The notoriously grueling Navy SEAL selection course grew so tough in recent years that to attempt it became dangerous, even deadly. With little oversight, instructors pushed their classes to exhaustion. Students began dropping out in large numbers, or turning to illegal drugs to try to keep up.

Unprepared medical personnel often failed to step in when needed. And when the graduation rates plummeted, the commander in charge at the time blamed students, saying that the current generation was too soft.

Those are the findings of a lengthy, highly critical Navy report released on Thursday, detailing how “a near perfect storm” of problems at the Basic Underwater Demolition/SEAL course, known as BUD/S, injured large numbers of students, sent some to the hospital and left one dead.

“The investigation revealed a degree of complacency and insufficient attentiveness to a wide range of important inputs meant to keep the students safe,” the report concludes.

The Navy ordered a review of the course in September, days after The New York Times reported that instructors kept students in frigid water for long periods, denied them sleep, hit and kicked them, and refused to allow many injured students to receive medical care unless they first quit the course, which is held on the beach at Naval Base Coronado near San Diego. Students said that medics regularly did not intervene, and sometimes participated in the abuse.

The problems came to a head with the February 2022 death of Seaman Kyle Mullen, a SEAL candidate who had been suffering from pneumonia and other ailments for days during the course’s most grueling section, known as Hell Week, but received no meaningful intervention from instructors or the course medical staff.

When Seaman Mullen took a turn for the worse and was struggling to breathe, the medical officer on duty twice advised other students not to call 911, warning them that calling for emergency help could interfere with training, the report found.

Based on the findings in the report, the Navy has made a number of changes in the course, and has reassigned eight sailors and officers for failing to perform their duties, including the commodore of the Navy Special Warfare training center, Capt. Brian Drechsler, and the training command’s chief medical officer, Dr. Erik Ramey. A Navy spokesman said a number of Navy personnel had been referred to Navy legal authorities for possible punishment.

Reached by phone, Regina Mullen, Seaman Mullen’s mother, said she was pleased that the Navy was admitting to shortfalls in the medical system, “however, I am upset that there is still no accountability to date.”

In a statement, the commander of all of Naval Special Warfare including the SEALs, Rear Adm. Keith Davids, said that the SEALs would work to enact the report’s recommendations for making the training safe, adding, “We will honor Seaman Mullen’s memory by ensuring that the legacy of our fallen teammate guides us towards the best training program possible for our future Navy SEALs.”

The Navy SEALs have tried for decades to strike a balance, making the selection course challenging enough to select only elite SEALs, but not so difficult that it leaves good candidates broken. SEAL training is seen by militaries around the world as a gold standard for special forces, so the design of the course has influence far beyond the small community of Navy SEALs.

Historically, an average of about three out of 10 sailors who try the course graduate to complete it. But the graduation rate has varied widely over the years, based in part on the whims of instructors, and the course has at times resembled institutionalized hazing. In all, about 11 students have died, and untold others have been seriously injured.

After a new leadership team took over the course in 2021, graduation rates dropped steeply. When the commander of Navy Special Warfare at the time, Rear Adm. Hugh W. Howard, was warned about the drop, he told subordinates that it was fine if no one graduated and that it was more important that the course remain tough. According to the report, the admiral added, “Zero is an okay number; hold the standard.”

Instructors, who often had little experience or training for the role, began to view their jobs not as teachers building new SEALs, but as enforcers “hunting the back of the pack” to “weed out” the weak, the report said. A gradual elevation of harsh tactics that the report called “intensity creep” allowed instructors to push the demands of the course “to the far end of the acceptable spectrum,” leaving students exhausted, sick and injured.

The course had long employed civilian veterans of the SEAL teams to be mentors, as a way to temper the young instructors. But under the new leadership, these experienced veterans were marginalized. Soon, fewer than 10 percent of students in some classes were making it through the course.

The course’s medical staff was ill-prepared to respond to the wave of injuries created by the harsh new dynamic, the report said, and “repeated exposure to these conditions caused both instructors and medical personnel to underreact to their seriousness.”

On top of that, the report said, the medical staff was “poorly organized, poorly integrated and poorly led, and put candidates at significant risk.”

In the case of Seaman Mullen, medics who saw him struggling to breathe during training failed to communicate what they saw to others who assessed him later. Medical officers in charge left the ailing sailor with very young SEAL candidates who had no medical training.

The commander in charge of the course at the time, Capt. Bradley Geary, was warned by civilian staff members and SEAL veterans about the potentially dangerous rise in the number of students dropping out of the course. The report said that Captain Geary “believed the primary reason for attrition issue was the current generation had less mental toughness,” and that he did not take action to address many of the problems.

“Allowing continued execution of the curriculum in this manner while accompanied by historic, rapid and significant changes to attrition demonstrated insufficient oversight” by Captain Geary, the report said.

When Seaman Mullen died, Navy personnel found performance-enhancing drugs, including testosterone and human growth hormone, in his car. An investigation then revealed wider drug use among SEAL candidates, and several students were expelled from the course.

The report reveals that performance-enhancing drugs have been a recurring problem for more than 10 years at the course, but the Navy has never set up a testing system to detect the drugs, and it lacks effective testing even now.

“Without a rigorous testing program producing timely results,” the report warns, the Navy “will be unable to effectively deter use.”

In the year since Seaman Mullen’s death, new leaders have made a number of changes at the course, including increased oversight of instructors, better communication among the medical staff and closer medical monitoring of students who finish Hell Week. Graduation rates have risen back to around the 30-percent level that the SEALs see as normal.

The report makes no mention of the scores of qualified candidates who may have been unfairly driven from the course by abusive instructors and poor medical oversight. Many such candidates serve the remainder of their enlistments in menial, low-level Navy jobs, scraping rust and sweeping decks.

Asked about the issue, a Navy spokesman said there were no current plans to make amends to sailors who were forced out of the course.

Dave Philipps is a national correspondent covering the military and has been awarded the Pulitzer Prize twice, most recently in 2022. His latest book is “Alpha, Eddie Gallagher and the War for the Soul of the Navy SEALs.” @David_Philipps • Facebook

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