Airman 1st Class Keigan Baker drowned on March 19 during a 2,000-yard surface swim. According to the Air Force’s report of the incident, the Air Force Combat Dive Center (AFCDC) “deviated from written policy when they did not implement the use of buddy pairs during the 2,000-yard surface swim training event.”

The use of buddy pairs is mandated by the Air Education and Training Command, which requires that such 2,000-yard swims should be conducted with each swimmer paired up with and tethered to another swimmer of comparable ability. This is to ensure that a swimmer doesn’t get separated and into trouble.

The report notes that classroom lessons on the surface swim listed buddy pairs and buddy lines as part of the swim, but the classroom instructor “verbally briefed the students [that] neither would be used for surface swim events.” Yet, it is required of instructors to “brief students that they will swim in buddy pairs for surface swim” training.

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