A US military investigation into the drowning deaths of two Navy SEALs while engaged in a boarding operation in the Red Sea on January 11, 2024, found the incident was preventable. The cause of the deaths was attributed to poor training, unfamiliarity with flotation gear, and possible improper maintenance of personal flotation devices.

The tragedy began with a Visit, Board, Search, and Seize mission executed by a forward-deployed element of SEAL Team Three based at Naval Amphibious Base Coronado, California, on a dhow suspected of running arms from Iran to Yemen. The boarding operation took place at night and in six-foot seas.

BACKGROUND:

Mission to Seize Iranian Missile Parts Bound for Yemen Leaves Two SEALs Missing – RedState

Biden's Iran Policy Has Now Killed Two U.S. Navy SEALs – RedState

The SEALs were operating from the expeditionary mobile base USS Lewis B. Puller and used two Combat Craft-Assault boats for the mission. 

129. [REDACTED] Lead Climber (or the Assault force, stated he got a “perfect hook.” [REDACTED] was satisfied with placement of the climbing ladder. [Encl. 27]

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.[REDACTED] boarded the VOI as the first assault, noting it was “Spicy, but not out of parameters. [Encl 27]

The dhow and combat craft roll increased, making boarding increasingly difficult. 

157. <<20:09:29.5 to :30 seconds>> [Special Operator First Class Christopher J. Chambers, 37] threw both of his hands over the rail, though his hands swiftly dropped below the rail cap indicating a fall due to lack of positivecontrol. [Enc. 62 (Images 03-04)].

Chambers fell nine feet into the ocean; he resurfaced and gripped the bottom rung of the scaling ladder five seconds after his fall. He held on for eight and a half seconds. As he was reaching for the CC-A, a wave swept him away. At this point, Navy Special Warfare Operator 1st Class Nathan Gage Ingram, 27, dived into the sea to assist Chambers. Ingram is believed to have carried about 80 pounds of gear when he dived in. The two men struggled to remain afloat and to regain contact with the scaling ladder. Within 32 seconds of Ingram entering the water, both men disappeared from sight. The entire event from Chambers's fall to the last sighting was 47 seconds.

The root cause of the incident was unfamiliarity with personal flotation gear and a lack of standard procedure for using, training with, or wearing it.

Flotation equipment that was properly maintained, working well and used correctly would have been able to keep them afloat until they were rescued, the report said. Other team members told investigators that while they knew the importance of their tactical flotation system — which includes two inflatable floats that attach to a belt and foam inserts that can be added — few had ever operated one in training and there is little instruction on how to wear it.

This is a classic case of "for want of a nail." If you've been in any large organization, particularly the military, you've seen it in action. Small problems get "assumed away" by preparing for larger problems. A high operational tempo encouraged familiarization and training with personal flotation gear to be ignored. No one complained because everyone thought they could stay afloat long enough to be rescued. In my experience, the higher the level of training, the more likely it is that small things not directly related to mission accomplishment get ignored. 

The Navy Special Warfare community has implemented changes in training and procedures to keep this from happening again.

Report of Investigation

SEAL Drowning Investigation by streiff on Scribd