VI. LESSONS LEARNED

A. Feedback

This incident demonstrates the importance of reporting the results of laboratory analyses back to the unit that initially provided that samples. Such reporting directly affects soldier safety and mission planning and helps to quell speculation and anxiety. It also provides chemical defense specialists with necessary feedback for assessing and improving their own capabilities. JCMEC personnel have indicated they normally did not report the results of analyses back to the unit unless chemical warfare agents had been detected. Such a policy might be useful for reducing otherwise burdensome reporting requirements, but—as this incident illustrates—it does not address the needs of the unit at the scene of the incident. In the future, designating a unit point-of-contact for subsequent JCMEC reporting of any results will help address this.

B. Sample-Processing Procedures

According to CRDEC, the bottles in which the samples were placed were not properly sealed. The Marines who conducted the reconnaissance at the cement factory did not properly seal these bottles, and JCMEC personnel did not catch and correct the mistake before sending the samples to CRDEC. This prevented CRDEC from providing the Marines with the conclusive assessment they desired. If forces in a theater of operations are to draw on CRDEC’s chemical analysis capabilities, they must provide CRDEC with the information needed to make a conclusive analysis, including properly sealed containers. Personnel at all echelons involved in this activity must know and understand these requirements.

This is a final report. However, if you believe you have information which may change this case narrative, please contact my office by calling 1-800-497-6261.


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