Department of the Navy Concludes Investigations into Assault Amphibious Vehicle Tragedy
7 Oct 2021

The Navy and Marine Corps released findings of separate investigations into the facts and circumstances surrounding the assault amphibious vehicle (AAV) tragedy that occurred July 30, 2020.

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

The Navy investigation, conducted by Commander, Third 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.”

The investigation by Third 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 institutional actions to ensure the safe execution of AAV waterborne operations. These actions fall into one of three categories: equipment, procedures, or training.

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). The 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. The investigation’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 either investigation, visit SECNAV FOIA website:


Headquarters Marine Corps