An estimated 200 soldiers from the 325th Maintenance Company and an unknown number of soldiers from smaller paint operations were potentially exposed to the hazards of CARC during spray painting operations during Operations Desert Shield and Desert Storm. These exposures occurred primarily due to the tasking of ill-equipped, poorly trained, and inexperienced service members to operate the two main spray painting operations in the Saudi Arabian ports of Ad Dammam and Al Jubayl. Despite repeated health and safety inspections over a seven-month period (December 1990 June 1991) that identified serious risks, hazards, and deficiencies, painting activities continued at these two facilities with only limited improvements.
The principal health threat associated with CARC is hexamethylene diisocyanate (HDI) and various solvents used in the spray painting process. Due to the lack of adequate personal protection, and a larger failure to adhere to applicable safety and occupational health policies and procedures, a number of soldiers directly involved in CARC painting may have suffered adverse health effects, primarily respiratory effects from exposures to HDI and solvents. However, this investigation cannot definitively link CARC painting operations to the undiagnosed illnesses reported by Gulf War veterans, except in a small number of cases involving a limited number of personnel, where soldiers were known to have been directly involved in painting operations.
Several recommendations for improvements in the policy regarding minimizing exposures to CARC paint during future deployments are identified in the lessons learned section.
VII. LESSONS LEARNED
The Gulf War brought on a heightened awareness of "dirty battlefield" hazards and their impact on the health and readiness of deployed forces. In the aftermath of the conflict, retrospective investigations and analyses, including this one, have identified deficiencies and gaps in the way the Department of Defense and the Services recognized and responded to non-traditional or unanticipated risk factors. This awareness has in turn produced a major new emphasis on improving medical readiness and force health protection policies, programs, procedures, and guidance aimed at protecting the health and safety of deployed US personnel.
The following section contains a number of important lessons developed during the investigation of CARC painting performed in the Kuwait Theater of Operations (KTO). Where appropriate, the Office of the Special Assistant recommends the following courses of action to address the noted shortcomings.
We determined that pre-deployment and post-deployment CARC-painting operations outside of the KTO were outside the scope of our investigation, although these deployment-related practices require further assessment by the relevant DoD occupational health and safety offices.
During our investigation of paint operations in the Gulf War theater, some soldiers reported that a number of standard procedures, including painting vehicles with CARC, were modified (or disregarded) in the rush to mobilize troops and equipment for Operations Desert Shield and Desert Storm. In some cases, safety considerations were compromised. In the future, military operational plans and policies should anticipate similar requirements, and be prepared to meet them without compromising occupational safety and health standards. Prior planning should improve the militarys ability to quickly establish field-expedient, but safe, CARC painting sites. Advance training, education, and guidance should raise the level of awareness of potential hazards involved when painting with CARC. The CARC-painting mission should be assigned to appropriate units before deploymentunits that could obtain the required procedural and safety training, procure personal protective equipment, and ensure direct oversight and guidance by trained, certified, experienced safety and occupational health professionals who have the command authority and support to ensure that operations are conducted in accordance with the applicable health and safety policies and procedures.
Painting In Theater
In general, US troops tasked to spray paint vehicles in-theater lacked the training, education, guidance, and oversight needed to ensure safe and successful mission accomplishment In addition, despite repeated warnings from health and safety specialists in-theater, tactical commanders charged with directing the CARC paint effort did not fully appreciate the hazards associated with spray painting CARC, or safeguard their health and wellness while still accomplishing their mission. In the future, CARC painting requirements should be more fully developed during pre-operation planning. Advance planning would enable commanders to assign the mission to appropriate units and personnel prior to deployment. The assigned units could obtain the required occupational safety and health training, procure personal protective equipment and the other materiel needed to perform their duties in a safe and efficient manner.
Recent guidance from the DoD and Joint Chiefs of Staff, along with implementing Service guidance, respond to these requirements. Service members with assigned duties requiring occupational health-related personal protective equipment are now required to deploy with appropriate personal protective equipment (respiratory protection, hearing protection, and personal exposure dosimeters).
The lack of pre-deployment planning prevented appropriate pre-deployment occupational health screening of members of the 325th Maintenance Company. Even if medical screening could not have been completed prior to deployment, properly trained leaders and soldiers would have known about the hazards of CARC painting and the need for medical screening before and during the painting operations. In addition, they could have identified a requirement for post-deployment occupational health screening. The purpose of medical surveillance is to detect any adverse health effects based on the specific hazards to which personnel are exposed.
Post-deployment occupational health evaluations prior to separation from active duty could have identified many of the problems encountered by members of the 325th Maintenance Company. Follow-up medical care decisions may have been more timely for those veterans. To remedy this situation, the services should develop procedures to identify target populations at risk (e.g., CARC painters), and ensure that appropriate post-deployment occupational health evaluations are administered in a timely manner.
Since the Gulf War, the Department of Defense has addressed the post-deployment issue. DD Form 2697, Report of Medical Assessment, November 1995, is now required as a minimum to provide a comprehensive medical assessment of active and reserve members who are separating or retiring from active duty. It is intended to serve as a medical history that will trigger further medical follow-up if the servicemember reports an unusual exposure, has health problems or concerns, or plans to file for disability.
Redeployment Painting Operations
The redeployment painting operations conducted in-theater were more mature than were the operations initially established for tan painting, however, routine safety inspections continued to document numerous problems. Occupational Safety and Health Administration (OSHA) regulations do not apply during actual combat. However, redeployment operations should strictly adhere to OSHA regulations.
In addition, paint surfaces received only minimal preparation, generally washing with water, before applying green CARC. Like the tan coatings applied several months earlier, these green coatings often began to peel after a short time. As a result of redeployment painting operations, some painters were needlessly put at risk to the hazards of spray painting for a paint coating that would most likely need to be reaccomplisheed in a more satisfactory fashion a short time later.
Recommended Steps to Reduce Potential Exposures During CARC Painting Operations
Potential exposures of soldiers spray-painting CARC could be decreased by:
|-||Developing augmentation sets that include all the personal protective equipment, tents, explosive proof lighting/electrical outlets, training materials, etc. for CARC painting operations. The augmentation sets could be placed in operational project stocks.|
|-||Type-classifying sets, kits and outfits that include all the personal protective equipment, tents, explosive proof lighting/electrical outlets, training materials, etc. for CARC painting operations for inclusion in appropriate maintenance units authorized equipment list (Table of Organization and Equipment).|
Efforts to Implement Lessons Learned
Lessons Learned are loosely classified as either systemic or individual failures. The problems associated with CARC painting operations in the Gulf were primarily attributable to individual or leadership failure to ensure that well-established health and safety guidelines associated with isocyanate painting operations were followed. Health and safety inspections repeatedly identified the problems, but corrective actions, when taken, were often short-lived.
The primary focus of our efforts to ensure that the lessons learned in the Gulf War are integrated into the Army's future planning (since the Army has the largest requirement for CARC paint operations). Our vehicle to facilitate the implementation (and institutionalization) of needed improvements has been a series of reviews conducted through the US Army Training and Doctrine Command's Campaign Plan Undersecretary of the Army. These force health development reviews analyze issues such as the problems with CARC painting across existing doctrine, organization, training, leadership development, material development, and policy domains to effect the needed changes. CARC is one of several issues being addressed in this manner.
In addition, we have coordinated our findings and recommendations with the applicable DoD offices, such as the Deputy Under Secretary of Defense for Environmental Security; the Office of the Assistant Secretary of Defense for Health Affairs; the National Guard Bureau; Joint Staff Deputy Director for Medical Readiness who coordinated with the Offices of the Army, Navy and Air Force Surgeons General; the US Army's Center for Health Promotion and Preventative Medicine; the US Army Research Laboratory (Polymers Research Branch); and the Federal Occupational Safety and Health Administration
As often cited, "those who cannot remember the past are condemned to repeat it." Therefore, our emphasis has been to inform and educate DoD's leadership on the hazards of CARC painting operations and the procedures needed to protect the health of our soldiers, sailors, and airmen.
If you have records, photographs, or first-hand knowledge and information regarding the events and activities described in this report, or can offer corrections or pertinent details, please call 1-800-497-6261.
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