boarding of VOI
1. Aronymous Conplin Allegations
8 Mission, Training, and Risk Management Standards
(1) Training
(@ Mision Guidance
(3) Risk Management
© Char Poon DTC Cle

NSW Gear, Maman,ndSuey
?
RE
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x FevoviD
Si COMMANDINVESTIGATION NTOTHE EACTS ANDCIRCUMSTANCES
a ons An
S. Recommendations
FOL
Aree Ens
Appendix C- Glossaryof Terms
SECTION INTENTIONALLY BLANK
‘
Eo
ON OR ABOUT 11 JAUARY 2024
INTRODUCTION
1. 44H Enclosure (1)directed an investigation into the fucts und circumstances surrounding the
loss at sea of two (2) U.S. Special Operations Command Central (SOCCENT) Task Force
THREE (TF-3) personnel on or about 11 January 2024. Pursuant 10 enclosure (1), as amended
by enclosure (2), and reference (a), enclosures (3) through (132) are submitted in supportofthe
findings of fact, opinions, and recommendations for the command investigation.
2. 464 The investigation centered its analysis on the evens specific to || January 2024, but in
Te yrs
meansby which a Naval Special Warfare (NSW) task uni i prepared for deployed operations.
Just as in other Navy communities,aNSW operational unit follows a scripted IDTC that ensures
heir training, preparation, and readiness fordeployed operations.
3. 4M During the course of the investigation, the team received support andcooperation from
all organizations, including U.S. Naval Forces, Central Command (NAVCENT), US. Central
Command (USCENTCOM), Naval Special Warfare Command (WARCOM), Naval Special
‘Warfare GroupONE and its subordinatc suppor clements, Commander, Task Force FIVE FIVE
(CTF-55), SEAL Team THREE (ST-3), Helicopter Sea Combat Squadron TWO SIX (HSC-26),
Task Force THREE, and the C-Platoon members, who provided statements.
4. (E84) Commander, NAVCENT, granted two (2) extensions due to the number of interviews
ameme
5. (84H) Scope of Investigation. Commander, NAVCENT, directed this investigation (0 inquire
into the facts and circumstances surrounding the loss at sea of two Task Force THREE personnel
overt 1 eg S08Sotto csltoncps re reearom
‘conducted arootcause analysisof the mishap, analyzing potential causal factors presented by the
—
a. (€84) On 28 May 2024, Commander, NAVCENT, amended the scope of the investigation
10 address additional matters: (1) whether the mission was adequately planned with the
appropritc oversight and Sailors were properly trained, equipped. and qualified for the specific
mission, and (2) whether allegations in an anonymous tpreceived by the Naval Criminal
Investigative Servi ibutcd to the facts and circumstances surrounding the deaths.
ommanget,
©.
granted an additional extension of the report's due date and added an
wom ispoc.(RR
’
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Subj: COMMAND INVESTIGATION INTOTHE FACTS AND CIRCUMSTANCES
b. (86h The Naval Safety Command (NAVSAFECOM) safety investigation. the technical
‘analysis of the mishap and of emergency flotation equipment, is elated 10 this incident, but
independent of this command investigation.
6. (EY Investigation Team Background. Commander, NAVCENT, convened this investigation
and assigned Rear Admiral as the investigating officer. The
investigation team included NAVCENT),
(COMNAV! 5 SN. (NSWG.
SN, (ST-3). SN, (NSWG-1),
"TF-3 Senior Enlisted Leader, served asa sublect mater expert for general
‘Questions about the Naval Special Warfare community. reported to TF-3 March
2024,after h theCourse of(hs Tavesugation, legal guidance was
vided by AGC,USN.The legal team was augmented 4]
: side from the legal expertise that supported this report,
he team Included officers from both the conventional uncestricted line and NSW. totaling nearly
one hundred five (105) years of experience, including command leadership at ll paygrades and
experience that includes deployed operations in all naval theaters.
7. (U) Report Structure. The findings of fact are divided by chapter.
a (U) Chapter One
(1)introds REE and their missionwhen[I
USN,a USN,were lost at sea. ChaplerOne (1)
al50 GetailsSEAL [eam THREE members: sdministrative and operationalroles,referenced
throughout the report.
b. (44) Chapter Two(2) details the sequenceof events of maritime interdiction operations
leading upto LI January 2024. TF-3 FWD executed two boardings in December 2023,
referenced in this report as Boarding One and Boarding Two. ChapterTwo (2) describes these
December 2023 boardings and also details the days from 05 1o 10 January 2024 leading upto | |
January 2024 (the third boarding),
. (8 Chapter Thrce (3) describes the seriesof events of 11 January 2024, theday ofthe
‘man overboard. ‘This chapter details the pre.mission planning, the change (o the operational
timeline, weather conditions and sea state during Boarding Thice, and the man overboard.
d. (EY Chapter Four (4) describes the 10-day search and rescue effort, which started
within seconds ofcalling the man overboard
e. (6 Chapter Five (5) details safety standards applicable in maritime inierdiction
operations. This chapter also explains equipment standards and proctices applicable to Naval
‘Special Warfare boardings. As a refercace. this chapter also summarizesa 2011 incident where
the U.S. Coast Guard experienced its own similar tragic mishap and their subsequent corrective
actions taken (0 address the mishap's findings.
10
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I. (E68 Chapter Sin (6) addresses an anonymous complaint NCIS received on 15 February
2024. The complaiat cots of our allegations against members of C-Platoon. The first
allegation stated] (C-Patoon LCPO) consumed alcohol aboard USS LEWIS B.
PULLER and t ement. The second allegation stated a
‘medicallyunfit to conductoperationsdue to amedical procedure obiainedCU of
cine prior 0 embarking USS LEWIS B. PULLER. The third allegation stated
Jused Performance Enhancing Drugs (PEDs) outside the knowledge and care of
USS. Navy medicie. The fourth allegation stated] USN, usedPEDS,outside
the knowledge and care of LS. Navy medicine.
8 (U)Chapter Seven (7) describes general training. equipment, mission guidance, and risk
‘management standards
8. (U) Physical and video evidence were examined during the investigation, und pictures have
been included as enclosures of physical or video evidence referenced.
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SURROUNDING THE LOSS AT SEA OF TWO TASK FORCF THREE PERSONNEL.
FINDI FACT.
OFNGS
Chapter 1. Overview
(U) This chapter int REE and their missionwhen|
TE ISN, were los! ut sea. This chapter also details
eam THREE mer Iminisirativeand operational roles, referenced throughout the
report
(U)SEALTeamTHREEand TaskForce THREE
1. (U) SEAL Team THREE (3) is an echelon IV U.S. Navy Command, assigned under
‘Commander, Naval Special Warfare Group ONE, in Sun Diego, CA. [Refs.b, c]
2. (EW SEAL Teuns under Naval Special Warfare Group ONE complete rotational
deployments to Geographic Arcas of Responsibility throughout the world, and are deployed with
Operational Control (OPCON) transferred from Commander, U.S. Special Operations Command
(SOCOM), to the Geographic Combatant Commander who then further delegates OPCON (0 the
Theater Special Operations Commander (TSOC) for employment through the DoD Global Force
Management Process. (Refs. b,c, d)
3. (E4H When deployed (0 U.S. Central Command as they were in January 2024, elements of
SEAL Team THREE were under the OPCON of Commander, U.S. Central Command, with
delegated OPCON and tactical control (TACON) to the TSOC, Commander, U.S. Special
‘Operations Command Central (SOCCENT). (Refs. b,c. d,
4. (8 Au the timeofthe mishap (in January 2024), elementsof SEAL Team THREE were
deployed to the U.S. CENTCOM Area of Responsibility and employed by SOCCENT within
Task Force THREE (TF-3) (formerly known as Naval Special Warfare Unit Three).
headquartered onboard Naval Support Activity Babin. (Refs. b,c, d,
S. (454)For the purposesof conducting maritime security operations in direct support of
NAVCENT,TF-3 was organized (0 include aTF-3 Forward (FWD)sub-element, embarked
aboard USS LEWIS B. PULLER (LBP), and placed TACONtoTF-55, NAVCENT's Warfare
Commander for Maritime Intecdiction Operations (MIO). [Refs g, b,
i y
6. (4 Commander, U.S. Naval Forces Central Command, (COMUSNAVCENT), tasked
Task Force THREE (TF-3) with conducting MIO. [Refs.e, g, h,
7. (E484 In order to support the operation, TF-3 produced a concept of operations
brieffor the execution of boardings, scarches, and seizuresofvessels suspected of (CONOP)
smuggling
12
aaREMOVED
FERRER MARKING REMOVED
SURROUNDING THE LOSS AT SEA OF TWO TASK FORCE THREF, PERSONNEL.
ONOR ABOUT I1 JAUARY 2024
Advanced Conventional Weapons (ACW) by nefarious actors via historic smuggling routes in
the Arabian Sea, Gulf ofAden, and Red Sea. [Ref. h]
8. (664 Risk to the force was considered in the planning ofthe operation to include: small arms
fire (rom mariners at sea, vessel collision at sea, crane operations, crushing injury, and man
overboard (MOB). Refs. g,
9. (EH) The planning teamalsoconsidered risk mitigation measures that were completed or
ould be completed prior 10 aboarding in order to lower the overall risk to force associated with
the operation. Specifically, the risks associated with a crushing injury were believed 10be
mitigated due to their raining of day and night casualty evacuation (CASEVAC) procedures
(Refs. g, h}
10. (6 Additionally risks ussociated with a man overboard were mitigated due (0 the CCA
crews" training and rehearsals of man overboard recovery and response. (Refs. gh]
11. (4 TF-3 was cenified, verified, and validated through an 18-month pre-deployment
training cycle on asset management, maritime assault, lethal useofforce, and post assault
procedures. TF-3 also rehearsed and validated CASEVAC procedures with HSC-26, the assigned
helicopter squadron to the operation, during previous raining serials. [Refs. gh)
12. (64) Overall, TF-3 leadership determined and briefed the general risk o force (0 be "Low"
for the operation. (Refs. gb)
(U)SEALTeamTHREF/Task ForceTHREERoles andResponsibilities
(U) SEAL Team THREE/Task Force THREE administrative leadership:
13. (©)IEUs. s¢rved as Commander, TF-3, based in Manama, Bahrain,
co-located ai US. Naval Foes Ceniral Command (NAVCENT) headquarters during the
planning and execution of the operation. [Encl 5]
14 USN, served as the ST-3 Executive Officer (XO). Specific 0 the
operation scrved as Deputy Commanding Officer, TF-3and the On Scene
‘Commander (OSC), while embarked on the USS LEWIS B. PULLER (ESB 3). [Ref. hl (Encls
6, 6a]
15. (ews) USN,servedasthe ST-3 C-Piatoon Commander andthe TF 3.2
Officer in Charge (OIC). Specific to the operation on 11 January 2024, served as the
Assault (or Ground) Force Commander (AFC). [Ref. h] (Enct. 7)
16. (ex)IRIN Us. crved us theTF 3.3 Commander (CDR) of Special Boat
Team 20. Specific to the operation on 11 fanvary2024[SEERserved as the TF-3 FWD
3
SS
REMOVED
EG OVD
SURROUNDING THE LOSS AT SEA OFTWOTASK FORCE THREE PERSONNEL
ONOR ABOUT |1 JAUARY 2024
Maritime Mission Commander aboard CCA C-1. As the Maritime Mission Commander,
fll
[BI 1c the search and rescue during the man overboard. (Ref. h) (Encl. 8]
1”.co I USN, served us he ST-3 C-Platoon Leading Chief Petty Officer
(LCPO), an enior Enlisted Leader specific 10 the operation on || January2024,KI
JERced the Helo Accu Fore (HAP) cam leader TF: 3.2 bose oneofthe two
copiersonboard the USS LEWIS B.PULLER. [Ref. h [Encl. 9]
1s. oo FT USN,served as the ST.3 ading Petty
Officer peilic 0 theoperationon || Ja ved as the
Assan Lead and SquadLeader aboard CCA C-1 as the frst man
overboard (MOB). [Refs.g, h}
19. (66H Combatant Craft ~ Assault (CCA) A-1 personnel on 11 January 2024.
» USN. served as the Patrol Officer for CCA A-1 and A-2.
Specific to the operation) odoon CCA A-1 and coordinated with the Joint
Operations Cater during the MOB. (Ref. g] (Encl. 10]
o. (ett[II Us scovec as on assaulier aboard CCA AL. [Rel g] (Encl.
i"
. ceo SRI US. scrved 5 the Bost Captain shoud CCA Al.
[Encl 12] (Ref. 5)
a SN, served as the lead Navigator aboard CCA A-1. [Ref.
8) (Encl. 13]
c.cts)IR Us, scoved as the Multi-Purpose Canine Handler aboard
CCA A-1. [Ref. g] [Encl. 14]
© cee IN 5. ste marcos ofc od ech
CCA AL. (Ref. g] (Enel. 15]
ocon
IRIN 5. «vcd us te Chie Engineer sbosrd CCA A 1
(Ref. g) (Encl. 16]
h ©) USN, served us the Navigator and Joint Terminal Air
Controllerabo TR g) (Encl. 17]
20. (U) Combatant Craft ~ Assault (CCA) A-2 personnel on 11 January 2024:
1"
MARKING REMOVED
I 1G REMOVED
SURROUNDING THE LOSS AT
ON OR ABOUT 11 JAUARY 2024SEA OF TWO TASK FORCE THREE PERSONNEL.
+. (0 IR SN. served as the Boat Captain aboard CCA A-2. [Ref g)
(Encl. 18]
b. (eos
SRR 5. vcd ss the Gunner snd Chie Engine aboard CCA
A2. (Ref. g] Encl. 19]
<. cu)IUs. <ve os the Navigator sbosrd CCA A2. (Ref.
(Encl. 20]
4 (est USN, served as the Chief Engineer and Forward Gunner
aboard OCA AL TReT 1 (Enc 21)
e co I. served as the forward-looking infrared (FLIR) video
footage operator and the Chief Engineer sboard CCA A-2. (Ref. g) (Encl. 22]
21. (E65) Combat Craft - Assault (CCA) C-1 personnel {in addition o| kor 15)
[op 16), and GER (FoF 18)) on || January 2024:Eh
a. ceoIRN 5CG, ved us the Maritime Security Response Team
(MSRT) Troop Chief, aboard CCA C-. (Ref. g (Encl. 23]
b. (eo USN. served us the Pavol Officer abowd CCA C-1. (Ref)
(Encl. 24]
<. (eet) INR]
Us. scrved as the Bout Captain aboard CCA C-1. (Ref. g)
(Encl. 25]
4 USN, was the Lead Climber for Assault
cl served as the first assaultr/climber to board Vessel of Forco aboard CCA
Interest (VOI). (Ref
8) (ER
e. cotINR us ccrved
when the MOBwascalled. [Ref. g) (Encl. 27) ss on acsalerclimber and was abo the VOI
fen I USN. served as the Navigator aboard CCA C-1. [Ref g)
(Encl. 28)
¢ out)IRIN
Us. sce ss
climber to board the VOI. [Ref. g) (Encl. 29) an ascaulier aboard CCA C-1, and the second
heb JUSN. served as the Radio Telephone Operator and assaulict
aboard CCA C-1. a5 the second man overboard. [Refs g, hl [Encls. 9. 33, 36, 40]
15
MARKING REMOVED
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SURROUNDING THE. LOSS AT SEAOF TWO TASK FORCE THREE PERSONNEL
i on USN. served as an assaulter aboard CCA cr.
was the fourth assaulier to VOL. (Ref. g] (Encl. 30]
i ceo I served as an assaulter aboard CCA C-1. [Ref. g]

(Encl. 31]
&.cect | UsCG. ois © (he MSRT sboard CCA C1, served
as an assaulicr/climber aboard VOI. [Ref. g] (Encl. 32]
Lo BI 5. 4 he Chic Ene shou CCA C1. (Ret.
8 (Encl. 33
rE ey
22. (@4 Operators aboard the helicopters “HELO 1or “HELO 2” [in addition i
RA
«(et sv. <crved s co-pito aboard sicrat HELO 1. (Ref. 5)
(Encl. 34)
b. oh[RI
Us. servedssco-pilot sbourd aircraft HELO 2. (Ref. g) [Encl
3s)
©. (eu , served as ST-3 C Platoon, Assistant Officer in Charge.
Specific to the operation /as aboard HELO 1. (Ref. g] [Encl. 36]
d. cect RR UN. scrved os co-pilot aboard aircraft HELO2. (Ref. g) (Encl.
3)
<. enh) a served as co-pilot and FLIR operator aboard aircraft
HELO |. (Ref. g] (Encl. 38]
1. ctsEI5. sved as the

swimmer aboard aircraft HELO I. (Ref. g | (Encl 39] Operaions Chief, gunner, and rescue
2. (et [RI sn. vd ss he Join Tactical Air Controller (ITAC)
aboard HELO 1." [Ref g ) [Encl. 40]
h. tee USN, served as the medic and Helo Assault Force (HAF) Lead in
theaircraft, 1 8] (Encl. 41)
i. eo
I CG. <crved us a HAFmemberaboard the aircraft HELO
1. Ref. g)(Encl. 42)
16
MARKING REMOVED
I1G REMOVED
Subj: COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES.
SURROUNDING THE LOSS AT SEAOF TWO TASK FORCE THREE
PERSONNEL
j ex SN. served as theSniper aboard aircraft HELO 2. Ref. g |

(Encl. 43)
k. es served as aircrew aboard aircraft HELO 2. (Ref. g]

[Encl. 44)
1. eo)RI Us. << 5 screw aboard sieralt HELO 2. (Ref. g]

m. (es ISN, scrved as the port side gunner aboard aircraft HELO
L (Ref. g) (Encl.
0. (oh) ISN, served as senior medical technician aboard aircraft HELO 2.
(Ref. g) (Encl
23. (U) SEAL Team THREE/Task Force 3 personnel not embarked aboard
USS LEWIS B.
PULLER:
a. (eu) SN, served as the ST-3 TWO Troop Commander. Specific

the operation) as deployed (0 Yemen and Qatar, and not with TF 3.2 and TF 3.3,to
(Encl. 47)
b. (eb) ISN, served as the ST-3 TWO Troop Leading ChiefPeity

Officer. Specific to the operation, vas deployed to Yemen and Qatar, and not
with TF 3.2 and TF 3.3. (Encl. 48]
c co
One Detachment LCPO, operatingUSN. served as the Special Boat
as Task Force 3.3 Detachment Team 20 and, Coastal Troop
LCPO in Join Operating
Center. [Encl. 49]
ao. cofus in Sun Dicgo, CA. at the timeof the incident und nok deployed with
TF3.2.and 3.3. [Ref.
g] [Encl. 107)
"
MARKING REMOVED,
1G REMOVED
ON OR ABOUTG11THE
SURROUNDIN
JAUARY AT
LOSS
2024 OF TWO TASK FORCE THREE PERSONNEL
SEA
(EY Figure 1- . Photographof the small boat assault team taken prior
0 the mission on | |
January 2024 depicting equipment worn prior to the mission. [Encl 58)
(U) Chapter 11. Maritime Interdiction Operations
(U) This chapter details thesequence of events leadingup o 11 January 2024, TF-3 FWD
xeited two boarding in December 2023, reference as Boarding One nd Bourding Two. This
2024, leading up to the 11 January 2024 boarding, the day of the man overboard January
chapter describes these December 2023 boarding and details the days from 05 to 10
(U) Bosdings One and Two (December 2023

24. (€U In early December 2023, TF-3 FWD embarked aboard USS LEWIS B. PULLER
Refs.)
25.
Refs, h] (Backs. 7,9, 12, 16,41)

26. (84 TF-3 FWD conducicd Boarding One on or about 10 December 2023, during daylight
hours. (Refs. g, h] (Encl. 7)
21. (G44) During Boarding One, TF-3 FWD boarded a large dhow, estimated to be fifty
(50) 10
sixty (60) meters (164-196 fect) in length. (Refs. g, h) (Encl. 7)
8
MARKING REMOVED
I {KING REMOVED
28. (86H TF-3 FWD conducted Boarding One in daylight while the sea state was calm. (Refs.
8h (Encls. 7, 36]
29. (644) Numerous interviews highlighted that Boarding Onc was conducted in good weather
and calm seas. (Encls. 7, 31,32, 36}
30. teu) RN GIGI
issues" and a “good tactical evolution.” (Encls. 7, 31,32, 36] oc Boring Onea “ro
31. (E44) TF-3 FWDconducted u post-event debrict Boarding One and lessons.learned were
incorporated into proficiency icsining and maturation ofof follow-on planning. [Encls. 7, 50, SOA)
32. (E44) TF-3 FWD conducted Boarding Twoon or
however, in an increased sca state than Boarding One. about 27 December 2023, also in daylight,
(Encls. 9, 40, 42]
33. (€6h) Boarding Two occured on a cargo dhow approximately twenty (20) metecs (65 fect)
in length, [Encls. 6, 31, 40, 42, 43]
34. (U)EN NRG: cb the
(bow-1o-stern oscillation along the centerline axis) duedhow in Boarding Two as pitching strongly
to thesea state. (Encls. 30, 43)
35. (U) RRso INR
rived the
Tow freeboard, meaning the dhow was siting low in thehow in Boarding Two as having a very
watee. (Encls. 30, 43)
36. (G4) Assaulers did no require boardingladderbecause they were abl (0 Sip across)
from the CCA 10 the dhow. (Encls. 30, 43)
37. (0)EoA
I cc the decks were cover i il ad ick, (Enel
30,43)
38
cts. 7, 30.1
39. (4 During the Boarding Two post-event debrief, TF-3 FWD noted that it was 4 ough
boarding due 10 i beingspatiallycompact with thirty-(our (34) people aboard, pitching seas, and
the vessel being heavily laden (and therefore, siting very low). (Encls. 7, 20]
40. (8h As part of his assessment
the Assault Force Commander, statedduring the Boarding Twodebric,
that the team was operating wellIED
and “dialed
scrving as
in." There
was good integration with the special bout eams and Coast Guard MSRT members. [Encl.
7)
19
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ETT ARKING REMOVED
ON OR ABOUT |1 JAUARY 2024
aloy TEL and| noted Boarding Two was well executed, with
0 sigaificant sues. (Encl. 7,9, am
42. ev)EI spccificaly highiighted thoRNhe Leading Petty Officer
and Tactical Lead, was very process andprocedure oriented. [Encl. 7]
(U)Boarding ThreeTarget Development(05-10January 2024) of Vessel of Interest(VOI)
«a
(Refs. h] (Encl. 61
VE ee
5 ;i
i. 8h] (Encl.6,7,8.51)
a
acl.0,7,8,31] #
MARKING REMOVED
I XG REMOVED
47.
(Refs. gh (Encl. 6]
48.
(Encl. 6]
49.
[Refs. g. h] (Encl. 52]

50.
5. 3h (Encl. 52)
51.
(Refs. g. h)
S52.
s.6,53]
53.
(Encls. 52, 53]

$4. (€Uh) TF.3 tenaively scheduleda time (0 start he boarding based on the imeof intercept
at 03002/0600 local,or time zone “Charlie” (0600C)on 12 January 2024. (Refs. g, h)
55. (U) 03002/0600 local was the estimated time of sunrisc. [Refs sh
56. (EY) 03002/0600 local was also the specific hour when the Operation commenced for
previous (wo boardings. (Ref. h] the
(U) Chapter 111. BOARDINGTHREE (11 January 2024)
(U)Morning:Gear Checks,Preparations,Review.
57. (GU With the location of the VOI now known, and courseand speed tracked by persistent
surveillance, TF-3FWDdeliberately planncd a timeline to intercept the vessel and conduct a
boarding in accordance with their approved standing CONOP. (Refs. 8h) [Encls. 52,53)
MARKING REMOVED
I, (\ RKING REMOVED
SURROUNDING THE LOSS AT SEAOFTWO TASK FORCE THREE PERSONNEL.
58. (6H TF-3FWD createda vessel specific bref that included timeline of actions and an
‘enumerated pre-boarding execution checklist 10 meet a boarding Lime for 0600C on 12 January
2024. (Ref. g]
59. (E81) TF-3 FWDscheduled the boarding and bricfd the plan on 11 January 2024 to USS
LEWIS B. PULLER. (Refs. g. h]
60. (GLH) Wind speed, sea state, cloud ceiling, precipitation, air and sea temperature, visibility,
‘wave height and height of wave swells were considered in the brief as well as establishing "GO/
NO-GO" criteria for boarding operations. (Refs. g, h)
61. (8H Localweather conditions predicted for the arcs in vicinity of USS LEWIS B.
PULLER for the periodof Thursday, || January 2024 through Saturday,|3 January 2024, are
provided in the boarding bricf. (Refs. g, h]
62. (€6h Predictedweatherconditions and possible impact to CCA and AFSB CraneOpson 11
January 2024 were identified, but within the permissible range to conduct operations in
accordance with pre-cstablished GO / NOGO criteria of six (6) fect swells. (Refs. g, h]
63. (E44) Weather was also within limits of CCA operations in accordance with U.S. Special
Operations Command Manual, which notes marginal thresholds for CCA operations as six (6) to
eight (8) feet, with unfavorable thresholds above ten (10) eet. [Ref.j)
64. (64 Similarly, weather was also within limits of CCA operations in accordance with Navy
Special Warfare Group FOUR Instruction, the administrative chain of command authority for the
small boat unit attached to TF-3, which notes: “The maximumsea height for conducting CCA
VBSS operations ix eight (8) feet. (Ref. c]
65. (66H Reference (c) also states that deployed NSW forces are capable of nighttime opposed
boarding from CCA insea states less than or cqual to eight (8). Ascastate “8” on the Beaufort
scale corresponds to a wind speedofGale Force winds (34-40 knots) and associated waves as
high as 18:28 feet (5.5 meters). (Refs. c, j]
66. (44h Predicted weather conditions showed abating conditions, with progressively calming
winds and sca staesover the period of || January 2024 through 13 January 2024, (Refs. g. h]
67. (E89 Estimated sca sate for 1200C-0000C on 11 January 2024 was NEthee to four (3.4)
feet swells with NNE five 10 seven (5.7) feet waves u every seven to cight (7-8) scconds. (Ref.
8
68. (€6 Estimated sca state for0000C-1200C on 12 January was NE four to five
swellsat every (7.8) seconds and NNE four (0 six (4-6) feet waves every cight to nine(4-5) feet
(8-9)
seconds. (Ref. g)
2
a,
REMOVED
I NG REMOVED
69. (U) According (0 the National Oceanic and Atmospheric Administration (NOAA), swells
are lower frequency waves that outrun the storm that creates them and travel great distances from
a wind source. Contrasted with wind waves that re high frequency waves gencrated ncar the
wind souce and depend on wind strength, duration and fetch - the uninterrupted distance over
which the wind blows without significant change in direction. (Refs. k, 1)
{L)Afternoon:Team OPORDBriefandROCDrill; CUSNCDirectiontoAccelerateTiming
70. (E64 On the afiemoon of 11 January 2024, TF-3 FWD planned, briefed, and rehearsed
timing ofactions 10 conduct their boarding a 0600C. (Ref. g]
71. ied thebriefand presctcd a clear explanationof the mission to the
boarding team members. (Ref. h] (Encl. 11, 36)
72. (€9h During his same hour, INI
or mande (COR) TE-3 brifed the
NAVCENT Daily War Council Brief (1530C) at NAVCENT. (Encl. 51]
7
(Encl. 511
7
(Encis. 51. 52)
75. (4 At the conclusionof this Was CouncilBric, NINN oc
(COMNAVCENT's intent tofSRI
(via 3 secure voice call and email), and inquired
whether they could execute thal same evening. Encl. 54]
76. (4 [EIS
N. scrved as Deputy Commodore (DEP CORE), TF-55, and the
FIFTH FLEET Maritime Interdiction Operations Commander. (Ends. 52, 541
77. (64H) TF-3 FWD conducted a rehearsal of concept (ROC) drill, which commenced at or
about 1600C. and members noted it went well, with no major standouts or shortfalls identified.
(Ref. h) (Encls. 3.7. 36)
3. eu At opoimarly 125C. Soi I cn csi of
conducting the boarding operation prior o 12 January 2024, [Encls. 54, 55)
29. (ety At approninately 1632C, SERN <cd to NAVCENT command
leadership that the boarding could be cxeculed per the TF 3 FWD On Scene Commander (OSC).
Further, he noted tha scas were a six (6) feet waves, and expected Ho abale. Estimated time of
execution would be 1900C. (Encl. 56]
2
MARKING REMOVED
I ARKING REMOVED
80. (EHBasedon the TF-3 mission slides, sunset was anticipated 10 be 1726C on 11 January
2024. (Refs. g, h)
1. (Gul A sproimaly 1635,IRR onc oRRR
‘emphasizing COMUSNAVCENT's guidanceto execute as “quickly
/safely”as possible, with a
goal 0 take custody that ight. (Encl. $4]
82. co I = that it was also acceptable (0 conduct a full sweep during
daylight ifthe mission could notbe conducted safely in the evening. [Encl. 54]
(Encl. 51)
{U)RevisedMissionPlanning andPre-Exceulion =VOI
(U) Reader's not: this section steps back in time briefly from the shove cxchange between TF-
5 and TF-3 (FWD), The exchange as noted above indicated that TF-3 (FWD) deemed the
accelecated boarding executable, The following reviews the discussion, planning, and revised
execution thatle 1 note to that the boarding was feasible.
84. (ee Buck aboard USS LEWIS B.PULLERJENpassed down to the team the
intent to conduct the boarding sooncr. and led a conversation about the time shit of the
operation. (Encls. 3,7)
85. (04)[RIM
Otic in Charge (OIC), TF 3.2IN
and|
3.3 assessed and determined that they could sil accomplish the mission, that thence (CDR), TF
environmental
conditions were within thei thresholds, and the mission was within the capability ofthe team for
execution. [Refs.c. g. b,j} (Encls. 6,7. 8, 521
86. (E64) TF 3.2 and TF 3.3 team leadership communicated to the members of their lea not (0
rsh te mission. EER however. ced is concer shou moving pte minofte
operation because t okrushed. [Encis. 6,7, 8, 23, 52]
87. (U) Seas were approximately six (6) feet wave height at ime of launching the craft. (Encls
6.9.22,24,49,]
88. (664 TF 3.2 OIC[RIN
sted in his interview that he desired to execute while there
was still remaining daylighi, but other crewmembers preferred 10 do it later 0 have more time (0
prepare. [Encl. 7)
MARKING REMOVED
{KING REMOVED
89. ch[RII
ocd in bis interview that he emphasized (o the team totake adeliberate
approach,
bu still "at our pace.” (Encl. 7)
90. ot)[IRIN 5 TF-3 Platoon Chief Petty Officer, asked everyone in the group of
their ability 10 execute, andal offered an “ok” and “good to go.” (Encl. 9]
91. (€4H The TF-3 FWD On-scene Commander(O50)NN 4 with key team
leaders, including the military detachment Officer-in-Charge (OIC) embarked uboard USS
LEWIS B. PULLER, the two-crafthelicopterdetachment OIC from Helicopter Sea Combat
Squadron TWENTY SIX (HSC-26), Special Boat Team TWENTY embarked, Boat Assault
Force (BAF), Helicopter Assault Force (HAP), and crane operators and deck crew responsible
for safely launching and recovering theCCAS. (Encls.6,6a]
92. (@4)[RIN
2
voced th same upon receiving hethewas concerned whe informed
news. However, JERR of thevow
timeline shift, and
edged the operation
was within their capabilites. (Encl. §, 23)
93. (E69 Without receivingany explicit dissent, key leaders reported back (0 the TF-3 (FWD)
OSC, tha it was feasible that evening and the TF-3 (FWD) OSC determined to execute the
mission. (Encl. 6,7, 54]
94, oot <4 ifsomeone was uncomfortable with the changes to the
‘operational Umeline, or believed it to be outside their capabilites, they would have spoken up.
(Encl. 49)
95. (E44) The team implemented miligations, with an intent 10 use white light and visible lascrs
10 account for the nighttime operation. [Encls. 6, 7,9, 10, 27, 30, 36, 40, 43]
96. (E44) From theTF 3.3 perspective. Special Warfare Combatant Crewmen (SWCC)
operators pushed the planned timelinean additional thirty (30) minutes late in order (0 provide
for additional mitigations and readiness preparations. (Encl. 28)
97. eet oic4 tha in his role us ead climber,
honest as [he] set the hook - that [he] hud the ubility to wave-off(he) “was going to be very
{and call) no go ifunsafe.”
(Encl. 26]
98. (U) Near time of execution, bosh visibility and illumination were low. |Encls. 38, 45, 57]
ection Congo =
99. (€u+SNRRIIIN <1 ol assoulters for a good light check because Boarding Thee
was a nighttime cvolution. [Encl. 26]
25
MARKING REMOVED
I 11XG REMOVED
100. (ett)[NNN <onducted the buddy check- (Encl. 26)
101. (© In complerng
his buddycheckof [rm p——
ater wings were "hard pointed” ). (Enel. 26
102. (E46 A pre-mission photo depicted tho = vexing at least one TSS
attached near his lef hip (a second walerwing (TFSS) was not clearly visible). (Encl. $8]
103. (E18 The method in which the TFSS is clasped EE belt could not be.
determined. [Encls. 25. 26,40, 41,43)
104, [aE
(U) wearing gloves a the time of th incident. (Enc. 58, 62 (Images
1,13)
105. (eb not exhibited any
the twenty-four(24) hours leading upto theincidentindications of orthopedic injury or ailment in
. (Encls. 8,9]
106. (E44) eo RRR bth
the time ofthe incident. [Encls. 38, 9, 60, 61, 62, 63, 64]wearing visual strobes on their helmets a
107. (eh[II concocted buddy checks vif ret 71
105. cutJ = win vo2) TESS cached tis bel. Enc 7.61
109. (E64 The method inwhich[SSE c1asped the TFSS (o his riggers belt could not be
determined. (Encls. 25, 26,40, 41,43]
to. © ec belt had a Cobra (brand name] buckle
capability.” An individual is required to press down onbothclips locatedthaatallows
the
a quick-release
top
the buckle simltancously in order 0 release the buckle. Onc-sided release (pressingandonlybottom of
one
clip) is impossible. (Ref. i (Encl. 59, 59a)
2%
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ON OR ABOUT || JAUARY 2024
(U)Figure2-2. Example of
a Cobra buckle, [FoF 110]
nm Sd wearing gloves at the timeofincident. (Encls. 62 (Images #11-12)
61,64)
12. was wearing a backpack with a three-prong quick release buckle when
he entered the water. [Eocls. 9, 62 (images #11-12), 61, 64)
113. (E65 The contentsof thebackpack included at least a Harris AN/PRC-117G radio with
battery, weighing approximately twelve (12) pounds. [Bacls. 36, 64, 65)
13a. (t coEo entra bateries sod simon [FI
backpack (0 Weigh approximately forty (40) pounds. (Encl. 36]
113b. (E44 The backpack appeared tobebuckled wheo[EEN <nicred the water. (Encls
36,62 (Images # 11-14)]
114. (ttIER
viously carried this backpack on pre-mission Full Mission Profile
rehearsals, as well
asduring the fist two boordings. (Encl, 40]
1s. (uh) commented oo
had the ight gear, and often carmied ex(ra gear 0 help teammates. (Encls. 23, 26, 36]
116. fe I, nol exhibited any indications of orthopedic injuryor ailment in the
twenty-four (24) hours leading up to the incident [Encls. 8,9]
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(U) VBSS Mission to VO)
117. (4 Combat Craft Assault (CCA) C-1 embarked the Boat Assault Force (BAF) as the
primary teamtoboard the VOL. (Refs. gh]
118. (86 The forces participating in the boarding event are includedas enclosure 66. (Refs. 5,
h) (Encl. 66]
112009(C)JAN24
Aetls
Asset Laydown
® pnd
7 uv ——
= : ~
um
i »
4
ll.cra rc atrpin |=T ag
Gall coum .
CD.
a Ed i
nn
(6H) Figure 3-1. Depiction of assault craftbout Cin elation to VOI (not drawn to sale).
119. (E81) Once the CCAS were in thesoc ccs
(4:6) fect, and “Tel good" ubout combined wind und sea state. (Encl. 10]the seas to be four (0six
120. eet) I 520 sc tbe six to cight (6:8) fet, (Encls
2.3
121. (E44) TF-3 FWD deliberately planned a slow approach, which took approximately one
our. [Encls. 24,29, 30, 31, 36]
122. (E61) While cn route 0 the VOL, were assessed as Six (0 soven (6-7) feet by the
Navigator aboard CCA C-1. (Encls. 24, seas
26)
123. (E44 Team members were geting wen during the ingress to the VOL. [Encls. 30, 33]
3
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124. (64) HELO | and 2 (helicopirs) were positioned roughly two-hundred
two-hundred (200) fect above the VOI atthe timeofthe incident. (Encls. 62, 66,(200) feet off and
67-71]
125. (66)The ladder apparatus used in boarding the VOI was in appropriate working condition
and did not display any noticcable performance deficicncies. (Encls. 26, 27, 72.73]
126. (U) The ladder rungs have ahigh fiction grip tape surface allowing for increased grip in
maritime conditions. (Encls. 72and73)
(2Approach #1-First threeAssauliers
121. (64h On the first approach, the CCA was riding well with minimum rocking. [Encls. 7, 8]
126. (E48 The VOI was rolling. but on par with what C-Platoon experienced in training and
other boardings. (Encl. 27)
ad Climber (or the Assault force, stated he
as satisfied with placementof the climbing ladder. Encl.got27]a “pecfect hook.”
130. (U) The rail cap upon which the ladder apparatus was placed for the boarding party to
climb had been recently painted and the surface was slippery. (Encls. 27, 30]
131. (U)The rail cap was elliptical in shape and roughly 1.2" by 0.75 by lateral and vertical
extents. (Encls, 72-73]
132. 6 boarded the VOIasthe first assault, noting it was “Spicy, but not
out of parameters. Enel 27)
134 ticipate
(Encls. 8, 26.29.31)
sonssv ve
(U)
Approach #2 Second ThreeAssuulters
134. (E68) CCA C-1 started 10 get out of position due (0 the
CCA C-1 to re-approuch the VOL [Encls.?, 8, 12, 34, 36] sea sate and ultimately required
13 i ach, the next three assaulters aboard were|
136. (E61) As the roll of the VOI increased, some assaulters went over the rl directly, without
the usc of the ladder
to board the VOL. (Encls. 22, 29, 31, 32, 36, 42]
17. ect ve the climb as not being “super bad" (Encl. 30]
2
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ONOR ABOUT 11 JAUARY 2024SEA OF TWO TASK FORCE THREE PERSONNEL
138. co to hang on 10 the ailingofthe VOI while irolledone full eyele
until he could Tet go and roll himself over the ailing and onto the deck of the VOI. (Encl. 30]
139. (G4 Aboard the dhow
JESS , recalled a newly painted surface at the top rail, and
noted thatthe new paint job “made i 3 tle sporty,” and that the top rail was likely wet or
slippery. [Encl. 30]
140. ceo)RII <0cescrives the cop ail as “slippery.” [Encl 26]
141 corI oi the VOI's
assauliers aboard the VOI (0 get the vesselincreased rocking and tried to communicate the
back underway, which would have steadiedwith
the VOL
(Encl. 7)
142 ultimately made it up (0 the wheelhouse area of the dhow, followed
b 5.23.26, 621
143. (6 Aboard thedhow [JIvetoed N clear the space nd ensure us security,
(Encls. 23,62]
144, ceo I ns 0 one at the helm or on the throttles, and the throttles were in
neutzal. (Encls. 8,23, 26,62)
145. (E48) After three more ussaulters made their wayonto VOI, CCA C-1 again had
difficulty holding its position and moved away from the VOIthe
set ts position alongside the vessel. (Encl. 7.8, 12, 18, 34,and re-approached a third ime to
40, 62]
146. (E44 At 2004C, TF-3 (FWD) reportedvia chatroom to TF-S5 tha th “intial assessment
isthe [VOI crewisco's|mpliant.” (Encl. 74]
(U)
Appr osch
#3=Man Overbourd
147. (@4) By the third approach, the VOI did not have any forward momentum. (Encl. 8, 10,
6
198. etre st ve cocking increase ss the vO stopped. (Encl 411
140. cu The CA C1 Bon Copan [JEI esr th VO as rocking, bot i
manageable. (Encl. 25)
150. (E44 Video evidence shows u clear difference
and third CCA upproach. (Encl. 62 (Images#01-08))in the rolling dynamics between the first
0
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‘atlempted 10board VOL. Blue circle depicts [Encl. 62 (Images #01-08)]

151 od that when it was his turn to climb the ladder, thehairs on the back
of his neck s10od up, soTi chose to time the VOI's roll placing his stomach on the cap ail and
rolling onto the dhow. (Encl. 32)
(66H Enclosure (62) provides a detailed deconstructionofevents observed via ISR video,
‘Timestamps are include
toassist
d the reader. All are common to the | Ithof January 2024,
and times are denoteda the local (CHARLIE) time converted from ISR reference data,
originally recorded in ZULU time. In sum, th following evens lasied approximately forty-
seven (47) seconds (between 20:09:29 and 20:10: 16).
152. (E81) <<20:09:29 (seconds)>> I a boarding attempt from the engine

compartment coveron the backofthe C A
10 the tal capof the VO. (Encls. 24, 62 (Images
0)
153. (G4 aciempted 10boardat thesame timeoI
howos
positioned forwardo nthe CCA. [Encls. 24, 28, 32,62 (Image 02))
3
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154. seas no contactbetwee [ISR <nNEN:
aected otcmpt 0 bows. (Encls. 32,62 (images 02,04) oud have
155. (eo) did not use the ladder upparatus in his boarding atiempt. (Encl, 62
(Images 02-09)
156. (eu) tempted ( gro the al cp directly from the engine compartment
cover of heTOR (images 02.04),
157. (8h <20:0929.5 130 conc
ail though hishands swifly dropped belowtSN e raf cap cating
both of his hands over the
a fll due 1 lack ofpositive
control. (Enc. 62 (Images 03-04)
% i re of th reader ime 20/09:30 s wed as the ime referenced for when |

lr |
158. (eth) III cic (0 have falen approximately nine (9) fect into ha war
based on the ai cap height above the waterline and the action ofa rolling ship whic in beam
seas. (Refs. g, h) (Encl. 62,72, 3]
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ONOR ABOUT [1 JAUARY 2024
159. (€8) The VOI wasrolling away sro (I thetime of hs fall. (Encl. 62
(Images02.04)]
160. (4H) <<20:09:31 (seconds)>> An unmanned scrial vehicle ost visual +[—_
afer his fall, due 10 the rockingof the VOI and the dronc’s positioning relative 10the VOT
(Encl. 62 (Images04-08)]
161. (88) <<20.09:35 (seconds)>>Fourseconds lair, a different airborne asset, HELO 1,
regains visual and video coverage. The remainderofall videoevidence is from the helicopier's
feed. [Eacl. 62 (Image 09)
162. H <<20:09:35 10 :36 (seconds)>> Roughly five (5) seconds after hisfal! lll
rips thebottom rungofthepoolladder portionof the ladder apparatus. (Encl. 62
mages 09-10))
163. (E49)<<20.09:38 10:38.5 (seconds)>>> Roughly cight (8) secondsafte his fal, with
arnt
CCA.
ipo the tors ongof he pot acJERR oc boy ints hc
(Encl. 62 (Images 11-12))
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JAUARY 2024
164_ (E64 <. :38.5 10 :40.5 (seconds)>> After eight and a half (8.5) seconds following
fall, his
releases from the ladder and reaches toward the CCA, but does notgain
conrol and is swept under byawave. (Encl. 62 (Images 12-15)]
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165. (E86) NSW CCAS have no handholdsofsurfaces to rab on the outside of the boat
(Encls. 62,72,73)
<<20:09:40.5 10 :41 (scconds)>> Now nearly eleven (11)
ppears 10 have gained marginal control of the caving ladderseconds
while
after hisron SE
he
ia water, roughly four (4) eet below the connection pointof he caving ladder withwasthesubmerge
pool
Iadder. (Encl.62(Images 15-16)]
161. (E60) <<20.09413 42 (seconds) SRI cape nt thewate towards ll

i had ben in the water for roughly eleven (11) seconds. [Encl 62
(images 17-18)
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168. (€84 Following] I: the water,

duration), video footage cone Visual of both operatorsbetween 20:09:43 10:53 (10seconds
wat withsome contactwith the caving adder extension. intermitiendy at the surface ofhe
36
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169. <<20:09:54 10:56 (eco SN is clearly
helmet breaks surface. (Encl. 62 (Images 19-32)) seen at the surfoce, and[fl]
170. (©6h A20.095 appescs 0 gain positive control of the caving
is indeterminate i if]had contact. (Encl, 62 (Images 33-35)] ladder, but it
171 8 <2009 36 cn To
six (26) seconds in the water. (Enc. 62 (Imageistof RRR ce vty vn
34)]
THIS SECTION INTENTIONALLY BLANK
ihc A
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172. <<20:09:57 10: n fier roughly fifeen (15) seconds in thewater JN

»
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ONOR ABOUT {1 JAUARY2024
173. (eh) <<20: 1000 cons JR cssone hand from the pool ladder, as he
appears
toattempt toregain situation (Encl. 62 (Image 38)]
174. (E64 <<20:1001 (et. oo overcome by an oncoming wave and

washedoff the ladder apparatus andback Tio the wate afer nincteen (19) seconds i the water
(Encl. 62 (Image 40-41))
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15. 601001009 ns Drm eo RR

the surface, but slips below twice. [Encl. 62 (Image 42-49))
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176. (€434) <<20:10:10 (seconds)>>

With his helmet
aTESS ‘waterwing. (Encl 6 (imagebarely
appears 0 deploy 50)
breaking the see |
177. (€t <a010:11 1 An unattached water wing appeared within
approximacly
one (1) foot o ast bserved location. (Encl 62 (mages 51-52)
“
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178. (€6h <<20:10:12 (cond J crys at the surface within

approximately
tw (2) feetofanun wing. (Encl. 62 (image50))
«
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179. (@64) <<20:10:13 to :14 (seconds)>
> cd
altempt 10shed his gear while at the surface. (Encl. 62 (Images movement
53-54)
appears to indicate un
180. (64H This is the last sighing of ihe water's tac. By is pio
been in the water approxi nds. (Encl. 62 (Imeges 53-54)]
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[ ——
181. (Eb <<20:10:15 (seconds)>> IR ipved below the surf; visual was not
regained. (Encl. 62 (Image 55))
(E68) CHAPTER IV. Search and Rescue Events
(U)OnSceneRescueEfforts
182. (E64) Man overboard (MOB) procedures,

SBT.20). wer soacted wit second of[REE
prescribed by Special Boat Team TWENTY
ins ioe water. ef 1 {Ents
6.7,18,28,57, 74,75)
183. (U) Man overboard
VOI, marking the locationprocedures include calling orientation of the MOB in relation to the
on th navigation suits, gaining visual custody, and marking the
posion with abuoyant tobe (ight. Rec] (Enc 6, 7:5,1, 17, 19.31.22)
150
{Enct 37)
185. (@4) determination at therewere two MOB, the Ground Force Commander
abso CCAUponC 1 RI
missionof avalable sets: (Encl 7) v0 te perme ecm(mane
“
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186. (ew After the MOB cal,NEI: hc VOI back in gear at an idie speed to
reestablish control of the vessel. (Encl. 26]
187. (©) CCA C-1 moved away from the VOI in order 10 avoid crushing the MOB. (Encl. 7)
158 ) Upon comin uc run Ic oo ND ~<

[Roating, but they were not at the surfuce. (Encl. 7]
189. ee that the search arca was well illuminated by helicopter lights and
helmet lights. [Encl. 7)
190. ho was aboard CCA Aa the MOB cal sted be so [fl

Jin thewaterand yelled MOB. (Encl. 14]
191. (Eu)
BA opined that it was very hard 10 see|
Riewi :auseof the
7 (Encl 14]
i52. or ERIN vc vc scucrs sou te VOL. acicat
He rs enon a
[= not resurfuced was thal they wore caught under the propellersof the VOI's rudder.
(Encl. 14]
193. (e849) ST-3 C Platoon’s Assistant Officer-In-Ch; in the
aircraft HE} nately 200 meters above in the airspace, saw fall into
the water and| go in after. (Encls. 36, 66]
194. (E54 Afer about one minute, said he thought to himself, “Where are these
195. (GH A TESS was recovered during the search and rescue on 11 January 2024, which
remained inflated and intact at time of recovery. The rigger's beltwas nol recovered. (Encls. 6,
7.25,53, 57,76)
195u. (E44 The strap to the TFSS, where it should have been attached (0 the riggers bell,
remained intact with no visible tearing. The CO2 canister indicated it had been activated to
properly inflate the TFSS. [Enc 76]
196. (E64 The recovered device showed no damage 0 the securing loop which might indicate
it had been ripped from & rigger's belt. [Encl. 76]
.
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ONOR ABOUT 11 JAUARY 2024SEAOFTWO TASK FORCE THREE PERSONNEL
(G4)Figure 4-1a. [FoF 196) Recovered TFSS
3 LA
(68H) Figure 4-1b. Recovered TFS. Found inflated, but subsequently deflaicd at the time of
photo
by53.571
helicopter, which ca be pose tbc 3s[RIE
197. (E44 The next day, on or about 1303C, 12 January 2024, a Kevlar helmet was recovered
et. (ool 6.7.5. 15.21
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ONORABOUT 11 JAUARY 2024SEA OF TWO FORCE THREE PERSONNEL
Pi : Ch
i oe
a oss A
(4 A i
/ = 39
¢ 7
1 %
» v4 Rx
LN pr tbo
LQ py
Nn G
(WH) Figure 4-2. [EEGITNNNNN covered helmet
198. (E44) Theprevailing expectation within the special operator community—expressed by
numerous interviews with C Platoon and SBD members—was that in the event ofa man
‘overboard, the operator would rewm 10 the surface to effect a rescue. This was noted in st least
12interviews. (Encls. 6,9, 10, 13, 15, 21,22, 26, 27, 36, 39, 40)
199. (Eb According t it was set up as a Radio Telephone Operator

(RTO) Manpack radio in backpack. TEnc]
2x. con Rimes be pc cies wd 40) ous, [ERs
unsure if the Waist stcap
oftheradio was buckled at the timeof the MOB. (Encl. 36]
201,
(Encl. 57)
202.
,
:
b.
i
: ont
@
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ON OR ABOUT I1 JAUARY 2024
I
t ay
(GuU.S.Naval ForcesCentralCommand(Manama, Bahrain)RescueEfforts
203. (E44 On IS January 2024, COMUSNAVCENT ordered the creation of an operational
planning team (OPT) to review all sources of information for the search and recovery efforts and
make recommendations on the durationofthe search. The OPT recommended
continue 10 the ten (10) day-mark at 1710Z on 21 January 2024. [Encls. 51,75)he search
204. GH) As of 15 January 2024 (four days into search
encompassed 7,500square nautical miles. (Encl. 75) and rescue), the searchareahad
205. (6) In developing the planned search, NAVCENT used ocean drift models as analyzed
through the US Coast Guard (USCG), Fleet Numerical Metcorology and Oceanography Center
(PNMOC), and European Mercator model (provided through Scripps Institute of Oceanography).
(Encl. 75]
206. (44) All models showed ageneral southwesterlydriftmodel despite small variances.
(Encl. 75)
12180000 2000
15 00 20
161A 0000 2400
(EY Figure 4-3. Comparison of MERCATOR and HYCOM draft tracks
207. (E64 On 21 January 2024, the scarch and rescue concluded aficr ten (10) days and
encompassed a search area of approximately 48.600 square nautical miles (64,360 square statute
miles). (Encls. 51.77. 78]
208. (4) The ten (10) day search accounted for the chance that sunken remains might
resurface. (Encl. 78]
48
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209. (U) The Depaniment of Defense's policy permits a maximumoften (10) days for service
members (o be in a Duty Status — Whercabouts Unknown (DUSTWUN), after which
a
determination must bemadeon either a service member's death or ‘missing status. (Refs. m,
n]
(Encl. 51, 57,75, 78]
(U)RecoveryConsideations
210. (U) Reference (0) outlines the Navy's Salvage and Recovery Program. (Ref. o} (Encl. 75]
211. (U)This instruction states that “The Navy respects the sanctity of human remains and
recognizes the sea asa fit and ial resting place30generally will 10 conduct operations for he
primacy purpose of recovering human remains.” (Ref, 0]
212. (@8h The OPT assessed _- wearing body armor,
clothes, boots, plus their gear, and were ungole (03 vier gear before losing
consciousness. (Encls. 51, 57, 75, 78)
213. (E6h The OPT estimated tha the seafloor, withina three (3)to nine (9) squ ical
mile radius from
—- tl int, was the mostlikelyarea to recover the bodies Si
Encl. 75.79)
218 based the estimated recovery area on the assumprion cha NNN
went straight down due to weight.” (Encls. 75, 78]
215. (U)Thewater depth in this areawasestimated at 12,0008. {Encls. 75,
78)
216. (E464 The NAVCENT Operational Planning Team (OPT) recommended to
COMUSNAVCENT nol to pursue recovery and salvage efforts following the unsuccessful
search and rescue at ten (10) days. (Encls. 75, 78)
217. (€44) This recommendation was based on the extreme water depth, uncertain
buoyancy
andocean current effects, the low probability of locating the remains,
on the sea serving as a final resting place. [Ref. m, n, 0] [Encls. 75, 78]and the Navy's guidance
9
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(U) CHAPTER V. Safety and Equipment
(EU This chapter details safety standurds applicable in maritime interdiction operations.
chapter also explains equipment standards and practices applicable to Naval Special WarfurcThis
boardings.
(64%Equipping aSEALTeamUni forBoarding TeamOperations
218. (E44) Standard SOF Personal Equipment Advanced Requirements (SPEAR) is a
‘comprehensive list of equipment available for issue to NSW operators for specific mission
skillets. [Ref. p] [Encls.60, 61,79)
219. (@44 The standard SPEAR equipment issued for MIO includes adetachable maritime
plate carrier, swimmer plates, lightweight ballistic helmet, and multiple drybags (watertight
flexible bags). (Ref. p] [Encls. 60, 61, 65, 79]
220. (E44) Personal gear is differcat from SPEAR gear, as personal gear includes consumable
items which do not require retum or turn-in, and is managed as partof the Personal
(PGI) form by the Logistics Support Unit (LOGSU). [Ref. pl[Encls. 6,9, 65. 79) Gear ssue
221. (88h PG items are recorded in the Defense PropertyAccountability System (DPAS).
[Encls. 63, 64]
222. (€6h As pan of personal gear. operators ar issued aTFSS (also refered 10 as “Life
Preserver, Underarm ~ NSN -1.524-5323"). The TFSS is also known as "water wings.” [Encls.
60,61,63,64,79)
223, (E44) NSW operators use an emergency flotation device manufactured by PECI Flotation,
LLC. model TFSS-5326 (TFSS). (Encls. 60, 61, 63, 64, 79, 80)
224. (6 In configuring a TFS device, the operator's bell is rigged through the TFSS loop.
“The TESS is further bracketed by other gear on the belt, which themselves are either threaded
nto the belt or secured via Modular Lightweight Load-carrying Equipment (MOLLE)
connectors. [Encls. 25,26, 40, 41,80]
50
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CNY Gn al
| : $n yo
A N
aM AA 2
Z & Fo f
Ce Ee
a he XN hu |
(©) Figure 5-1. FoF 226)
ry i\
b
A
BR Ll
(@0H) Figure 5-2. (FoF 226]
225. (U) The PECL TFSS is an inflatable aid to flotation device specifically designed to provide
eighty (80) pounds of flotation on the surface and forty-five (45) pounds of flotation
at a depth of
thirty-three (33) feet to assist or any equipment worn and an individual's natural buoyancy,
which can vary based on specific body composition (.¢. bone, muscle, fai, blood, etc.). (Encl.
80)
226. (U) Bach TFS system consists of one each independent left and right-and units. (Encl. 80]
51
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227. (U) The minimum buoyancy per system (two floats on the riggers belt) is 80 pounds lift in
seawater, at the surface. The minimum buoyancy per unit is 40 pounds (one float) lift in
seawater, at the surface. [Encl. 80]
228. (U) The TFSS system utilizes a manually activated CO2 cartridge for primary inflation and
an oral inflation tube for secondary inflation. (Encl. 80]
E 2 =| |
; al a]
[ KC p
Ty
eT
Tr Rc
{a \ N
(U) Figures 5-3 & 5-4. Demonstrationofan activated TESS sysiem

229. (€6H) In October, 2009, U.S. Army Operational Test Command reported on the
performance of the Tactical Flotation Support System-5326 during an abbreviated operational
test (AOT). (Encl. 82]
229a. (84 The ost was Lo substantiate the fir, form, and function as well as. operational
procedures for the TFSS. Generally, the Army test found that the TFSS was effective, with
many positive remarks in the post-jump questionnaire (esting was done in conjunction with
parachute operations). (Encl. 82)
230. (E64) During this same AOT, however, there were two comments indicating challenges.
with operation. One comment highlighted the operator had (0 use two hands to deploy the TESS
after five (5) unsuccessful attempts with one hand. Anothertester noted that for one device, they
had to pull it four (4) times, but it ultimately inflated. [Enc]. 82]
231. (E84 The Naval Special Warfare Command Parachutingand Cargo Airdrop Operations
Manual issues policics and guidance that govern the conduct and training of NSW parachuting
52
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Subj COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES
and cargo airdrop operations. For both static lin and military free-fall parachute jumps, the
policy is that the TFSS devices willbe worn on a separate bell, around the waist. (Ref. q]
23a. (U) The TFSS manufacturer's instructions also state that
the hip level with a separate belt.” Activation handles should be TFSS dovices should be worn at
visible, free, and clear. [Encl.
80)
232. (E49) Besides the Naval Special Warfare Command Parachuting and Cargo Airdrop
Operations Manual and general instructions provided by the manufacturer, there are no other
NSW instruction discovered that specifically addresses and outlines the manner of wearing a
TFSS-5326. (Ref. q
233. (Eth) NSW Operators ure issued adetachable plate carrier manufactured by Eagle
Industries. Plate carriers are body armor vests that protect an individual from high-level threats.
(Encls. 60,61, 63, 64, 65, 79, 83]
SY ar
or
| 24
£ — 4
(= os:
y a 8
4%“ES p N A8
y
I;
; aJ 3
A id
(86) Figure 5.5. Detachable Plate Carrier
234. (EH) The carrier has the ability to house four (4) ballistic plates, one (1) on the front, one
(1) on the back. and one (1) on eachside, and includes extensive connection points. (Encl. 83]
235. (0) The detachable maritime plate carrier is designed to achieve buoyancy by inserting
foam into several points in the carricr, including the sides, front, and back. (Encl. 83]
236. (EW) Operators configure their kit based ontheir assigned role in u mission- for instance,
one operator noted being specifically “neutral” for buoyancy based on an assigned role to be in
the helicopter (Helo Assault Force). (Encls. 7,29, 32, 33]
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231.(E84) Others noted that the more foam you put in your kit the more bulk you have, so
staying slim to avoid intesfering with the ladder on a climb or 10 enable an ability to crawl
through small spaces is important. (Encls. 11, 32, 47)
238. (EU Several operators noted that they keep thei kit the same rather than changing it
between missions. (Encls. 22, 32, 33]
239. (EHA standard issue gear kit for a NSW maritime interdiction mission that may have
been worn on the night of question includes the equipment below. [Encls. 60, 61,63,64, 65)
a. Shooter Belt
b. Water wings (TFSS)
<. (3) Pistol Magazines
d. (4) Md Magazines
c. Pistol Holster
1. Glock pistol
8 Md iflc
h. Suppressor
i. Laser
J. Eo“Tech opic for Mé
k.Issuod Plate Carrier
1. Toumiquet X 2
m. Medical Blowout Kit X |
0. Helmet
©. Strobe.
p. Night Vision Googles Mount
4 Night Vision Googles
. lssued Jet Ski Vest
s. Radio and MCAS Communication System
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SURROUNDING THE LOSS AT SEAOFTWO TASK FORCE THRFE PERSONNEL
BRE ono
i Cp {
ihe out
f |
oa FE \ A
em TR )
hm
(8 Figure 5-5. FoF 239,
240. (U) Total gear is estimated 0 weigh about forty (40) to forty-eight (48) pounds. (Enc. 65)
(U)Pre:Mission SafetyCheckof"BuddyCheek”ofEquipment
241. (U) Wis standard practice 10conduct pre-mission “buddy check” immediatly prior to
executing an operation. [Encls. ,9, 10,25, 31, 65]
242. (EH A pre-mission buddy check consists of Team Members pairing up with cach other
andone member taking tums voicing every piece ofgearon a list. (Encls. 9, 10. 25, 31, 65)
243. (@6H) Pro-mission buddy checks are tailored to the specific mission and to the operator's
role in the mission. [Encls. 7,9, 10,25, 31, 65]
244. (EU) Pre-mission buddy checks mainly include weapons, magazines, special equipment,
medical, and communication checks. (Encls. 7,9, 10,25. 31, 65]
245. (EH Operators break this down ino three (3) categories, ist, second, and hind line gear.
Encl. 7, 651
246. (4H) Fics line gear is designated as a uniform and items in your uniform and pockets
{Encl 65)
247. €4#) Second line gear is the plate carrier and attached items 0 include: armored plates,
helmet, ight vison, magazines, communication. and specified ordnance orexplosives. (Encl
65)
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248. (EH Third linegear is considered a packofsome sort wom over the plate carr that can
be casily takenoff mainly for special equipment, food, water, etc. (Encl. 65)
249. (E84) Thecheck is for physical prescrice ofgear, not necessarily functionality. (Encls. 7,
65)
20. co IIv4 ts ess ht he pertr wit whom bs i paved es
checked theif own gear [or effectiveness and that it works. (Encl. 26)
251. (E44) There is no formal standing operating procedure or instruction that outlines this
‘common practice. (Encl. 65]
252. (8h A buddy check takes about two (0 three (2-3) minutes unless an operator forgot a
pieceof gear and must retrieve it. (Encl. 26]
(U)GeneralMainienance StandardsofEquipment
253. (U) Naval Sea Systems Command (NAVSEA) provides formal maintenance procedures for
equipment via the Planned Maintenance System (PMS). (Encl. 84]
254. (U) Specific maintenance requirements for the TFSS-5326 Life Preserver is found under
the NAVSEA Maintenance Index Page (MIP) 5832/024-53, and includes 1 specific maintenance
requireancat (0 include an inspection and lubrication of the TFSS tobecompleted annually and
after issue (Maintenance Requirement Card (MRC) 53 1BS4Y). (Encl, 84)
2548. (U) The manufactureroftheTFSS similarly states an annual inspection should be
performedfor the device or when it is exposed to water. (Encl. 80]
255. (U) There is also a formal requirement to inspect the TESS prior to
and to rinse the TRS after each use (MRC 53 1BSS Y). (Encl. 84 use (MRC 43 1BS6 N)
wo
statedHE
they Were unaware
of formal maintenance procedures Lo check their TRS - but received
on-the-job training in what 10 check for. [Encls. 7,9, 24, 27, 43, 48]
257. (E44) Team members described a need to ensure: (1) the bladder was sirtight, (2) the
actuating mechanism was clean and freeof rust, (3) the actuation tab moves freely, and (4) the
actuation tsb would puncture the installed CO2 cartridge. These general stepsare consistent and
included in the prescribed PMS for the gear. (Encls. 7,9. 24, 27, 43, 48]
258. (E44 In July 2022, the Special Assistant for Safety Matters (CNO NOS) issued a Safety
Assurance Letter (0 Commander, Naval Expeditionary Combat Command and Commander,
56
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Naval Special Warfare Command, highlighting concerns during safety assessment visit in the
fleet. (Encl. 84]
259. (Eh The Safety Assurance Letter noted “an absenceofrequired maintenance and
documentation actions on Life Prescrver, Tactical Flotation Support System (TFSS-5326)."
(Encl. 84)
260. (E44The Assurance Letter recommended immediate use of the 3-M program to conduct
and document maintcaance on the TFSS. (Encl. 84]
261. (E84) In March 2023, via letter, the Special Assistant for Safety Matters (CNO NO9F)
notified Commander, Naval Expeditionary Combat Command and Commander, Naval Special
Warfare Commandof continued deficiencies with TFS inspections in the fleet. (Encl 84)
262. (8 The leer noted that, “Naval Safety Command
Flotation Support System (TFSS)-5326s individually issuedAssessors
to
continue (o see the Tactical
personnel without the required
‘maintenance actions documented of completed.” (Encl, 84]
263. (44)The 30 August 2023 NavalSafety Command Semi-Annual Report noted that “since
March 2023, CNSC assessors have observed a marked increase in TFSS-5326 maintenance and
documentation by NECC and NSW commands...CNSC will continue to monitordocument | ©
TFSS-5326 maintenance during ll aicborne assessments going forward.” (Encl. 85]
264. (E44) Based on the actions by NECC and NSW noted above, CNSC closed this Safety
Assurance Letter (SAL). (Encl. 85)
265. (E64 NSW Group ONE SEAL teams are tracking TFSS maintenance completion via
locally-prepared worksheets, 10 include serial numbers, the manufacture date, and inspection
date. [Encls. 86.89)
266. (BUH) Across SEAL Teams ONE, THREE, and FIVE annual periodic check or the
situational check is not consistently documented, although inthesome documents “annual” is
denoted. (Encls. 86-89]
267. (8) There is variance in types of maintenance documentation across the teams (SEAL
‘Teams ONE, THREE, and FIVE) and NSW Logistics Support Unit-ONE. (Encls. 86.89)
268. ¢€61) Maintenance documentationof TESS is nol tracked via the Navy's SKED 3.2
program of record. (Encl. 86-89)
269. (€64) Within ST-3, documentation indicates TFSS maintenance
specifically within Alpha, Delta, and Foxtrot platoons, including expiredprocedure
gear,
failures
seized inflation
valves,or leaking bladders. (Encl. 83)
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270. (€8 For ST-3 C-Platoon. a functional check and maintenance check on TFSSs (not
specified as the annual or situational “R" check) is noted as being complete on § February 2024,
following the mishap.(Encl. 88]
271. (84 No records of checks are available for ST-3 C-Platoon pre-incident. (Encl. 88, 90)
272. (884 ST-3 TFSS maintenance tracker was incomplete and has missing information
(Encls. 88)
273. (64h Defense Pro ystem (DPAS) recordsdo not indicate issuance of
FSSloeither although both were observed with TFS in their
possession dur s and pre-mission photos. (Enc. 60, 61. 62, 63, 64, 76]
274. I ricnance documentation available forthe TFS belonging |
(Encis. 38,91)
(U)UnitedStatesCoast GuardDrowning Incident 2011)
275. (86h USCG suffered the loss ofa Marine Safety andSecurity Team (MSST) operator
(Matitime Enforcement Specialist Third Class) in 2011. Although thereare no safety messages
or directives thal nolify or make any of the USCG's findings controlling or a requirement on the
other services, th incident does provide context 1o this investigation. (Encl. 92]
a. (E84 First, when the operator (ME3) was recovered, it was determined tha his Tactical
Flotation Support System — at the time (2011) the same version that NSW uses today (2024)
did not have CO2 cartridges installed. Hence, skthough the Guardsman
activate the device in the water, the inflation bladder could not activate. may
The
have atiempied to
USCG.
investigation notes tha the operator had previously activated his emergency devices as part of
Basic Tactical Operator's Course pre-requisite training. (Encl. 92)
b. (E84) Second, he invesiigation determined the quick release featureof the operator's
ballistic platc system was fouled by other gear and that
the way it had been configured. (Encl. 92
276. (4H) The Coast Guard's findings indicated that although there wastraining on proper set
up ofequipment, in this instance. gear checks involved a leader
students visualized und checked theirgear ic., held it up for thecalling out items while the
instructor
of COZ cartridges was not specific item called out, oaly for the prescceoftothe sce). The presence
TFSS assembly,
itself. (Encl. 92]
271. (86 The USCG investigation directed, among hers, three key things:
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a. (E44) Revision (0 training, actics, and procedures (TTP) to betler assess equipment
readiness in advanceofevolutionsrequiring the use of a TFSS system and Ballistic Protection
Systems (BPS). Further, the gear check (should) specifically include & minimum two-person
Physical checkofcach CO2 canister (within the TFSS]. (Encl. 92]
b. (€64) For USCG 0 analyze and assess systems that might better accountforboth
‘conscious and unconscious operators, to include consideration of auto-inflation systems; (Encl
92)
c. (8) Establish a policy that prior to each evolution for which a Ballistic Protection
System is required, an appropriately certified instructor, hook and climb master, or fast-rope
master, must inspect and “verify that each BPS in use... properly configured to release without
interference by miscoutcd straps or other equipment.” (Encl. 92)
278. (E64 Today, the USCG uses the Mustang MD1250 as its tactical flotation system. [Encls
23,93,94)
279. (E61 The Mustang MD 1250devices are rigged such that one side is automatic (in the
event that the operator is unconscious or otherwise unable (0 execute manually),
(the shooter's sidearm side) is manual $0 as (0 permit unfettered access to tacticaland the other
weapons.
[Encls. 93, 94)
280. (U)The Mustang MD1250isa low profil safety device, which provides emergency
flotation. Using a hydrostatic device, each pouch will automatically inflate when submerged
four (4) or more inches of water. or the automatic hydrostatic function can be disabled by in
installing a cap over the hydrostatic device, allowing manual activation only by pulling the
beaded handle. (Encl. 93]
281. (U) This permits the uscr(0set the MDI250 for manual inflation for aviation operations or
quickly convert to automatic for maritime operations. (Encl, 93)
282. (U) Each unit provides thirty-five (35) pounds of buoyancy.
device provides seventy (70) pounds of total buoyancy. (Encl. 93 Worn as a pair, the emergency
283. (E64) USCG outlines minimum flotation requirement for tactical operationsas the
inherently buoyant Coast Guard Approved Type Iil Personal Flotation Device (PFD). [Ref. r,
Part 2, Ch. 4, A2. Note | (pg. 225)
284. (G64) USCG policy noes thatanoption to meet this requirement includes the Tactical
Flotation System, MD-1250. [Ref. , Part2, Ch. 4, A.2.d. Note | (pg. 2-25)]
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285. (E44 A note within the USCG Rescue and Survival Systems Manual states that the “MD-
1250s the only PFD authorized to be wom in conjunction with a ballistic protection system.”
(Ref. r, Pan 2. Ch. 4, A.2.d. Note |(pg. 2-25)
286. (85h The USCG prescribes a formal maintenance check for the MD 1250 10 be performed
quarterly and any time after activation oruse 10 ensure its readiness for operations. [Encls. 93,
94]
287. (E89 USCG procedures require serial numbers for tracking and to document mainienance
‘completion. The formal procedure is documented in the Maintenance Procedure Card (MPC)
KBOI23.0. [Encls. 93,94]
288. (U) PECI, the manufacturer of NSW's current version of a TESS, also manufactures an
automatically activated emergency flotation device, model Auto-TFSS, designed to inflate when
totally submerged in water, and includes a back-up manual lanyard. (Encl. 81]
289. (U) The PECI Auto-TFSS has the sume performance parameters ss the in-use TFSS-5326,
(Encl. 81)
290. (88) USCG special operators are required(oconduct a semi-annual Water Survival test as
delineated in COMDTINST M16260.4C. [Re. 5]
291. (E86 This test takes operators through a series of exercises, requiring them (0 respond 10 a
waler emergency and demonstrating all modes of recovery, including oral, manual, and
automatic inflation of a Tactical Flotation System (TFS), in addition to doffing tactical gear.
(Encls. 92,93, 94]
(EthNavalSpecialWarfare CommandParachuting and CargoAirdiop Operations
292. (E44) While there are no formal equipment inspections required prior1o boarding vessel
in maritime interdiction operations, Naval Special Warfare Command Parachuting and Cargo
Airdrop Operations do have formal inspections procedures in place and providesome context
‘The Naval Special Warfare Command Parachuting and CargoAirdropOperations Manual notes
that when canducting parachute operations, a trained specialist wha is designatedtoconduct a
Jumpmaster Personnel Inspection (MPI) will personally check the equipment configuration of
jumpers to ensure proper wear and operationofparachute equipment. (Rc. g)
293. (64H Jumpmasters conducta personnel inspection prior to operations tha includes a check
10 ensure the TFSS is worn on a separate belt, and freeofobstructions. [Ref. 1)
294. (EU The Jumpmasier will “squeeze (the] lower portion of TFSS-5326 to ensure [4] CO2
bottle is present on both units.” Further, an additional check will open the protector flaps to
ensure the unit is closed properly and the closing pin is routed through both closing loops. (Ref.
[3
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al
(U) CHAPTER VI. Anonymaus Complaint Alleging Misconduct by TF-3 Charlie Platoon
(U) This chapice adresses the anonymous complaint NCIS received on 15 February 2024. The
four allegations eu cnbers of the C-Platoon are addressed in tum.
actionsoc AMMRMRMIN C750 LCPO) (regonty commune saberThepS first
PULLER (LBP) that affected his judgement. The second allegation stated
as medically unfit conduct operations due 10 4 medical procedure ol
U.S. Navy medicine priorto embarking LBP. The third allegation state
used Performance Enhancing Drugs (PEDs) outside the knowledge and careof U.S.
avy medicine. The fourth allegation stuted| USN, used PED:s, outside the
Knowledge and care of U.S. Navy medicine.
©tegasionsoJFIBAcooAcesndAvot Abon UssLEWIS PULLER
295. (U) The NCIS anonymous complaint dated 15 February 2024 lieged tro[I+
abusing alcohol throughout ST-3'sdeployment aboard LBP. (Encl. 95)
296. (E44 The introduction, possession or useofalcoholic beverages aboard any ship, craft,
aircraft of in any vehicle of the Department of the Navy isprohibited, except as authorized by
the Secretaryofthe Navy. [Refs y,2}
297. (4) Per reference (2), numbered fect commanders are authorized to permit consumption
of up 10 1wo 12-ounce cans or bole of beer by cach member of the crew or embarked unit
during an appropriate one day stand down at sea, in conjunction with morale building activities
“This consumption is permitted on « onc-time basis following each 45-day period at sea. (Ref. 2)
298. (E46 USS LEWIS B. PULLER set oul (0sea on 1218Z on 2 December 2023. (Ref. aa]
ST-3 C-Platoon embarked aboard USS LEWIS B. PULLER comprisedof SEAL operators and
support personnel. (Refs. g. h] (Encl. 126]
299. Deleted
300. (4 While underway, ST-3 C-Platoon operators slept in tents located on the flight
of USS LEWIS B. PULLER. This tent area was colloquially known as the “Alaska tent.” deck
opi id not have an issue with alcohol dependency.
also believed that alcohol consumption did no affect hs leadership or
tactical decisions during their time working together. (Encl. 126]
302. (eo EIN iviially slept in ship's berthing. but eventually moved to the “Alaska tent”
with the other C-Platoon operators. [Encl 128)
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303. (e+ ated he observed the presence of alcohol once, while
USS LEWIS B. PULLER following the conclusion of the 10-day search for nd
(Encl. 128)
304. (€tsh)HIN: there wasa toast among teammates. JEN declined to provide
more details when probed about the toast with questions such a, how he knew there was alcohol
present, and who participated in the tous. (Encl. 128]
305. cor cote did notvives JRcoming alcohol abotrd USS
LEWIS B. bul observed a bolle of the deck following the conclusion of
theten (10)day search I EE ro recall the type
ofliquor. (Encl. 97-98]
306. eo RII occ that hewitssecsIRN inkoutof acup from the
ship's galley, und could not confiem the beverage was alcohol, butremenbereo EAT
seferencing a “mixed drink.” [ENN rcsINMGURIMII recrcicing this mixed drink
around Christmas day, but does not recall an exact date. [Encls. 96-97)
307. (4H) Upon conclusion of the seach and rescueeffortson or about 21 Januiry 2024, most
of C-Platoon disembarked the USS LEWIS B. PULLER. [SENSIS «\ongwiih[SE
(NGI ee responsible for packing up the “Alaska tent,” which contained C-Platoon’s
personal gear and equipment. (Encl. 129, 130]
308. (e+
RN Us, sccved us the TF 3 FWD Intligence Analyst,
attached to ST-3 during the entire 2022-2024 cycle, and embarked aboard USS LEWIS B
PULLER, though not as C-Platoon personnel. (Encl. 129]
309, wi the “Alaska ten,” 0 include C-Platoon’s personal gear and
equipment, id not see anything to indicate C.Platoon was in possession of
alcohol or that consuming alcohol occurred. (Enc. 130]
310. (e n wi the “Alaska tent,” to include C-Platoon’s personal gear and
equipment, did not see any alcohol or indicators that alcoholwas consumed
(Encl. 129)
3 ained embarked USS LEWIS B. PULLER after 21
January 20 packe ateroom. REE i not find
anyalcohol in personal effects nor signsofalcobol consumption. Encl. 126]
312. ces 5 s.potca TF as the Communications Department
Represcntaive, while cmbarked aboard USS LEWIS B. PULLER. (Encl. 131]
313. (eo <\cot in the ship's male berthing and rarcly entered the “Alaska tent,”
but maintained a professional relationship with ST-3 C-Platoon members. (Encl. 131]
a
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314. (@4#) On oneoccasionJN arched through the “Alaska tent” to ensure that
communication equipment was not let behind, unENN not se any alcohol
(Encl. 131)
315. cet)| o- ve besrd unythingabou RN possessing o consuming
alcohol aboard USS LEWIS B. PULLER. (Encl. 131]
316. eo{RII sv. scrved us 7-3C:Plutoon’s communications support for the
2022-2024 inter-deployment training cycle and cmbarked aboard USS LEWIS B. PULLER with
the Platoon. (Encl. 132)
317. ceo
[RIN ad professions imeractions iSoho heir time
working together and neversuspected[JI of havin issues with alcohol. (Encl. 132)
315. (ut III cciaized around the Alaska ten during off-duty hours, but slept in
ship's berthing while embarked aboard USS LEWIS B. PULLER. [Encl. 132)
319. oH cc: observed the presence ofalcohol while cmbarked or heard
anything that would make her think C-Platoon members were in possession of alcohol. (Encl,
132)
320. uh)
und staicd theydid not observe] der the influence of alcohol while
aboard USS LEWIS B. PULLER. [Encls. 96-101, 130]
321. eo I: cy cid no sec alcohol sbosrd USS
LEWIS B. PULLER. (Encl. 100-102]
Ss ETE
J2: 2
healthy relationship with alcohol und tha alcohol did not impair his decision
‘making as u leader throughout C-Platoon’s inter-deployment trainingcycle. (Encls. 96-101]
323, ot vod his rights per the Uniform Code.
Aricle 31b, before his interview with the Assistant Investigating Officer
(Encl. 103)
324. (E6# In response to the al egations ofpossessing andconsumingalcohol while aboard
USS LEWIS B. PULL eS cc that, “none of the SEALS from Charlie Platoon
were ever drunk while underway and alcohol was never consumed in the weeks leading up to
operations.” (Encl. 103)
325. (U) The next allegation in the NCIS anonymous complaintaieeR was
wrongfully using PEDs. (Encl. 95]
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SURROUNDING THE LOSS AT SEA OF TWO TASK FORCE THRE. PERSONNEL.
326. (6h PEDS without a medical prescription ae prohibited in the US. Navy. Performance.
enhancing drugs include steroids, human growth hormones, and selective androgen receptor
modulators, known as SARMS, and are similar o anabolic siroids. (Refs. ab, ac]
327. (66H Article 15-105of the Manual of the Medical Department delineates the conditions
which are considered disqualifying foc Special Operator (SO) duty. Re. ad]
328. (EHHPersection (4X) of Article 15-105, “anycondition requiring chronic medication or
dietary modification...may be waived for qualified SO personnel.” [Ref. ad)
329. (E89 Scction (4)(6) of nice 15.105 specifically enumeraies "hypogonadism or other
conditions requiring ongoing useof exogenous lesosterone or testosterone analogs” us
disqualifying.” (Re. ad]
330. (8 Section (4)n)8) of Aric 15-103 states, "or designated SO personnel, useofany
medication that may compromise mentalorbehavioral function, limit aerobic endurance, of pose
a significant risk of mentally or physicaly impairing side effects is disqualifying. Any medical
requirement that necessitates close monitoring, ogular tess..is disqualifying.” (Ref. ad)
331. (@Hh Section (4X8) of Article 15-105 additionally provides tht, "SO designated
personnel taking medicines prescribed by a non-DoDproviderare disqualified until reviewed
and approved by the Service member's Undersea Medical Officer” (Ref. ad]
332. (84 Service members may submit waiver requesting onc or more
waived. The outcome of the request is adetermination by the responsiblephysical standards be
waiver authority as (0
whether the physical standard is waived or not. (Ref. ad}
333. 2023, Commander, Naval Special Wasfure Command, Rear
Admica USN, disseminated force:wide guidance announcig urinalysis testing
for PEDs to begin November 2023. Encl. 106]
334. (G4Per tha guidance, members with concerning symptoms were encouraged 1 speak
with the medica providers fo diagnosis and proper treatment for conditions requiring
prescription supplementation and medication. (Encl. 106]
335. (E48 The Naval Special Warfare (NSW) Force MedicalOffice. [ERR
[MD. MPH. CPE. USN, disseminated guidance to al NSW Senior Medical Officers
tating that the “goal ofthe progran is o identify the medications that people are using and
make sure they are munaged corrctly and being used safely.” (Encl. 106]
336. ( SN. SEALTeam THREE Medic ead.confirmed
hat following the relaseof mail o the Force, ame forward
1 SEAL Team THREE hat he had a prescription for testosterone
replacement therapy (TRT) from aciviliandoctor in San Diego, CA. (Encl. 104]
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331. (ub acknowledged TRT is medicallydisqualifying for special operators and
requires a waiver. notified SEAL Team THREE Triad and Naval Special Warfare
Group One Medical of new medical status. (Encl. 104)
338 tained a medical recommendation from a U.S. Navy urologist regarding
medical status. To avoid inducing adverse effects from altering the TRT
regimen in a deployed and remote environment, the urologist advised to continue TRT as
prescribed from the civilian provider until return from deployment. (Encl. 104]
339.
(Encl. 104]
0) 5c Unauthorized MedicalProcedure
340. (U) The next allegation in the NCISanonymous complaint alleged
[SNE 2s not
fit 10 conduct operations because he received an unauthorized medical procedure in Bahrain prior
to embarking USS LEWIS B. PULLER. (Encl. 95]
Encl. 95)
343. The Naval Branch Health Clinic Bahrain onboard Naval Support Activity Bahrain is
limited in scope of services to include medical homeport, ancillay services, occupational health,
general dentistry, und administration. The local civilian section supplements all other medical
services, including emergency care. (Ref. 1]
344.
[Encls. 104, 105}
De 104, 105)
(Encls. 104, 105)

247. eo
SR th ST-3 TRIAD were svar of J IProctor v4
follow-on care. [Encls. 103, 104]
65
MARKING REMOVED
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348. eo RIN Us. Cormand Surgeon for Commander, Naval Amphibious
Force, Tusk Force 51/5th Marine
Expeditionary Brigade, provided an independent assessment of
IRIN
ic. cr specific to the (1) mecca procedure iageoned snd reed 0 26
November 2023, and (2) the subsequent follow-on care TE from
IEE Encl. 123)
249.
nl
350.
(Encls. 104, 123]
Ew a
w legd PED U
352. (U) The final allegation in the NCIS anonymous complaint aicgeENN
USN, waswrongfullyusing PEDs. (Encl. 95]
353. (U) The Assistant Investigating Offic
JIS es, conducted
an in-person interview
woo RE I denied wrongfully using performance enhancing drugs. (Encl.
354. (U) There is noting if Iecicsi recor inaicaring thr he was using PED
(Encl. 104, 123)
355. (U) The C-Platoon members interviewed had no knowledge of using PEDs
during the 2022-2024 inter-deployment taining cycle at SEAL Team THRE. (Encls. 96-101,
104]
CHAPTER VIL. Mission, Training, Equipment, and Risk Management Standards
Authorities and Command and Control
356. (U) The Missions, Functions, und Tasks (MFT) of Commander. U.S. Naval Forces
Command (COMUSNAVCENT) are delineated in OPNAVINST 5450341, dated 13 Central
September 2023. [Ref. u]
357. (U) COMUSNAVCENT commands and controls warfighting-focused, forward postured,
ready and capable maritime forces to maintain freedom of navigation; deter and counter state and
non-state aggression; defeat violent extremism, respondto criscs and strengthen partner nation’s
66
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SURROUNDING THE LOSS AT SEAOFTWO TASK FORCE THREE PERSONNEL
‘maritimecapabilities in order {o promote a secure maritime environment in the USCENTCOM
area of responsibility. (Ref. u]
(Eh Figure 6-1. Notional Chain of Command

358. (U)The MFTof Commander, Naval Special Warfare Command (WARCOM), ure
delineated in OPNAVINST 450.221E dated 23 January 2018. (Re. v}
359. (U) WARCOM's MFTS are to recruit, organize. train, man, equip. educate, sustain, secure,
and maintain combat readiness, and deploy Active Component and Reserve Component NSW
forces and personnel to accomplish special warfare missions assigned by Commander, United
States Special Operations Command (USSOCOM) or geographic combatant commanders
employing special operations forces (SOF). (Ref. v}
at LL
MARKING REMOVED
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361. (E44The order provides that SOCCENT may transfer Operational Control (OPCON) and
/or Tactical Control (TACON) of all attached, allocated, and apportioned forces as necessary to
accomplish the MSO, MIO,and OPE missions. [Ref. f)
{U)CommandandControlStrvetureofST-3
361. (U) ST-3 Standard Organization and Regulations Manual (SORM), died 31 July 2020,
articulates the roles and responsibilities of command personnel. Chapter Three, section 309
‘outlines these responsibilities within the Operational Task Units. [Ref. bl
362. (U) The ST-3 SORM identifies leadership positions and corresponding responsibilities:
a. (U) Task Unit Commander (TU CDR) Maintain the overall readiness of the Task Unit
(TU) and report all mars conceming the operational readiness of the TU to the Commanding
Officer (CO). Ensureproperconduct, safety, morale and welfare ofTU personnel and keep the
‘commandinformedon all matters affecting combat readiness and discipline. Equip, cnsure
sufficient training, conduct operations, and manage personnel. Enforce the command's standards
and SOPs, and use ORM to mitigate risk while accomplishing realistic valuable training and real
world missions. (Ref. b]
b. (U) Platoon Officer-in-Charge (PLT OIC) =Report to the TU CDR and maintain the
overall readiness of the platoon to support mission execution. Ensureproper conduct, safety,
morale and welfare of platon personnel, and keep the command informedofall matters
affecting combat readiness. Equip the platoon by signing for sub custodyofitems assigned to
the platoon, being responsible for the technical publication allowance, and coordinating for the
scheduled maintenance and upkeep ofassigned equipment. Ensure (ruining and readiness of
platoon and equipment maintenance / repairsare performed. Enforce the command'sstandards
and SOPs, anduse ORM to mitigate risk while accomplishing realistic valuable training and real
world missions. (Re. b}
. (U) Task Unit Senior EnlistedAdvisor(TU SEA)- Responsible for all aspects of the
‘conduct, safety, morale and welfare of TU personnel. Keep the TU CDR informedofall matics.
Validate, develop, and conduct waining as Subject Mater Expert (SME) in all tactical aspects of
NSW operations. Manage organization and TU equipage and enforce the command's standards
and SOPs. (Ref. b]
d.(U) Platoon Leading Chief PeuyOfficer (PLT LCPO) - Keep track of platoon personnel,
ensureproperconduct, safety, morale and welfure of platoon personnel. Manage/ inform
organizationand equipageofplatoon. Train the platoon and enforce the command's standards
and SOPs. (Ref. b]
¢. (U) Platoon Leading Petty Officer (PLT LPO)- Keep the LCPO informed, track
personnel, organize the platoon to accomplish tasks, enforce command standards and SOPs,
68
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prepare for assignment as u platoon LCPO, and mentor the platoon department representatives.
Ref. b]
(64h
Capabilities
of 4NSWBoarding Team
Di
364.
ef. Figure 0-2 (July2023)
(€6H) Figure 6-2. FoF 364)
(€4#TrainingaSEALTeam UnitforDeployed BoardingTeam Operations

365. (EH) SEAL Teams Platoons complete a twenty four (24) month Interdeployment Training
Cycle (IDTC) consistingofsix (6) months of Professional Development (PRODEV), six (6)
©
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months of Unit Level Training (ULT), six (6) months of Task Group Integration Training
(TGIT) (formerly known as SIT), unda six (6) moni deployment. This is outlined in
CCOMNAVSPECWARCOMINST $3500.3, the Force Readiness Manual (FRM), 2016. (Ref.
d.pg.33)
366. (Eu) During the PRODEVphase, each platoon focuses on meting the Personnel,
Equipment, and Qualification (PEQ) standards specified within the NSW FRM. This includes
personnel readiness, equipment acquisition and familiarity, and qualification attainment through
individual schools or courses of insiruction. (Ref. d (pg. 3-4)]
367. (EHH During the ULT phase, SEAL Team Platoons attend blocks of training with their
respective Troops. These blocks include, in no particular order: Military Free Fall, Maritime
Operations, MIO, Combat Swimmer / Diving, Land Warfare, Special Reconnaissance, Close
‘Quartecs Combat, and Special Operations Urban Combat. This phase of raining forms the
individual platoons and their respective troops into competent maneuver elements ready to begin
TGIT. (Ref. d (pg. 3-5))
368. (E44) During the TGIT phase, the SEAL Team begins to operate as a Task Group,
increasing interoperability with non-organic units, capabilities, and assets. TOIT ultimately
results in the SEAL Team's participation in a Final Bate Problem, whereupon successful
completion, the SEAL Team will be certified and ready to deploy. TGIT can also include other
tailored training for maneuver clements to better prepare for expected deployment AORS. [Ref.
d (pg. 3-6)
369. (6 Specific to MIO /VBSS, unitsarerequired to demonstrate Mission Essential Tasks
(MET)s via the following core training proficiency exercises (TPE) [Ref. d (pg. H-7 to H-11)J:
a. SEAL.I.11 Afloat Forward Staging Base (AFSB) Operations
b. SEAL.L.14 Helicopter Fast.rope Insertion
c. SEAL.3.03 Static Shipboarding
4. SEAL 3.04 Underway Shipboarding - Boat Assault
©. SEAL3.05 Underway Shipboarding - Ai Assault
370. (GH) FRM Exercise SEAL 3.04, Underway Shipboarding via Boat Assault outlines the
taining and execution stundards fora boat assault. (Ref. d) (pg. J-211)]
371.
[Ref.d (pg. J
211)
i)
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‘ON OR ABOUT 11 JAUARY 2024
372.
(Ref. d (pg. J-211))
an
el. d (pg. J-211)]

374. (€6#) ST-3 C-Platoon and the SBT-20 detachment (TF 3.2 and TF 3.3,respectively)
conducted one week of VBSS mission training 10 include small boat interdiction, casualty
evacuation, and tactical movements and close-quarters combat (CQC) inside ships in Bahrain.
[Encl 6, 49)
VL, (Encl. 65)
(Encl. 67-71A)
£64 MissionGuidance to SEALTeamUnitsforBoarding Operations

am.
(Ref. ¢
378. (E44) COMNAVSPECWARGRU FOUR Instruction 3120.28 outlines guidance and

standard operating procedures for CCA operations. This CCA Operations Manual notes: “The
maximum sea heightfor conducting CCA VBSS operations is cight (8) feet. The experience of
the CCA crew, experience of the assault force, and if it is a training evolution or operation
should be taken into consideration. Ultimately, the Patrol Officer will make the call to continue
or abort mission." [Emphasis deleted]. [Ref. c, pg. 69]
379. (E44) USSOCOM MS25-6cc: Critical Meteorological and Oceanographic Thresholds for
SOF Operations notes marginal thresholds for CCA operations as six (6) 10 cight (8) feet, with
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unfavorable thresholds above ten (10) feet. For a transit in excess of one hundred (100) nautical
miles, the marginal thresholds are (wo (2) to three (3) fect, and unfavorable thresholds above five
(5) feet combined scas. The manual provides the additional context for consideringseastatc
thresholds that, “For boat operations, conditions up 10 and including the unfavorable threshold
‘can impact accuracy of weapons, crew endurance/ alertness, and speedofadvance and may also
diminish as scas increase. Above this threshold, damage Lo craft and equipment or serious injury
10 crew members is possible. Sea State alonc is not an absolute indicator of crew /craft safety.
Wave periodicity. direction of travel, and crew experience can lower or raise the unfavorable
threshold. For initial planning purposes, however, sea stte is a primary consideration factor for
safety of navigation, crew, and overall mission success.” (Ref. j, pg. C-7)
wd 8.0] i"
381. (EH “Naval Special Warfare Operational Risk Management,” outlines the force's
implementation of ORM. I notes, *(Tlhe success of NSW is based on a willingness to balance
risk with opportunity in taking the bold and decisive action necessary 10 triumph in battl....Risk
‘management is an effective t0ol for mitigating the inherent risk in *high risk” training and
achicving success in combat” (Ref. w]
382. (4) The instruction outlines the force's "Risk Assessment Worksheet Process.” as List
Hazards, Assign Risk Level to Hazards, Assign Control Measures, Determination of Residual
Risk, and the Implementation of controls. (Ref. w, Enclosures (2) and (3)
383. (4)The purposeofRisk Assessment (RA) is10provide a structured process lo identify
and assess hazards. This process allows for the identification and assessment of hazards (0
determin risk levels finding ways to eliminate, reduce, and control the risks 0 make them
ucceptable 10 the responsible decision maker. (Ref. w]
384. (44 The instruction permits standing RAS, provided the CO / OIC signature date has not
exceeded one calendar year, the training evolution has not changed, and the evolution safety
officer and senior person present review, sign, and date the worksheetor a coversheet the day of
the evolution. (Ref. w]
385. (E64) NSW Group ONE's Training Detachment (NSWG-1 TRADET), responsible for the
instruction and preparation of NSW-1 ST-3 C-Platoon for their deployment, prepared standing
RAs for training evolutions which arc reviewed annually and signed by the NSWG-1 TRADET
Officer in Charge (OIC). (Ref. w}
”
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386. (U) The 2023 version of the NSWG-1 TRADET RA form for MIO/ Shipboard Visit,
Board, Search, and Seizure (SVBSS) Hook and Climb noted specific risk mitigations for certain
events. For example, fora "Man Overboard” event the RA indicates: "Flotation wormbyall
personnel.” The isk mitigations fora “Pool Ladder Lifts and/ or Separates from Platform or
Vessel" and “SEAL Injured / Crushed duringLadderClimb" event provides: “Neutral
wom by all Personnel.” Finally, as a mitigation for “SEAL injured during transit” cvent,Flotation
it
provides: “Flotation and PPE worn.” (Encl. 50]
387.
ef.
Ref. d (pg.
)
389.
(Ref. d]
390. (61 In preparation for specific blocks of raining prior (0 their deployment, NSWG-1
TRADET outlines SEAL platoon requiremenls for execution via a “Trip Package,” which is
intended to serve as a pre-lraining block primer (0 focus team preparations. (Encls. 50, S0A, 79,
9A)
391. (4H) For MIO / VBS, the 2023 trip package provides, “Buoyancy Requirement; All
operators arc 10 have completed a buoyancy test of all equipment prior o raining.” (Encls. 79,
719A]
392. (E44 For MIO / VBS, the 2023 trip package (MIO) Gear List prescribes, under Personal
Gear, “neutral lotation.” (Encls. 79, 79A]
U) Swim Buddy
393. (664 The 2023 NSWG- | TRADET RA form for CRRC Long Range Navigation, CRRC
Dewatering, Swimmer Surf Passage, and Swimmer Propulsion (Surface) notes specific risk
mitigations for “Drowning,” 10 include; “All personnel have an assigned swim buddy”; and
“Swim buddy enters water if swimmer flls (rom boat” (Encl. 50]
”
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co RivoviD
394. (4) The CCA Operations Manual notes, “(Sjome Assault Forces SOP will be for another
essauler tojump into the water with the man overboard in case consciousness is lost.
what the Assault Force actions will be50everyone knows how many people to expect Ensure(0 look
for” (Ref. c; Encl. 1, Ch. 3, 9(c) (pg. 4]
395. (Eb) Numerous interviews with NSW and adjacent supporting clements noted an
‘expectation that inthe event ofa Man Overboard (MOB). a second person wouldjump in to
assist (referred10as the “buddy rule”). This was noted in at leas seven different interviews.
(Encl. 4,6,8, 35,36, 37, 38]
396. (44) From 16 January 2023 - 03 February 2023,ST-3 TWO Troop, which includes
Platoon and D-Platoon, completed the ULT block of Maritime Ops (MAROPS)/ Over the C-
(OTB) that included missions of Swimmer Surf Passage und Swimmer Propulsion (Surface).Beach
(Enchs. 36,47)
397. (E44 The ORM RA for the MAROP /OTB S block was signed on 17 January 2023.
[Encls. 36,47, 48, 109)
398. (EH) From 10-21 April 2023, ST-3 TWO Troop, which includes C-Platoon and D.
Platoon, completed the ULT block of MIO. (Encl. 110]
399. (8) In preparationfor the MIO block of training 10-21 April 2023, ST-3 TWO Tr
trip package, with assigned trip T
POCs — C-Platoon an
for Delta Platoon. The package outlined NEW " pointsofcontact for
raining, the anticipated schedule. and the required personal and departmental gear lst. (Encls
79,794]
400. (E45) The ST-3 TWOTroop MIO trip package listed neutral flotation as part of MIO
personal gear. This aligns with the 2023 editionofthe NSWG-1 TRADET trip package that
stated 2 need for neutral flotation in the personal gear list. [Encls. 79, 79A]
401. (6) During TWO Troops MIO block of training, the NSWG-1 TRADET RA form for
MIO/SVBSS Hook and Climb was completed on 19 April 2023. (Encl. 79)
402. (8) On IS May 2023, ST-3 C-Platoon conducted a Full Mission Profile (FMP)
Assaull Force (BAF)/ Helicopter Assault Force (HAF) MIO as par of ST-3 TGIT FinalBoat
Problem, from which they cmecged certifiedto deploy for the CENTCOM AOR. (Encls. Battle 69, 70)
403. (E45) All ST-3 TWO Troop leaders were in theirprescribed positions atthe time of the
team’s Final Battle Problom and deployment when the team was deemed ready to deploy. (Encls.
i-17)
ia
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404. ( 8 On 22 June 2023, ST-3 C-Platoon and USCG MSRT WEST, conjoinily, conducted
Close Quarters Combat (CQC) and Sensitive Site Exploitation interoperability training in San
Diego, CA. (Encl. 118)
405. (Eh On26 June 2023, ST-3 C-Platoon and USCG MSRTWEST,conjointly, conducted
Close Quarters Combat (CQC) interoperability training in San Diego, CA. (Encl. 119)
406.(E68 On 19 July2023, ST-3 C-Platoon und USCG MSRT WEST, conjoitly, conducted
MIO and AtSea Space Accountability (ASSA) Trainingpi side onboard HOS DOMINATOR
at Naval Air Station North Island. (Encl. 120]
407. (E81)On07 September 2023, ST-3 was annotated by CNSWC as completing ll assigned
Mission Essential Task List items (METLs). (Encl. 121)
408. (E69 Throughout both C-Platoon and the SBD's IDTC, members noted they had seen a
wide breadthofenvironmental conditions, including nighttime operations and all weather
conditions. NSW operutors specifically noted thai the teamhad exposure 0 “sporty” sca states
and environmental conditions. (Encl. 14, 30)
409. (E44) ST-3 C-Platoon had high confidence following completion of their MIO block,
noting tha theteamcnded on a high note, and fel it was their strongest block of training.
(Encis. 7,30, 36,41, 48)
(U)Buoyancy ChecksandTESSTraining
410. (E86 There are no publications o directives discovered that mandates specific procedures
fora "buoyancy test” However, scribed buoyancy tests, ao known us
4 "dip est,” as a process o ensure an opecator i positively buoyant. Operalors jump in the water
with all the gear they intend to wear on mission. to ensure positive buoyancy is mainiained. Any
change 10 personal equipment, another dip test should be accomplished. [Encl. 65)
411. (Gh Buoyancy tests are conducted with a full combat foad out of what wil be wom on
the specific mission by the opcrator. “The tes s initially conducted in a conirolled environment
such1s a pool before transitioning to the sea. Operators will don all combat cquipment required
for the mission, slide into the pool, and check for positive buoyancy. 1not buoyant,
supplemental flotation material will be added or specific cquipment may be takeoff maintain
positive buoyancy. After positive buoyancy is maintained operators will, if available,toJump
High dive or something equivalent, to ensure positive buoyancy is maintained at depth. (Encl.off65]a
412. (6 An effective buoyancy test does nok require a TFSS to be activated. [Encl. 65]
7s
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413. (E6h Some members recall testing thei buoyancy while wearing their personal gear ("dip
tests”) during OTB or Dive Phase Training. Of them, some recall using diffrcat gear than what
was in usc during the CENTCOM boardings. [Encks. 7,9, 13, 14, 20,48]
414. (EH) Special Warfare Combatant Crewmen (SWC) membersofthe Special Boat
Detachment in panicular outlined that buoyancy tests oceura the schoolhouse whethera part of
initial accessionorPRODEV with an emphasis on positive flotation. (Encls, 12, 16-17, 22]
415. (EH) Other members described buoyancy tess being conducted individually. [Encls. 20,
2,41)
416. (Eh Team members did not recall any personal buoyancy tests upon deployment and
subsequent training aboard USS LEWIS B. PULLER. [Encls 8, 10-11, 14, 19, 27-29, 31,33,40.
41,43,47,49)
417. (EH The mos frequent noted personal buoyancy test by team members was during the
OTB block of wining. This ruining was conducted in late winter/early spring in Southern
California. During this time, wetsuits and/ordry suits would have been uscd, which provide
some levelof inherent buoyancy. (Encls. 7,9, 13, 14 19,20, 48)
418. (€84 Specific to maritime operations,| were both issued
the following equipment
a. Light Weigh Ballistic Helmet;
b. Maritime Platc Carrying Vest, detachable (BAY, MMAC-R 2019, KIT, MC);
c. Ballistic Swimmer Cut Plates, GEN V;
d. Multiple Thicknesses of Ves! Floution;
¢. Multiple Water ications Cables and Adapters, Boom Microphones (no
boom microphone f
1. Water Proof 5;
& Maritime LCS Pouches (small bags for ammo/supplies). [Encls 60-61]
419. (€H) Fow operutors had ever operated specifically TFSSs ina training scenario. Even
fewer had ever actuated the devices in order to gain familiarity and confidence with activation in
emergency situations and to checkifany adjustments need to be mad, such as the length and
tightness of the pull sing. (Encls.9, 14, 15, 24-25, 28-29, 33, 36, 43, 49]
420. (€64) Additionally, some operators highlighted the necessity of deploying the TFSS in
order 10 achieve positive buoyancy. This is contrary 10 the view that one can be either be
positively or ncutrally buoyant simply based on supplemental buayant material being added to
specific gear worn via foam inserts n vests or in dry bags. [Encls 9, 14, 15, 24-25, 28-29, 3,
36,43,49)
7%
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—
Subj: COMMAND INVESTIGATION INTO THE FACTSAND CIRCUMSTANCES
SURROUNDING THE LOSS AT SEA OF TWO TASK FORCE THREF, PERSONNEL
421. (Eh The Augusi 2023 ST-3 Defense Organizational Climate Survey (DEOCS) raised no
‘concems with regards to risk management, training, safoty or equipment issues that might have
provided early identification
ofissues within TWO Troop. or specifically within C-Platoon on
those topics. (Encl. 122)
(LD BuoyancyChecks:Neutralversus PositiveBuoyancyandConflicting Guidance
422. (€4 Neutral buoyancy impics thal a person would neither sink nor ric in the water
columa. Altematively, if a person was positively buoyant, they would float at the surface of the
water. Across the breadih ofa SEAL Platoon’s broad operations and missions it may require
different personal gear configurations. A long-range waterborne infiltration requiringa swim-in
10 the objective might require different personal equipment and related buoyancy requirements as
‘compared 10 a shipboarding via boat assault. In a helibore operation over water, positive
buoyancycould risk pinning the individual insidea sinking airframe. [Encs. 21-29, 37)
4
(Ref. ¢
424. (0 In preparation for specific blocksof training prior o their deployment, NSWG-1
TRADET outlines SEAL platoon requirements for execution via a “Trip Package,” which is a
training aid for aparticular topic. For MIO/ VBSS, the 2023 trip package (MIO) Gear List
prescribes, under Personal Gear, “neutralflotation.” (Emphasis added) (Encl. 79)
425. (6The ilored ST-3 TWO Troop MIO trip package for training conducted in April
2023 listed neutralflotation as pantofMIO personal gear, (Emphasis added) (Encl. 79)
426. (4h During cranc launch and recovery, the CCA Operations Manual statcs that proper
personal protective equipment (PPE) will be worn at all times when working under cranes, 10
include a helmet and positiveflotation when conducting waterborne operations. (Emphasis
added) [Ref. c]
421. (€8h In addition, CCA MOB procedures also call 10 ensure a person in the water is
wearingpositive flotation device. (Emphasis added) [Ref. c]
I...
oo joined the Navy in 2012, completing Basic Underwater
Demolition? SEAT in mid-2013 and the SEALQualification Training (SQT) in 2014,
[Encl. 116)
(a
2. on his fourth deployment cycle, completing three offour cycles
assigned to entral Command Arca of Operations. (Encl. 116]
n
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‘SURROUNDING THE LOSS AT SEA OF TWO TASK FORCE THREE PERSONNEL
(ON OR ABOUT 11 JAUARY 2024
40, eo I ce a5 a member of Commander, NSW Group ONE Training.

Detachment "TTRADET), as a Land Warfare Instructor. (Encl. 116]
31. (ett[Icovo'etcd a operations) assignments as a member of ST-3. (Encl.
116}
ax (co an accomplished swimmer: u state champion in high school, and

competing al
the collegiate Division 1 level with the University
of Massachusetts at Amherst and
the University of Maryland swim teams. [Encls. 116, 123, 124]
433. enhEl Records include [Encl 116]:
+ NSW Preparatory Course 10/10/2012
+ BUD/S Basic Orientation, Ist Phase Through Hel Week 2/15/2013
+ Basic Underwater Demolition/SEAL (BUDS) Post Hell Week, 151, 2nd, and 3rd Phase
61712013
+ HAP PHYS 7222013
+ Pre-SEAL Qualification Training 7/12/2013
+ COLD WEATHER ENVIRONMNTL SURV 8/9/2013
+ SERE Level-C 8/9/2013
+ Navy Static Line Parachutist 11/16/2013
+ Military Free-fall Parachutist (MFFP) 12/13/2013
+ NSW SERE Level-B 1/17/2014
+ SERE Level-C 1/17/2014
+ NSW BASIC COMBATIVES 1/31/2014
+ SEALQualification Training (SQT) NEC 026A 2/1/2014
+ SEAL Qualification Training (SQT) Course CIN K-431-0059 2/7/2014
+ NSW Diving Supervisor 5/16/2014
+ NSW Range Safety Officer (RSO) Course 5/23/2014
+ Joint Terminal Attack Controller (NAWDC JTACC) NEC 822A 7/3/2014
+ Joint Terminal Attack Controller
+ (NAWDC JTACC) NEC 822A 7/3/2014
+ NSW Communications 10/3/2014
«Helicopter Rope Suspension
+ Techniques (HRST)/Cast Basic Roper 10/7/2014
«Joint Terminal Attack Controller
+ (NAWDC ITACC) NEC 822A 12/16/2014
+ NSW Sniper NEC O19A 6/1/2016
+ NSW Sniper NEC O19A 8/1/2016
«Helicopter Rope Suspension
«Techniques (HRSTVCast Master 8/19/2016
«Helicopter Rope Suspension Techniques (HRSTVCast Master 4/4/2018
8
a
MARKING REMOVED
x ove
+ HAP PHYS 5/112018
+ SmallArms Range SafetyOfficer (RSO) 85872018
+ HRST Rope Master 12/10/2019
+ JSOU JointFundamentals CEP-1 1.011-3701 5/15/2020
+ Dynamic (Fire snd Movement Maneuver) Range RSO 5/21/2020
+ Indirect (Mortars) Fire RSO 5/21/2020
+ Laser RSO 5721/2020
+ Rockets (Stand.off Weapons) RSO 5721/2020
+ Small Arms Range Safety Officer (RS0) 5/21/2020
+ NSW Instructor Training (NSW 1QC) (NITC) (SNEC 80SA/9502) 6/26/2020
+ NSW Instructor Trining (NSW 1QC) 7/1/2020
+ NSW Leading Pety Officer (LPO) Prepartory Couse CIN K~431-8001 2/4/2022
+ Joint Terminal Attack Controlir Instructor (/TAC-1) NEC 823A 7/1/2022
+ HAP PHYS 8372022
+ NSW Advanced Combatives 8/26/2022
+ Dynamic (Fire and Movement Maneuver) Range RSO 9/26/2022
+ Helicopter Rope Suspension Techniques (HRST)/Cas Basic Roper 9726/2022
+ Indirect (Mortars) Fire RSO 9/26/2022
«Joint Terminal Attack Controller (NAWDC JTACC) NEC 822A 92672022
+ Laser RSO 9/26/2022
+ Military Free-full Parachuist (FFP) 9726/2022
+ Navy andMarine Corp Parachuist (Nava Parachutist Insignia) 9/26/2022
+ NSW Range Safety Officer (RSO) (OQUAL) 9726/2022
+ Range Officer.in-Charge (ROIC) 9/26/2022
+ SEAL Leading PenyOfficer (LPO) NEC O26L 2/1/2024
434,oi a,USN, joined the Navy in 2019,completing BUD/S and

SQT in 2021"
435. (E84 Upon completion «sor joined ST-3 and
was on his first deployment
cycle. (Encl. 117)
436. “I Recordsinclude Encl. 117]
+ NSW Preparatory Course 2/7/2020
+ BUD/S Basic Orientation, 1t Phase Through Hell Week 5/30/2020
+ Basic Underwater Demolition/SEAL (BUD/S) Post Hell Week, Ist, 20d, and 3rd Phase
31972021
+ HAP PHYS 6/9/2021 COLD WEATHER ENVIRONMNTL SURV 10/8/2021
+ SERE Level-C 1082021
+ NSW BASIC COMBATIVES 10/15/2021
”
RE
MARKING REMOVED
I ING REMOVED
+ NSW SERE Level-B [1/5202
« SERE Level-C 11/2021
«Navy Static Linc Parachutist 11/12/2021
«Military Free-fall Parachutist (MFFP) 12/10/2021
+ SEAL Qualification Training (SQT) Course CIN K-431-0059 12/17/2021
+ SEAL Qualification Training (SQT) NEC 026A 12/20/2021
+ NSW Range Safety Officer (RSO) Course 2/11/2022
+ NSW Communications 6/1072022
«NSW Advanced Combatives 8/26/2022
«Military Free-fall Parachutist (MFEP) 3/9/2023
+ Navy and Marine Corp Parachutist (Naval Parachutist Insignia) 3/9/2023
+ Small Ams Range Safety Officer (RSO) 3/9/2023
(1)Special BoatTeam Guidance andMOBProcedures
437. (EW) During a MOB, the immediate actionsofthe boat crew arc subjectto the following
directives:
a. Communications must be clear and concise to disseminate all updaies to all craft;
b. All boats shall hit their respective MOB buttons on the NAVNET GPS systems;
. Immediately followed by crewman throwing a boat strobe in vicinity of last known
position of MOB;
. All hands shall keep a watch utilizing the naked eye, CCFLIR, any available
rotary or fixed wing, and night vision equipmentifapplicable. Ref. c (pg. 42) asset i.e.
438. (B44) CCA MOB procedures fora conscious person in the water are subject (0 the
following directives:
a. They shall make every effort (0 get the attentionof theboatcrew to expedite
b. They shall ensure they are wearing positive floation. a sound signaling devicerecovery;
such as a
whistle, a visual signaling device such asu strobe, and personal radioto get positive
communication with the detachment. (Ref. c (pg. 42)]
439. (€64) CCA MOB procedures for an unconscious person in the waler are subject {0 the.
following directives:
a. Personnel shall have positive flotation to keep them afloat in the event the MOB is
unconscious;
b. Boat crews will make every effort o recover the MOB;
¢. Boat Captain will make the recovery approach downwind of the MOB;
d. Crew will deploy rescue swimmers to retrieve MOB as well as prepare medical
equipment. (Ref. c(pg. 42)}
30
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SURROUNDING THE LOSS AT SEA OF TWO TASK FORCE THREE PERSONNFL
ON OR ABOUT [1 JAUARY 2024
440. (E65The CCA Operations Manual notes, “During the climbing portion, whichever boat is
astern of the Contact of Interest will act as a safety boat in case a climber falls off the ladder or a
MOB situation occurs. Ifun assaulter fall, the boat alongside will stay alongside and continue to
upclimb assauliers.” (Ref. c, pg. 74]
441. (4H) The CCA Operations Manual notes, “Assaulters will generally require extra gear to
be hoisted up once on deck. The preferred method is to up climb all assaulters and then hoist up
gear as required.” (Ref. cpg. 75)
442. (€61) Reference(c)dated 27 August 2018 lists no specific contingency planoc Standard
Operating Procedure thal accounts for recoveryof a submerged operator who has gone
overboard. (Ref. c)
443. (G4) Neither references (g)or (h) designate role for a search and rescuc swimmer
(Refs. gh]
444. (€6H) Neither the CCA Operations Manual nor the NSW Group FOUR Engineering and
Maintenance Manual ideatifics a comprehensive list oflifesaving equipment to be carried in the
craft. The PassengerBrief template contained in the CCA Manual does make mention of life
rings, but itistheonly mention ineither reference. (Refs. ¢, x}
La el
81
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OPINIONS
|re I were caused by the weight of their gear and
general lack of buoyancy. Despite conflicting guidance as 10 buoyancy standards, no guidance a
suggests negative buoyancy for VBSS missions. This negative buoyancy was the toot cause of
these deaths. (FOF 1133, 239, 418, 420, 422-427]
2. (64H Supplemental buoyant material (i... foam inserts added to their vests or added ( dry
bags containing theirequipment, if carried) and properly functioning inflationdevices, could
have kept these operators at the surface while awaiting recovery, as recovery ussets were in place
andpoisedfor response. (FoF219, 235, 420)
l,l eam..y
4. (€8H) Deficiencies, gaps and inconsistencies identified in doctrine, tactics, techniques and
procedures included conflicting guidance on buoyancy requirements, issues with maintenance of
emergency buoyancy equipment, and failure to recognize risks to buoyancy and the role
emergency flotation devices and supplemental buoyant material should play in achieving
buoyancy. (FoF 188,233, 253-274, 362b, 391, 393, 419, 422-427, 439)
(10 Opinionsspit
SRN o
5. (6h There is no indication or Ec: and /or cognizant abilities were
hampered prior o the boarding of the WOT that would have negatively fected his ability ta
execute the mission. (FOF 105,432)
6. (644 Despite getting (wo (2) hands over the rail cap, hands immediately
slippedoff the rail cap and then his hes zap earea Trom view, indicating that he
had fallen from the rail. 1 is possible impacted the rail cap with the top of his
chest, collarbone, or possibly his neck orhead. (FOF 136-139, 162-164)
7. (44 The rolling ofthe VOI in beam seas andthe extemal contours of the VOL as it rolled
away fron during his fall increased the likelihood of physical contact and impact
between the VOI and {FOF 158-159, 186-187)
8. (644 The near simultaneous boarding attemplbyboth| jo 1
ion or impact on the mishap becauseof their physical separation rom one another.
from the forward part of CCA C-1 (and forward of the boarding
ladder) whi wempted to board the VOI from the back part of CCA C-1. [FoF
151-154)
8
MARKING REMOVED
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ON OR ABOUT || JAUARY 2024
9. (E61) Subsequent 1 his fall, while at the bottom of the fadder and partially in the water
JE
ars 10 rotate his body towards the CCA in an apparent effort to communicate with
(FoF 162, 163)
10. ceo) As[II (orsbisbody back
in an apparent attempt 0 recover back to the CCA, towards the CCA, he releases from the ladder
but was unable to ind any hand-hold to
establish control as there are no hand-hold surfaces a the stem. [FoF 164.165]
1 conI wearing approximately 40-48 poundsofgear and the weight of
the geardirectly 10his drowning, [FoF 162-164, 166 171,240]
12 conI negativelybuoyant, based on observationofhis continued
difficulty 0 break the surface. (FoF: 162-164, 166-171)
13. cect)INIvss. i properly secured
manually actuated by pulling the grab handics, should tohave
the wearer, fully operable, and both
providedup tscombined eighty
(80) pounds of added buoyancy (depth dependent) and pot the surface.
(FoF 23,24, 225.2290]
14. eon
[RIIss ofdeath wes drowning. (FoF 162-181,212, 214, 228.258)
15. (€49 There is no indication oo suffered any injuryof

1 or cognizant abilities were hampered n any way prior (0 theboarding of thethat
VOI
his athletic and
that would
have negativelyaffected his ability to excute the mission. (FoF 116]
16. (uh) as the only person that appeared 10 have had direct sighting of[ll
amidst the cmecgency, and likely he only person to rapidly capture andassess the
on
166-167)
[111s ccs ewe Fok 63160
17. (64) tered the water in an effort 10 rescue
/ a his
own life at 67)
18. (E81 While it is not possible to kno mindseta the timeofentering the
water, it appears clea from the documentaly EF he made 4 conscious decision (0 do 50
a0d alempiedtoassist his teammate. [FoF 163-167)
19 oe weighed approximately 52-80 pounds: Approximtely 40-
48 pounds for the boarding gear and approximately 12-40 poundsfor the on-the back radio (12
8
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ONOR ABOUT |1 JAUARY2024
pounds) and backpack (possibly holding extra baticrics, supplies and gear). [FoF 112-113a, 199.
200, 238.2401
20. (Et,ovr foe in thesoe negatively
buoyunt, The gear and radio ruck sack likely contributed to this negative Buoyancy. [FoF 112.
115. 172-181,199-200, 240]
21 immediate tactical action of capturing the VOL, the carrying ofa tactical radio
b couldhavebeen avoided undhoistedaboard the VO at alater time. [FoF21h,
¥
2. Eo) Afer fell ino the water, his movement appeared consistent with an
atiempt 10 shed Puch as his radio nck sack. (Fo 176, 179]
23. (UD The investigation team does not hold the opinion cidental)
unhooked his riggers bel, to which his TESS was presumably t a c h e d
belt buckle requires both clips located at the top and bottom of the buckle 10be pres obra
simultancously in order for i release. One-sided release (pressing only one clip) is impossible.
(FoF 23:25, 110]
24. (EU The design of the recovered TESS, which was inflated a the surface, precludes the
possibility of i becoming unthreaded from a belt worn by an operator even if the belt buckle
would have been mistakenly released. The maure of the TFSS mounting system, woven through
the belt and worn on a hip, ensurcs tha fictional forces ofother bel mountedsaul
the buckleitselfwould have prevented the TFSS from breaking free. Thus, ikl
tigger’ belt / shooters belt been accidentally relcased, th entire assembly would have come to
the surfuce attachedto the inflated TFSS. (FoF 195-196, 226]
25. (4) The activated TFSS that came to the surface originated fr
investigation team forms his opinion based on the proximityof is positon
immediately after being actuated and the unlikely probability that the TESS originated from
{raveling beneath the surface in a horizontal movement towards the proximity of
FoF 195]
2, ot I scvior atleast one TFSS iL at sclf-recovery. though the.
deployed not stay positively atached t kit. The recovered device
showed no damage to the securing loop to indicate 11 arigger’s belt, Thus, the TFSS
waslikely improperly secured. (FoF: 177, 195, 195, 196]
n eoJ of death was drowning. [FoF 167.181, 228-258]
“
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‘ONORABOUT 11 JAUARY2024
wpe Connonsovo Ro ED
28. (€6h) Based upon video evidence, it does not appear that either operator became entangled
with the caving ladder which would have inhibited their ability to recover. (FoF: 166, 168, 170]
29, (E84 The behavioral characteristics displayedby[GIN| dicate
that subsurface hazards likely did no affect either member while in the walBPR . 168,
170
30. (€69 It is undeterminedwhethe JERI activated or stiempted to sciivate his TFSS
or if some other unknown failure occurred. (FoF: 229, 265-271, 273-276)
31. (© is undetermined sete Rivas or attemped (0 activate his
secondary TFSS or if some other unknown failure occurred. (FoF 229, 265-271, 273-276]
32. (€0H) The manufacturer states a TFSS provides eighty (80) pounds of positive flotation on
the surface, but only forty-five (45) pounds at a depth of thirty-three (33) feet. Due to the
degradation of performance us the device descends in water dcpth, it is possible that evenif the
members activated theTFSS, the additional buoyancy may have been insufficient lo reverse their
descent. [FoF 225)
(U)Search andRescueEfforts
33. (804) MOB procedures, us executed by the TF 3.3 detachment, were appropriate, prompl,
and in accordance with prescribed guidance. (FoF 182-185, 437.445)
34. (E64) Although not a requirement identified for the CCA, a means to deploy an additional
flotation device, such us a life-buoy
ora lifeguards pool buoy, may have provided another
defensive layer to a struggling swimmer in the water. (FoF 372)
3s. eonRE hances of survival would have increased had they
been at the surfaceas a resul live buoyancy due (o the proximityof the CCAs and
recovery assets. (FoF 182-185, 198]
36. (EH) At time of mission and in the immediate follow-on response, there was sufficient and
appropriate allocationof support on scene to rapidly find, fix, and recover an operator at the
surface. (FoF: 184,201-202]
37. Sufficient resources were committed 10 the search and rescuc effort in the chance that
~_ at the surface. (FoF 201-202, 204-207]
85
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{U)
Bourding
of VOI
38. (E44) On I1 January 2024, 1eam members demonstrated a familiarity with boarding
proceduresdue(ohaving already completed two successful boardings in December 2023. They
continued 10 iterate and improve on each successive mission. (FoF 70.71)
39. (G44) Although there was an accelerated timeline for mission execution relatedto the VOI
based on higher HQ interest, theassociated time-compression and consequential reduction of
ime (0 prepare were no causal factors in the mishap. All team members reported adequate time
to make deliberate and contemplative decisions regarding their individual and force readiness.
(FoF 85, 90-94)
40. (E464) Bused on the interviews, the decision (0 execute the boarding of the VOIduring the
periodofdarkness on 11 January 24 wasdeemed within the scopeof their training and with due
‘considerationtothe environmental factors expected. [FoF 85, 90, 92-94)
41. (EH) Execution of the boarding of the VOI was within the doctrinally defined and
Interdeployment Training Cycle (IDTC)-rehearsed tactical capabilitiesof ST-3 C-Platoon. (FoF
363,371-376)
42. (85H) Given the shift of timing from u planned 12 January2024 morning daylight event lo
an 11 January 2024 nighttime event, the tcam took deliberate stepstoconsider identification of
additional hazards, means (0 mitigate those additional hazards, and udjusted the plan
accordingly, demonstrating sound application ofrisk management on a compressed timeline.
(FoF 95.97, 99)
43. (4h Environmental conditions during the boarding of the VOI were within
and CNSWG-4 VBSS threshold guidclincs. TF-3 (FWD) leadership,both TF 3.2 USSOCOM and TF 3.3,
were working under the described bricfed threshold. (FoF 62-64, 119, 122]
44.(4hThe uscofwhite light during the boarding ofthe VOI was a deliberate and
appropriate miligation o account for the shill 10 a nighttime boarding. It did not have any
negative impact on the mishapof the subsequent search cffort. [FOF 95)
45. (€6HThe Boarding Team ladder played no role in the mishap; several operators used the
ladder 10 scale the cap railof the VOI, while others timed their moves in ordet to get directly
over the rail without assistance from the ladder. [FoF 125)
46. (64H) Helicopter operations and associated rolor wash did not playa role in the mishap.
(FoF 124]
47. (8) The crew abourd the VOI was compliant and responsive 10 the maneuver clements’
directives throughout the operation and had no causal effect on the mishap. [FoF 146]
[3
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SURROUNDING THE LOSS AT SEA OF TWO TASK FORCE THREF. PERSONNEL
48. (E44) Duringtheboarding of the VOI, the embarked crew stopped the vessel, which
subjected the VOI to the will ofthe sca. As a result, the VOI settled with its beam perpendicular
10 the incoming seas, increasing the initial rolling movement seen during the carly phase of the
assault, (FoF 142, 144, 147.150)
49. (EH) At the time of CCA approach #3 10 the VOI, the assaultteamonly had six (6)
5 and were outnumbered by VOI crewmembers. The Assault Lead,(ill
ikely took into account the potential risk 10 force with adelay in establishing
ing conditions (ic. getting the VOI back underway and pointed into the seas). (FoFbeter133,
135, 142, 145)
Tesiing, Mist Goiialt :
(U) This forward-deployed team was manned,trained, and equipped to be ready for operations,
receiving its full and complete pre-deployment training entitlement. They were aware that
Maritime Interception Operations (MIO) would be their primary deployment focus, ind
concentrated theirpre-deployment training preparations accordingly.
(1)Training
50. (G44) The NSW Force Generation Model provides deploying SEAL
exposure (0 the range of missions a platoon may execute during deployedTeam platoons broad
operations. I
consistently uses a crawl-walk-run approach to reinforce confidence and build readiness. [FoF
10-11,25,70, 77]
51.(664)TheNSW ORM regime provides a thorough review of potential hazards across the
breadthof NSW high risk activites, and prescribes a template for sound risk management
decision-making whether in training or real world operations. {FOF 8-12, 381-383)
52. (€6#) Training for contingencies is a valuable and worthwhile investmentof and
resources. The fact that so many members had activated emergency inflation onlyime
others not at all is insufficicat to build confidenceandcompetence in an operator'sonce, and
ability to
operatein extreme conditions. (FoF 442, 445]
(2) (Uy Mission Authority and Guidance
53. (€4#) Commander, U.S. Naval Forces Central Command (COMUSNAVCENT), operated
within the scope of authoritis o direct the maritime interdiction operalion in accordance with
assigned mission and capabilities. [FoF 74, 356-357]
54. (4) The authorities and meansof execution of the boardingof the VOI were congruent
with the Commander's authorities to execute the boarding. (FoF 74, 356-357, 360-361)
87
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(3) (U)Risk Management

55. (E44) While some references poi (0 the need for positive buoyancy, such as NTTP 3-
07.11M and the CCA Operations Manual, COMNAVSPECWARGRU ONE Training
Detachment MIOguidancedenoted a neutral buoyancy requirement during VBSS missions.
‘This was the guidance provided to ST-3 TWO Troop during their pre-deployment training cycle.
As such, there was widespread confusion and differing understandings of safety requirements
among operators with regards (0buoyancy requirements during operations. (FoF 363, 386, 400,
423,420,423, 425)
56. (E61) The FRM frequently cites a need for buoyancy tests, as gear,protective clothing,
equipment are constantly changing. However, it does not prescribe the specific buoyancy and
‘needed for specific missions. This implies 4 reliance and trust in NSW operators to tailor their
gear 10 te mission. (FoF 388]
57. (01) Because “buoyancy (est personnel” is listed SB times in the FRM, it can be interpreted
that tis crucial that operators have a thorough understandingoftheirbuoyancy condition
regardless of mission and equipment provided. Furthermore, it is reasonable to expect that
buoyancy tests would be as frequent and often conditions checks (0 assure operators of their
‘own, up-to-date, self-assessment of buoyancy. (FoF 388]
58.(GH)The lack of specificity with regard to buoyancy type being neutral, positive, or
negaive also implies a level of the trust and autonomy given to the SEAL Team members to
determine their own mission-dcpendent and preferred level buoyancy. The role and load
requiremants that a memberi filling during an operation may dictate different requirements as
well. Hence, no singular standard can be uniformly applied. Some members may prefer less
bulk depending on their assigned role 50.25 10 be more mancuverable and agile, bu that comes at
the expense of supplemental buoyancy ora reduction in the amount ofgear taken on mission.
‘Other members may prefer more buoyancy even though the additional flotation may make them
bulkierand less mancuverable. The lack of standard unnecessarily increases the risk for the
operator. [FoF 192,236, 386-387,392. 400, 422-427)
59. (4) During their pre-deployment taining cycle, C-Platoon conducted at least one
validated buoyancy test, likely during the Over-the-Beach (OTB) portion of the ULT, as team
members recalled the test and ts proximity to the OTB mission training. Because this test was
performed in a different operating cavironment with different gear and equipment,
effectively provide a buoyancy test that would translate 1 the current operations in itthedidMiddle
not
East. [FoF 396,413, 417]
60. €64) There may have been another set, or multiple, of buoyancy tests within the (ruining
cycle, but individuals either could not recall details, or were absent from training during a given
block when additional testing would have occurred. [FoF 359,413, 415.416]
88
MARKING REMOVED
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61. (€6H) Any personnel or gear buoyancy tests apart from the OTB block of training were ad
hoc, informal, o performed at the individual level, without consistent oversightof the individual
operator performing this requirement. (FoF 359,413, 415-416)
62. (Eh Members of C-Platoon derived their sense of buoyancy sccurity from the OTB and
'VBSS blocks of waning. These blocks of raining were completed in Southern California during
winter time and required the useofdrysuits and wetsuits which, themselves, impart their own
inherent buoyancy. C-Platoondidnote-validate their kits in the absenceof drysvits and
‘wetsuits foc VBSS missions in the warmer waters of the Middle East. [FoF 417)
63. (6) Further, when deployed, C-Platoon personnel rotated between the Helo Assault Force
(HAF) and Boat Assault Force (BAF) across the threc (3) boardings, anddid not tailor their
personal gear (0 achieve a specific buoyancy, whether positive or neutral. This further increased
confusion and likelihood of mishap. (FoF 236-238]
64. (EU)TF-3 (FWD) operators operated with unrecognized risk. This risk was unrecognized
because missions-hased buoyancy ests had not been conducted prior to the mission to account
for differing operators’positionsand equipment carried. (FoF 8, 188, 198]
65. (Et) From NSW accession training at BUD/S 10 pre-deployment training, SEAL
candidates and SEALS are taught to act as a swim buddy and jump into the water order to help
or save a teammatc. Therefore, given the incorporation of swim buddies as a risk inmitigation
contained within NSWG-1 TRADET RA, and the inclusion of swimbuddiesas a possible.
outcome in theCCA Operations Manual, i is a reasonable expectation that a NSW member
would jump in the water after a struggling teammate in order to provide sid. (FoF 393-395}
66. (4 Teams conduct pre-mission buddy checks. This process is described us an
‘expeditious and finalreview of gear and cquipment that an operalor has immediately prior to
executing the mission. In this instance, safety gear was considered lems such as radios, strobes
on helmets, and presenceof TFSS. More specific checks to confirm buoyancy, suchasaddition
of flotation foam, would be useful as forceful backup to the individual to ensure their mission
readincss. (FoF99.101, 107-108, 241-252)
67. (E64) Compared to equipment and safety checks conducted as par of standardized diving or
air (parachute) operations, the buddy checks performed on 11 January 2024 were more informal
and reliant on the experience and expertise of individuals conducting the buddy checks. An
important opinion earlier in this section is that theactivated, and recovered, TFSS was likely
incorrectly affixed to the operator. It is possible that a more thorough or formal buddy
inspection could have caught this possible error. (FoF: 100-101, 107-109,196-197)
MARKING REMOVED
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Subj: COMMAND INVESTIGATION INTO THE FACTSANDCIRCUMSTANCES
ONOR ABOUT 11JAUARY 2024
(4) (U) C-Platoon DTC Cycle
68. (44) ST-3, TWO Troop, C-Platoon completed the prescribed intcr-deployment training
cycle (IDTC) with specific emphasis on missions they would be expectedtoconduct during a
U.S. CentralCommand (USCENTCOM) deployment in support of SOCCENT and NAVCENT.
[FoF 396-409]
69. (E64The ST-3, TWO Troop leadership cadre participated in key elements ofthe IDTC.
Most notably, by the time the troop concluded their Final Batic Problem, the leadership team
wasstableand consistent; there was no changeout that risked disruption toteam cohesion as
they concluded preparations for deployment. (FoF 365, 367, 396, 398, 402, 407-409)
(UNSW Gear,Mainicnance,
andSafety
70.(66) There is widespread confusion about theroleof the Tactical Flotation Support System
(TESS) in contributing to any buoyancy requirement. Some operators described they could not
achieve positive buoyancy absent TFSS activation. This is contrary (o the view thatonecan
either be positively or neutrally buoyant simply based on supplemental buoyant material beingbe
added (0 specificgear wom via foam inserts in vesis or in drybags. (FoF 410-412, 419-420)
71. (8 Further, although many team members stated the important rolctheTFSS plays in
schieving positive buoyancy, fewhad ever operated the device in a training scenario to build
familiarity and confidence with activation in emergency situations. More formal practice and
rehearsal is required 0buildconfidence andcompetence in use of the device. (FoF 410-412,
419-420)
72. (E44) When handling a TFSS in the current NSW configuration, i is apparent that
threading a igger's belt through the device's strap is the appropriatc meansofaffixation.
it any other way would inherently compromise the intended design and reduce the surety ofTo rig
effective performance of the device. (FoF 110]
73. (6 The only formal guidance regarding wear ofa TFS is captured in AIROPS
(parachuting) proceduresforthe useoftheTFSS-$326 alongside various parachute
configurations. Further, the safety controls ofaJumpmaster inspection demonstrate an
appropriate means to validate proper wear of the lifesaving device prior to executing a mission.
(FoF 231-232, 292-294)
74. (86H As made apparent through interviews, the TFSS is used for missions beyond
AIROPS. SEAL team members mentioned their use as part ofa standard kit during maritime
‘operations near and over water. However, no other Navy reference points o their use in varying
missions, forcing a reliance on pass-down and corporate knowledge us to their proper use. (FoF
223:224,231 232, 292-294)
%
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ON OR ABOUT 11 JAUARY 2024SEA OF TWO TASK FORCE THREE PERSONNEL
75. (Eh Maintenanceof NSW TFS is not tracked, documented, or formally performed to the
Navy's 3M standard. Pre-mishap maintenance records are not availabe for the platoon and thus
would fil any reasonable audit. Lacking such an audit rail it cannot be ruled out tht the
devices malfunctioned or did not perform to specifications. FoF 257.274)
76. (@4) The NSW-issued TFS are manual-operation only, and provide no means of
aulomatic emergency actuation in the eventof an unconscious or incapacitated operator. The use
of a device that provides for atomic deployment, such as through the use of 4 hydrositically
actuated inflation mechanism, may provide better performance to account fo such emergency
situations. (FoF 228.229, 276, 278.280, 267-288)
(U)Anonymous ComplaintAlsgingMisconductbyTE-3 CharliePlatoon
77. (U) A boleofalcohol was likely presen sbosrd USS LEWIS B. PULLER (LBP). (FoF
295,303-306)
78. (U) The evidence does not sufficicatly support tha|S:
LBP in violation of Navy policy. [FoF 295, 303-306, 311, 320, 324) onsumed alcohol aboard
79. @uh Even consumed alcohol aboard LBP, it is unclated o the drowning of
[FoF 157, 158,167, 214, 240)
i 335339)
299, 340-346) 5
Zam
83. (U) The allegations pertaining to
— ll outside the scope of hi investigation.
84_(€04) The (acts and circumstances surrounding in the anonymous cor
ve not contributing factors in the drowning r
OF S18, 167, 214, 240]
9
MARKING REMOVED
IRKING REMOVED
(U) RECOMMENDATIONS
1. (U) RECOMMEND COMNAVSPECWARGRUONEconsider nomination-[
ote laudatory commendation. In his effort to provide rescue und
teammatehe ulimately gave his own life, demonstrating heroism and bearing assistance
witness to
(0 is
the best
of the SEAL Ethos.
2. (U) RECOMMEND COMNAVSPECWARCOM consider expeditious review and update of
the FRM. Last updated in 2016, much has changed in NSW, not only in termsofthe previous
twodecades land warfare operations, butalso the advent and introductionofan catire host of
newtechnologies and capabilites. Coupled with arencwed emphasis on the maritime
environment, such a central document that outlines execution across the entire breadth of NSW
capabilities is ripe for review and updic.
3. (U) RECOMMEND COMNAVSPECWARCOM clarify buoyancy guidance and expectations
for given missions. In this instance, operators were trained 10 a neural standard with the
personal confidence that a combinationofathleticism, capability, willpower, faith in
activation of the emergency TFSS wouldbring them tothe surface. Some alsoandhighlighted
difference when embarked in aircraft, where positive buoyancy would be detrimentalin an the
emergency. Its further recommended that buoyancy requirements be outlined as 10 the role the
TFS plays in achieving that desiced buoyancy: more specifically, whether it is part of inherent
buoyancy, or considered as an additional, emergency, and redundant source of buoyancy. USCG
guidance provides an example for consideration.
4. (U) RECOMMEND COMNAVSPECWARCOM provide clarifying guidance regarding a
Buddy Rule. The investigationteam could find no formal reference on the topic, but id find
mention in 8 CNSWG-4 CCA operations manual and a mitigation in an ORM RA from
CNSWG-1 Training Detachment. Numerous NSW members interviewed during this
investigation operate with a strongly held conviction, someofit enculturated from BUDS, of the
obligationand moral duty to follow a Man Overboard into the water.
5. tet) RECOMMEND COMNAVSPECWARCOM consider formalizing appropriate portions
ofthe pre-mission buddy check. During ths specific VBSS mission, the buddy check system
was informal, undocumented, and thoroughness leftto the individual
qualiy assurance check. Accomplishment also presumes each buddyoperator conducting the
knows the correct standard
for gear requirements. Contrast such checks (0 those conducted duringjump/ parachute
evolutions, where a qualified jumpmasterconducts specific equipment checks to confirm
readiness to jump. Similarly, the USCG uses several master specialists, includinga water
survival training master, hook and climb master, and fast-rope master,
situ master level knowledgeofequipment, configuration, and salty forcharged wilh providing in
evolutions
specific checks. NSW should consider how crucial and key safety checks might be (0appropriate,
conduct
akin 10 existing safety checks completed by jumpmaster and dive master specialists.
92
——REMOVED
IKING REMOVED
SURROUNDING THE LOSS AT SEA OFTWO TASK FORCE THREF. PERSONNEL
ONOR ABOUT || JAUARY 2024
6. (U) RECOMMEND COMNAVSPECWARCOM consider requirement for formal and
periodic demonstration ofcompetency using emergency lifesaving equipment. Some
interviewed in the investigation noted they had activated emergency lifesaving devices only once
within a career. An cqual lot noted they had never actuatedtheir emergency gear. In
‘comparison, Navy guidance calls for semi-annual requalification and refresher training for both
small arms weapons and firefighting self-contained breathing apparatus (SCBA). Similarly, the
USCG Water Survival Training Program requires active duty personnel in specific specialties
complete competency checks on a semi-annual basis, incloding pool immersion in full personal
‘combat gear and requiring full activation of their flotation safety system by both the installed
CO2 actuator and manually through attached oral inflation tube. Such s NSW-tailored program
may warrant inclusion in the FRM.
7. (U) RECOMMEND COMNAVSPECWARCOM review and consider appropriate
documentation and tracingofcompleted formal maintenance on personal, and specifically
lifesaving gear. Ensuringproperoperation of many pieces of NSW gears executed atthe
individual level, with on-the-job training 10 learn how (0 effectively maintain what may be « vital
piece of safety equipment. A NSW operator may receive hundreds of pieces ofgear over the
courseofaprofessional carcer. As demonstrated in this tragic mishap, perhaps some picces of
gear warranta more formal maintcnance and documentation procedure. NAVSEA has provided
a series of formal maintenance proceduresforthe TFSS-5326 device, and while team members
‘could describe general checks 10 ensure operation of gear, it does not follow the formality of
execution and documentation as oulined in the Navy 3M program.
8. (U) RECOMMEND COMNAVSPECWARCOM conduct industry survey and analysis of
alternatives to provide operators a means of fil-safe buoyancy. Aside from determining the
necessity for inhercal buoyancy, systems thatcan provide supplemental and additional buoyancy
with automatic operationarc available. USCG tactical operators uilize the Mustang MD-1250
‘Tactical Flotation System, which includes an automatic, hydrostatically-activated inflation
device. Likewise, PEC, manufacturer of NSW'sTFSS presently in service, also makes a system
‘with automatic activation. The use of such systems may increase chance ofsurvival,especially
in the eventofan unconscious or incapacitated person in the water.
9. (U) RECOMMEND COMNAVSPECWARGRU FOUR, as the ISIC for NSW special boat
teams, review and consider changesto lifesavingequipment inventory carried on CCA. While
there arc lifesaving tools available on SBT craf, including a shepherds hook, recovery ladder,
strobe marking devices, and chem-lights, a throwable flotation device, whether a life ring or
lifeguard's pool buoy, could have provided either operator additional flotation in the moment of
criss.
10. (1) RECOMMEND COMNAVSPECWARCOM direct NSW units conduct a Safety Stand
downto reestablish the standards outlined in various NSW guidance and reference documents
specific to buoyancy tests. Individual buoyancy checks and buoyancy checksofcquipmen can
be found throughout both FRM guidance and existing ORM RA. In the instance of this platoon,
9
aaEMOVED
Ra
Subj:
SAROUNDING THEwya
LORS NOTA Or weTin POSSTwpaE PERSONNEL
COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES
such checks cenainly occurred at least once, but fora wholly specific set of environmental
conditions and mission that was different than the environmental conditions and mission in the
mishap instance. Teams must continuously assess their mission and conditions and be confident
in their personal safety configuration. If there is risk that this perspective is prevalent across the
ee
11. tet) RECOMMEND COMNAVSPECWARCOM consider procuring a vesscl or training.
fagade that better replicates expected regional vessels encountered in deployed ship boarding
scenarios. Today, all CONUS-based ULT trainingis executed on similarly configured USS
ships or larger contracted vessels. While these are challenging missions, they are far different
than a ship boarding assault of CENTCOM specific dhows or PACOM specific regional
bt
12. (U) RECOMMEND COMNAVSPECWARGRU ONE consider administrative action to
Am I REINS i kc) on unathoised voi of

address alcohol being onboard the USS LEWIS B. PULLER. Although found not to be a root
liquor was onboard the USS LEWIS B. PULLER and possibly uscd to share a toast by members
of C-Platoon in honor of their fallen comrades contrary to Navy regulations
Shik
”
a
Appendix A
References:
(2) JAGINST 5800.7G
LT—
i
(i) Cobra Buckle Manuel
(j) USSOCOM M 525-6, NSWC METOC THRESHOLDS TABLE, pg. C-7, did 08
November 2022
(k) NOAA Definition of Waves
() OPEN
(m) MPM 1770-020
(n) DoDI 1300.18
(0) OPNAVINST 4740.2H, did 07 Jan 2021
(9) COMNAVSPECWARCOMINST 4400.1A
(q) CNSWCINST 3000.3D did 09 August 2023
(£) COMDTINST M10470.10H (did October 2020)
(s) COMDTINST M16260.4C did Oct 2020
(1) OPEN
(4) OPNAVINST 5450.341A, did 13 Sept 2023
(v) OPNAVINST5450.22|E, did 23 Jan 18
(w) COMNAVSPECWARCOMINST 3500.2C (did 27 Jan 2017)
(x) CNSWGFOURINST 3102b
(3) U.S. Navy Regulations 1162
S——
(ac) DoDI 1010.16
(ad) Manual of the Medical Department Article 15-105
Appendix B: Enclosures
(1) Appointing Order dtd 23 Jan 24
(2) Ext. to App. Order did 27 Feb 24
(3) Amended App Order ICOTF 3 Loss of Life CI
(4) Open
(5) Email -|
(6) Interview
(6a) Email -|
(7) Interview Summary]
(8) Interview Summary,
(9) Interview Summary)
(15) Interview Summary.
(24) Unterview Summary,
(27) Interview Summary|
(41) Interview Summary|
1

(50) COMNAVSPECWARCOMINST 3500.2C - RA ‘Worksheet, SVBSS Hook and
Climb (2023)
(50a) COMNAVSPECWARCOMINST 3500.2C -RA Worksheet, SVBSS Hook and
Climb (2024)
(51) Interview Summary.}
(52)
(53)
(54) Ema lof [1 Jan2024
(59)] follow-ug
(56) email to] U1 Jan 2024
(57) IMFRdid06February2024
o —
(58) Group Pic
(59a)
annCobra Belt Buckle image
(62),
(63)| PAS Records
(64)] PAS Records
(69)] MEE MFR
(66) Force Laydown Graphic
(67) TF3FWD SITREPS 04 December 2023
(70) TF3 FWD SITREPS 07 December 2023
(10pm HAR
(71)
enfo vs it
TF3 FWI December 2023
(72) Picture ofCCA Ladders

(73) Picture of Vessel CCA STBD quaner
(74) Demented Viking MSO chat
(75) MOC XO - MFR on Search PR
(76) Recovered Gear Photos
(77) MOC XO Email RFI (total sq mi search)
(78) MOC D Email Re Recovery Recommendation
(79) TWO Troop MIO BLOCK Trip Package. pdf
(792) NSWG-1 TRADET MIO training package
(80) TFSS 5326
(81) PECI Auto-TFSS
(82) USAOTC AOTR did October 2009
(83) MMAC-R Manual_R02
(84) NSClirded 21 Mar 23 (w/ encls of NSCltr did 13 July 2022)
(85) NAVSAFECOM Semi-Annual Report - 30 August 2023
2
(86) LOGSU-| AIROPS TSS PMS Tracker

(87) STI TFFS PMS Tracker
(88) ST3 TFSS PMS Tracker
(89) STS TRS PMS Tracker
(90) Email TYCOMRi NSWC Deputy Nd email)
(91) ST3 XO Email
(92) Final Action on USCG Incident
(93) MDI250 Datasheet
(94) Formal MPC (USCG)
(95) NCIS Anonymous Complaint
(96) Signed Interview y)
(97) Email Rel
(98) Sign Interview Summary}
(99) Signed Interview Summary)
(100) Sigaed Interview Summary
(101) Signed Interview Summary,
(102) Signed Interview Summary]
(00 NTT 3 Medical DH Memo.
(105) Email FW: FORCE WIDE PEDS TESTING
(106) RFI Re FW: FORCE My
(108) OPEN
(109) After Action Report - SEAL Team THREE TU2 MIO did 24 April 2023
(110) After Action Report- SEALT 12 OTB did 7 February 2023
(111) NTRMS Biography Card IC
(113) NTRMS Biography Card 1CO
(115) NTRMS BiographyCard ICO
(116) NTRMS Biography Card
(117) NTRMS Biography Card
(118) Email- Subj: C PLT Training Event did 20 June 2023
(119) Email - Subj: C PLT Assaults Training did 26 June 2023
(120) Email- Subj: C PLT MIO [TERATIONS did 29 June 2023
(121) NAVSPECWARCOM MER ICO ST-3 CV2 Status
(122) DEOCS Cover Page
(123) MEB Surge are EE
(124) UMass Swi
(125) UMaryland Swi
(126) Interviewnotes I
(127) OPEN
(128) Interview notes (CO
(129) Interview notes IC
(130) Interview notes [Ce
(131) Interview notes ICO)
3
2
Appendix C
LIST OF ACRONYMS
aM Navy Maintenance and Material Management

ACW Advanced Conventional Weapons
AF Assault Force
AFSB Afloat Forward Staging Base
Aoic Assistant Officer in Charge
AOT Abbreviated operational test
ASSA At Sea Space Accountability
BAF Boat Assaul¢ Force
C-ACW Counter Advanced Conventional Weapons
CASEVAC Casualty Evacuation
CCA Combat Craft - Assault
CDR Commander
CENTCOM United States Central Command
sk Commander, U.S. Fifth Fleet
cree Combined Force Maritime Component Commander
CFsOCC Combined Joint Special Operations Component Command
CHENG Chief Engineer
CNSWG-4 Commander, Naval Special Warfare Group Four
cocom Combatant Commander Command
com Commander
COMNAVSPECWARCOM Commander, Naval Special Warfare Command
COMUSNAVCENT Commander, U.S. Naval Forces Central Command
CoNop Concept of operations
cq Close Quarters Combat
CTF-55 Commander, Task Force 55
CUSNC USS. Naval Forces Central Command
Appendix C
DPAS Defense Property Accountability System
ERSS Expeditionary Resuscitative Surgical System
EUCOM United States European Command
FLIR Forward-Looking Infrared
FMP Full Mission Profile
FNMOC Fleet Numerical Meteorology and Oceanography Center
FRM Force Readiness Manual
FvB Flag Verification Boarding
FWD Forward
GFC Ground Force Commander
HAF Helicopter Assault Force/Helo Assault Force
HELO Helicopter
H-Hour The specific houron D-day
at which an operation commences
HM Hospital Corpsman
HQ Headquarters
HSC Helicopter Sea Control Squadron
DTC Inter-Deployment Training Cycle
ISR Intelligence, Surveillance, and Reconnaissance
Joc Joint Operations Center
ITAC Joint Tactical Air Controller
LBP USS Lewis B.Puller (ESB-3)
Lcro Leading Chief Petty Officer
LPO Leading Petty Officer
MAROPS Maritime Operations
MEC Maritime Enforcement Specialist Chief Petty Officer, U.S. Coast
Guard
MFT Missions, functions, and tasks
METOC Naval Meteorology and Oceanography Command (weather)
MIO Maritime Interception Operations
Appendix C
MOB Man Overboard
Moc-D Maritime Operations Center Direction
MSRT Maritime Security Response Team
N4 Logistics Department in the Navy
NAV Navigator
NAVCENT U.S. Naval Forces Central Command
NAVSEA Naval Sea Systems Command
Nels Naval Criminal Investigative Service
Nsw Naval Special Warfare
NYG Night Vision Goggles
oic Officer in Charge
OPCON Operational Control
OPORD. Operations Order
opt Operation Planning Team
OPTASK Operational Task
ORM Operational Risk Management
ots Overthe Beach
PED Performance Enhancing Drugs
PEQ Personnel, Equipment, and Qualification standards
PID Positive Identification
PLT Platoon
POARM PlanOFAction and Milestones
PRODEV Professional Development
RHIB Rigid Hull Inflaable Boat
ROC Drill Rehearsal ofConcept Drill
RTO Radio Telephone Operator
SAR Search and Rescue
SATCOM Satellite Communications
Appendix C
sBCS Special Boat Team Senior Chief
SBD Special Boat Detachments
SBT Special Boat Team
SEA Senior Enlisted Advisor
SEAL Sea Air and Land
SEL Senior Enlisted Leader
SITREP Situation Report
SME Subject Matter Expert
sol Special WarfareOperatorFirst ClassPetty Officer
so2 Special Warfare Operator Second Class Petty Officer
SOCCENT USS. Special Operations Command Central
SOF Special Operations Forces
sop Standard Operating Procedure
SPEAR Standard SOF Personal Equipment Advanced Requirements
sQr Scal Qualification Training
ST Seal Team
swee Special Warfare Combat Crewman
TACLEAD Tactical Lead
TACON Tactical Control
ud Task Force
TESS Tactical Flotation Support System (Water Wings)
Ta Tusk Group Integration training
Tor “Time on Target
TRADET Training Detachment
TPs Tactics, Techniques, and Procedures
Tv Task Unit
uw Underwater
ur Unit Level Training
Appendix C
USCENTCOM US. Central Command

usc U.S. CoastGuard
USSOCOM US.SpecialOperations Command
BSS Visit, Board, Search, and Seizure
Voi Vessel of Interest

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UNITED STATES CENTRAL COMMAND

OFFICE OF THE COMMANDER

Conrolled by: CUSNC.

3.66h Inresponse to this AWARCOMvillmest urdutyand obligation to learn

c. (U) Recommendation 4 is in progress. NSWG-4 iscurrentlyrefiningman overboard

4d. (G4)Recommendation § is in progress. COMNAVSPECWARCOMisdrafting a force wide

(0) Recommendation isin progres. COMNAVSPECWARCOM ildet afysan

(3) Approach #3 - Man Overboard

Chapter IV. Search and Rescue Events

a. On Scenc Rescue Efforts

b. USS. Naval Forces Central Command (Manama, Bahrain) Rescue Efforts

¢. General Maintenance Standards of Equipment

d. United States Coast Guard Boarding Incident (2011)

Chapter VI. Anonymous Complaint Alleging Misconduct by TF-3 Charlie Platoon

a. Allegations i Alcohol Abuse and Use Aboard USS LEWIS B.

vo. Ategationso[RI veovthorized Mecca procedure

a. Authorities and Command and Control

b. Command and Control Structure of ST-3

c. Capabilities ofa NSW Boarding Team

&. C-Platoon Interdeployment Training CycleExecution

i. Bouyancy Checks: Neutral Versus Positive Buoyancy and Conflicting Guidance

© Char Poon DTC Cle

SECTION INTENTIONALLY BLANK

SECTION INTENTIONALLY BLANK

i ceo I served as an assaulter aboard CCA C-1. [Ref. g]

1. ctsEI5. sved as the

j ex SN. served as theSniper aboard aircraft HELO 2. Ref. g |

k. es served as aircrew aboard aircraft HELO 2. (Ref. g]

1. eo)RI Us. << 5 screw aboard sieralt HELO 2. (Ref. g]

a. (eu) SN, served as the ST-3 TWO Troop Commander. Specific

b. (eb) ISN, served as the ST-3 TWO Troop Leading ChiefPeity

SECTION INTENTIONALLY BLANK

(U) Chapter 11. Maritime Interdiction Operations

(U) Bosdings One and Two (December 2023

Refs, h] (Backs. 7,9, 12, 16,41)

[Refs. g. h] (Encl. 52]

(Encls. 52, 53]

(U) Chapter 111. BOARDINGTHREE (11 January 2024)

SECTION INTENTIONALLY BLANK

‘atlempted 10board VOL. Blue circle depicts [Encl. 62 (Images #01-08)]

152. (E81) <<20:09:29 (seconds)>> I a boarding attempt from the engine

% i re of th reader ime 20/09:30 s wed as the ime referenced for when |

161. (E60) <<20.09413 42 (seconds) SRI cape nt thewate towards ll

“THIS SECTION INTENTIONALLY BLANK

168. (€84 Following] I: the water,

THIS SECTION INTENTIONALLY BLANK

172. <<20:09:57 10: n fier roughly fifeen (15) seconds in thewater JN

174. (E64 <<20:1001 (et. oo overcome by an oncoming wave and

THIS SECTION INTENTIONALLY BLANK

15. 601001009 ns Drm eo RR

176. (€434) <<20:10:10 (seconds)>>

THIS SECTION INTENTIONALLY BLANK

178. (€6h <<20:10:12 (cond J crys at the surface within

(E68) CHAPTER IV. Search and Rescue Events

182. (E64) Man overboard (MOB) procedures,

158 ) Upon comin uc run Ic oo ND ~<

190. ho was aboard CCA Aa the MOB cal sted be so [fl

(G4)Figure 4-1a. [FoF 196) Recovered TFSS

THIS SECTION INTENTIONALLY BLANK

199. (Eb According t it was set up as a Radio Telephone Operator