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Special tactics airman drowned after ‘buddy pair’ system not followed in 2,000-yard swim

The training swim test in which a special tactics airman drowned March 19 was conducted without the usual “buddy team” system typical for such swims, an Air Force investigation found.

The report did not reach any conclusions about exactly what caused Airman 1st Class Keigan Baker to drown in St. Andrews Bay, Florida, near Panama City, while attempting to swim 2,000 yards.

But, it said, the rules of the combat dive course stipulate that such 2,000-yard swims should be conducted with each swimmer paired up with and tethered to another swimmer of comparable ability to ensure a swimmer doesn’t get separated and into trouble. That was not done in this case.

Baker had also taken two Unisom, an over-the-counter sleep aid, the night before the swim without medical authorization, in violation of Air Force instructions and the dive class policy. Its ingredients were still present in his blood at the time of his autopsy, the report said.

Baker, 24, was a combat controller who enlisted in the Air Force in June 2018 and was assigned to the Special Tactics Training Squadron at Hurlburt Field, Florida, in January 2020. He was originally from Longview, Washington, and received a bachelor of arts degree from Eastern Washington University.

He was on temporary duty to the Air Force Combat Dive School at the Naval Diving and Salvage Training Center at Naval Support Activity Panama City, Florida. The dive school, officially known as the 350th Special Warfare Training Squadron, Detachment 1, teaches students basic diving, advanced rescue diving principles and advanced combat diving fundamentals.

Students at the dive school are required to finish a 2,000-yard surface swim — more than a mile — in simulated combat gear, to check each student’s swimming ability. Like his classmates, Baker wore a mask, a load-bearing vest with a pair of 2-pound weights to simulate ammunition magazines, a personal flotation device, a dive tool and a rubber AR-15.

The swim in which Baker drowned took place on the fourth day of his class. Baker and his classmates took part in multiple physical activities, including a 1,000-yard surface swim while wearing gear, during the first three days.

This surface swim was supposed to begin at 6 a.m. March 19, but a fog forecast prompted instructors to push it back three hours. Baker’s classmates said he appeared to be in good spirits, and they noticed nothing out of the ordinary, aside from mentioning soreness in his hip flexors the previous few weeks.

During this swim, eight instructors and a safety diver took part — two more instructors than the minimum requirement.

But there were a few changes from standard procedure, the report said. The ammunition pier that usually serves as the finish point was under construction, so the instructors instead used a floating barge about 100 yards east of the ammo pier to drop the buoy marker that served as the finish line. They also shifted the starting buoy marker 100 yards to the east of its usual location.

There was also a privately owned, 65-foot yacht anchored in the swim path, the report said. An instructor checked to make sure there were no fishing lines coming from the yacht, and did not ask the yacht to move.

There was also more boat traffic than usual during the swim, which the report said was attributed to the later than usual start of the swim, as well as people trying to get out on the water due to the coronavirus stay-at-home restrictions. At one point, an instructor on a boat broke away from the group of student swimmers to stop two civilian boats from entering the training area. Another instructor on a boat also directed a fishing boat away from the swim lane, and later directed swimmers around the 65-foot yacht.

The students began the swim at about 10:15 a.m. Almost immediately, the swimmers noticed the current was pushing them northwest, though it wasn’t strong enough to present a safety risk.

The student who was closest to Baker said he seemed to be having no trouble swimming, but after about 100 yards, that student lost track of who was swimming near him.

Another student swimmer followed Baker, who was the stronger swimmer, for a while without noticing anything wrong. Baker pulled away from that student around the time they approached the yacht, and the student lost sight of him.

One by one, a little after 11 a.m., the students began to reach the finish point. The instructors first realized something was wrong when two students still had yet to report their times, but only one student could still be seen swimming. The instructors took head counts, but Baker was nowhere to be found.

The instructors began looking for him, and soon called the dive school superintendent to report a student was missing and ask for search and rescue help.

In all, 87 personnel on 18 boats, a police helicopter, and a C-130 — including five dive teams and assets from the Air Force, Navy, Marine Corps, Coast Guard, Florida Fish and Wildlife Conservation Commission, and Bay County Sheriff’s Office — searched for Baker for hours.

A Fish and Wildlife Conservation boat ultimately detected something underwater on sonar at about 4:15 p.m. A diver soon found Baker’s body, which was then recovered. He was declared dead at 4:30 p.m.

His dive gear was intact, the report said, and there was no sign he tried to activate his personal flotation device. There was also no sign of trauma or broken bones.

The report concluded there was confusion among the dive school staff on the necessity of the buddy-pair system during 2,000-yard surface swims.

The rules say buddy pairs should be used, and “buddy lines” are standard training equipment, the report said. But some instructors at the school felt swimming in pairs was inappropriate when they were supposed to be individually evaluating students.

Two weeks before Baker’s death, the report said, several dive school instructors discussed using buddy pairs, and the “prevailing sentiment” was that they should be used for the 2,000-yard swim. Two days before the fatal swim, an instructor briefed the students on surface swims. The approved slide presentation listed buddy pairs and buddy lines, but the instructor told the students neither would be used for surface swims.

This contradiction during the briefing contributed to instructors' confusion, the report said. An instructor brought it up with the staff superintendent, who confirmed that buddy lines would not be used for surface swims and that they were to be individual assessments.

The report said Baker was in good physical and mental health, though he was reported to use over-the-counter medication to help him sleep. He had some musculoskeletal problems common to special warfare airmen, the report said, but performed well at the fitness test and swims conducted earlier that week.

“As a community, special warfare operators are driven, highly motivated individuals who strive to push themselves to the limits of their physical abilities,” the report said. Baker “was no exception, and fellow classmates classified him as one of the smartest and strongest in the class.”

The report does not reach a firm conclusion as to what caused Baker to become incapacitated and drown, but lists several factors that may have contributed to it.

Baker told another student that morning he had taken two Unisom capsules the night before the swim, and commented at breakfast that morning that he felt fatigued, the report said. His autopsy showed he had diphenhydramine levels in his blood of 54 nanograms per milliliter, the report said, more than the levels required to produce sedative effects. Diphenhydramine, or DPH, is the active ingredient found in Unisom.

However, the report acknowledged that post-mortem changes can affect blood concentrations of substances between the time someone dies and the autopsy, and the blood measurements cannot reliably indicate the actual levels of DPH in his blood at the time of his death.

Baker wore a full wetsuit during the swim for increased buoyancy, the report said. The wetsuit also would keep swimmers warm in cold conditions, but carried the risk of the swimmer becoming uncomfortably warm when swimming aggressively in warm weather. The weather and water conditions that day were mild, the report said, but an exertional heat injury could not be ruled out as a potential cause of his incapacitation.

Exertional heat injuries typically happen when someone is strenuously exercising in a warm environment, the report said, as well as when loaded up with clothing, equipment and protective gear. The possibility of a heat injury can be increased by drugs and other substances that impair sweating, the report said.

“Development of fatigue from exercise in the heat is multifactorial and associated with several physiologic processes, but the probability is amplified when combined with gear that both inhibits heat release and adds weight/drag, substances that can alter thermoregulation and psychomotor performance (antihistamine), and drive to perform at maximal effort,” the report said.

Baker’s autopsy found no signs of head trauma, bone fractures or trauma to anything other than his lungs, which showed the effects of drowning. There was no evidence he had suffered a heart attack, stroke, or pulmonary embolus, had a seizure, or vigorously struggled while drowning, the report said.

The autopsy findings did not support a diagnosis of heatstroke, the report said, but heat could not be ruled out as a factor.

Correction: This article originally incorrectly stated Baker told an instructor he had taken two Unisom the night before the swim.

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