The independent investigation into the handling of Jordan McNair's heatstroke during a May 29 football practice concludes that University of Maryland athletic trainers reacted too late to the offensive lineman's symptoms, and suggests a culture of mistrust and intimidation contributed to the situation that led to McNair's death June 13.

Maryland contracted with Dr. Rod Walters to conduct the investigation, which also examined the university's athletic training protocols, in June. At the conclusion of a University System of Maryland Board of Regents meeting Friday at Towson University, Walters provided a timeline of the May 29 events based on interviews with every coach and four athletes who were at the workout, as reported by The Diamondback student newspaper and The Washington Post.

4:40 p.m.: The practice begins with team members performing 10 110-yard sprints in what the university described as a "basic conditioning test." McNair completes seven of the sprints, but is unable to finish any of the remaining three in less than 19 seconds — the benchmark for offensive linemen.

4:53 p.m.: McNair reports cramping.

5:22 p.m.: McNair is removed from the field in a motorized cart and is treated in the athletic training room for 23 minutes.

5:26 p.m.: McNair managed to walk into the team training room, though he complained of cramping in his lower back.

5:50 p.m.: McNair begins yelling at athletic trainers, an indication of a change in mental status consistent with exertional heatstroke. 

5:52 p.m.: Head athletic trainer Wes Robinson instructs athletic trainer Steve Nordwall to contact emergency medical services. Nordwall instead contacts team physician Valerie Cothran, who tells Nordwall to call 911.

5:55 p.m.: Nordwall calls 911, more than an hour after the onset of symptoms. McNair goes into seizure, his jaw clenched and his body convulsing. His airway is obstructed by a "brown foamy sputum."

6:02 p.m.: A second 911 call is placed.

6:27 p.m.: McNair is in an ambulance en route to the hospital — more than 90 minutes after first exhibiting symptoms.

A number of factors contributed to the tragedy before practice even began. The workout had been scheduled to take place inside Maryland's stadium, but construction forced a late move to practice fields. Indoor practice was ruled out due to inadequate field space, according to Walters, who added that athletic trainers had to "rush to get hydration products and other emergency equipment to the synthetic turf practice field." Accuweather.com indicates that the high temperature in College Park that day was 83 degrees.

Players were given a gallon of water to drink before practice. McNair, who had consumed only a bowl of cereal that day, left his unopened water gallon in his locker.

University officials stated they intend to implement 27 recommendations outlined in Walters' 74-page report, but have not taken any action regarding personnel. Robinson and Nordwall remain on leave, as does head coach D.J. Durkin. Strength and conditioning coach Rick Court agreed to a settlement with the university and resigned. The report quotes Robinson as shouting "tell [McNair] to get the f*** up" during the workout and that players should "drag his ass across the field." Reports have indicated that two teammates helped McNair complete the final sprint of the 10. Players described a lack of trust between players and football staff, and that "The Pit" — where players go during practice when injured — was to be avoided at all costs.

Among the athletic training staff's major shortcomings on May 29 was the failure to administer a cold plunge to McNair upon the first signs of heatstroke. Athletic training staff members feared that their smaller stature relative to McNair's size (6-foot-4, 325 pounds) put the student-athlete at risk of drowning in a plunge pool.

According to the Post, medical experts have said that patients have a 100 percent survivability rate when heatstroke is treated promptly and the body temperature is lowered within 30 minutes. According to hospital records, McNair’s temperature reached 107 degrees and wasn’t lowered to 102 until 7:20 p.m.

AB reached out this morning to the National Athletic Trainers' Association for reaction to the Walters report, but did not get an immediate response. However, others have shared their opinions. Former CBS college football reporter Jon Solomon, the current editorial director at The Aspen Institute, a non-profit think tank, tweeted the following Saturday. "Some lessons from McNair's tragic death: 1. Have cold water immersion available on the field and done immediately when symptoms arise. This means cold tubs. This is widely known by athletic training community and a complete failure by Maryland. 2. Have a hydration/medical emergency plan at every venue. Maryland changed venues at the last minute for May 29 workout and was unprepared. To all CFB programs: You have a ton of facilities; do you have legit medical plans at each one? 3. Athletic trainers must build trust with players. Some Maryland players described an untrusting environment. They have to believe trainers care about their best interest instead of yelling "drag his ass off the field" when symptoms arise."

Paul Steinbach is Senior Editor of Athletic Business.