Navy concludes probe of amphibious assault vehicle incident that killed nine

The Navy and Marine Corps released findings of separate investigations into the amphibious assault vehicle (AAV) incident that claimed nine lives on July, 30 2020.

The probes revealed that a combination of maintenance failures and human error caused the deaths of eight Marines and one Sailor.

The sinking happened during “Operation Gator Smash,” a mechanized amphibious raid during the 15th Marine Expeditionary Unit’s first at-sea, integrated training exercise with their Navy counterparts with the Makin Island Amphibious Ready Group led by Amphibious Squadron 3.

The Navy investigation, conducted by Commander, 3rd Fleet, examined the Navy’s role in the incident and revealed gaps in doctrine and procedures by the Navy and Marine Corps.

“The Navy and Marine Corps learned from this tragedy and we are codifying the lessons we have learned as an organization so that the deaths of these Marines and Sailor are not in vain,” said Vice Adm. Roy Kitchener, Commander, Naval Surface Force, U.S. Pacific Fleet. “We are reworking procedures and doctrine, clarifying aspects of amphibious operations, and instituting new training requirements to prevent future tragedies.”

“This tragedy should have never happened,” said Kitchener.

The victims were:

  • Pfc. Bryan J. Baltierra, 18, of Corona, California
  • Lance Cpl. Marco A. Barranco, 21, of Montebello, California
  • Pfc. Evan A. Bath, 19, of Oak Creek, Wisconsin
  • Navy Hospital Corpsman 3rd Class Christopher Gnem, 22, of Stockton, California
  • Lance Cpl. Jack-Ryan Ostrovsky, 20, of Bend, Oregon
  • Lance Cpl. Guillermo S. Perez, 19, of New Braunfels, Texas
  • Cpl. Wesley A. Rodd, 22, of Harris, Texas
  • Lance Cpl. Chase D. Sweetwood, 18, of Portland, Oregon
  • Cpl. Cesar A. Villanueva, 21, of Riverside, California

Gnem was posthumously advanced to the rank of petty officer third class and posthumously awarded his enlisted Fleet Marine Force Warfare Specialist qualification, having met the criteria set by the Navy for both before his death.

Ostrovsky was posthumously advanced to the rank of lance corporal, having met the criteria set by the Marine Corps before his death.

The investigation by 3rd Fleet led to comprehensive updates to the Wet Well Manual to include clarification regarding safety boat requirements, ship requirements to ensure positive control of AAVs during evolutions, as well as additional improvements to the integration of training between the Navy and Marine Corps.

Additionally, all Navy commanding officers will attend the Senior Amphibious Warfare Course before taking command. Future AAV operations will require a comprehensive and integrated communications plan to be submitted before AAV operations can occur.

The Marine Corps previously concluded two investigations; a safety investigation, Oct. 1, 2020, and a command investigation, Feb. 25, 2021.

As a result of these initial investigations, the Marine Corps directed 23 actions to ensure the safe execution of AAV waterborne operations, each that falls into one of three categories: equipment, procedures, or training.

An assault amphibious vehicle approaches the amphibious assault ship Wasp (LHD 1) in 2019. (Photo: US Navy)

Equipment actions include a combination of equipment advances and additional inspections such as procurement and sustainment of a Waterborne Egress Capability program, electronic tablets for crewmembers to manage associated technical and procedural manuals, and new criteria for hull watertight integrity, bilge pump function, communications systems, and emergency egress lighting systems.

To address procedural actions, the Marine Corps administered publication and policy reviews to operating procedures, technical manuals, and safety structure requirements during training. These include updates to training and qualification prerequisites, authority and decision making procedures, and safety boat requirements.

Finally, training actions include implementing additional standards for water survival, underwater egress training for both crew members and embarked personnel, and standardized knowledge tests for crew members.

Recently, the Marine Corps concluded a subsequent command investigation, led by Lt. Gen. Carl E. Mundy, focused on the formation of the 15th Marine Expeditionary Unit (MEU).

That investigation found a confluence of factors, including COVID-19 impacts, task-saturation and reduced manning, poor communication, and inadequate training and equipping played significant roles in contributing to the conditions that allowed for the tragedy to occur.

Mundy’s recommendations include a comprehensive review of relevant orders, programs, and training curricula as well as increases in material inspection and reporting requirements, leadership manning, preparation and oversight.

Senior Marine Corps and Navy personnel are conducting a Strategic Review of Amphibious Operations to build upon the findings and recommendations of these investigations. That review will assess all aspects of current amphibious operations with special consideration for future concepts of amphibious operations. 

To view the Navy investigation, click here.

To view the Marine Corps Investigation, click here.

The Marine Corps’ command investigation into the sinking, released in March, blamed a “chain of failure” over seven months, including poor safety measures and a “combination of maintenance failures, due to disregard of maintenance procedures, AAV crewmen not evacuating personnel when the situation clearly demanded they be evacuated, and improper training of embarked personnel on AAV safety procedures.”

The Navy Command Investigation will be posted on the SECNAV FOIA reading website. Due to technical issues there may be a slight delay.

A copy of the Navy investigation is available online.

A Navy-ordered investigation into the service’s role in the 2020 fatal sinking of a Marine Corps amphibious assault vehicle that killed nine found faulty assumptions, confused command roles and communications, conflicting policies, gaps in amphibious warfare training and certification, deficient doctrine, and poorly maintained vehicles.

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