TAB I - General Accounting Office Comments

The General Accounting Office (GAO) reviewed the August 27, 1997, narrative and listed its findings in the report, "Gulf War Illnesses, Procedural and Reporting Improvements Are Needed in DOD’s Investigative Processes." Based on its findings, GAO agreed with our original assessment an exposure to mustard agent was likely; however, it recommended we revise the interim case narrative to reflect new or unreported information noted in its report. GAO’s findings and our investigative results follow.

A.  Finding 1

1.  GAO - In-theater Urinalysis

Information we discovered causes us to question the existence of the soldier’s positive in-theater urinalysis for mustard agent. OSAGWI based the existence of this test on an Army Central Command message reporting a positive in-theater test for thiodiglycol. However, OSAGWI was unable to find any documented test results from this urinalysis, and OSAGWI investigators did not perform sufficient follow-up with the involved individuals to verify that this test had actually taken place…. OSAGWI had not interviewed either the senior medical officer or the officer who wrote the message describing the positive in-theater analysis….[138]

2.  Our Investigation

The revised narrative confirms the GAO finding. We make clear only one urinalysis occurred. Reports of a positive in-theater urinalysis were incorrect, based on hearsay information.

During his examination by Colonel Dunn, the senior medical officer, PFC Fisher provided a urine sample. Colonel Dunn took the urine sample back to the United States where the US Army Medical Research Institute of Chemical Defense, Aberdeen, Maryland, analyzed it. The results of the urinalysis were negative for thiodiglycol. According to Colonel Dunn, no urinalyses were performed in-theater.

B.  Finding 2

1.  GAO - Failure to Interview Key Officials About Tests Conducted on the Soldier’s Clothing

[T]he results of the tests conducted on March 2, 1991 (the first day of testing), for mustard agent on the soldier’s clothing cannot be confirmed with the available documentation, and OSAGWI did not interview some key officials involved in the case about the tests.[139]

2.  Our Investigation

During our investigation, we reviewed information the Fox vehicles’ commander had e-mailed to us. He was not available for a personal interview during our re-investigation because he was serving in an overseas assignment.

We did interview the Fox MM-1 operator who tested PFC Fisher’s coveralls and his flak jacket.

Over the course of three days, Fox vehicles tested PFC Fisher’s clothing and flak jacket on two occasions. On March 2, 1991, one Fox vehicle’s crew tested his coveralls; on March 4, 1991, two Fox crews working simultaneously examined PFC Fisher’s flak jacket.

Using electronic mail, the company commander of the crews who conducted the Fox vehicle tests of PFC Fisher’s coveralls and flak jacket provided his recollections of these events. He recalled that after an hour of testing, his MM-1 operator printed a spectrum for sesqui-mustard. The company commander notified division chemical personnel of the test results.

We located the MM-1 paper tape printout he had mentioned, which revealed alarms for phosgene oxime, thiophosgene, lewisite, and S-mustard (sulfur mustard) or HD. Of these agents, only S-mustard (HD) was in Iraq’s inventory. The printout revealed no spectrum for any chemical warfare agent. We transcribed this information and included it as Tab F in our final report.

The MM-1 operator who tested PFC Fisher’s coveralls recalled the test revealed the presence of a lewisite HQ/HD mixture. He also believed the MM-1 indicated the presence of chemical warfare agent; however, lewisite was not in Iraq’s inventory and, as stated above, the printout showed no spectrum for any chemical warfare agent.

C.  Finding 3

1.  GAO - Uncertainties About the Identity and Validity of Key Physical Evidence Sent to the United States for Testing

DOD did not adequately identify or ensure the validity of important physical evidence. We noticed a difference between the inventory of items that the Commander of the Fox vehicles had reportedly packaged for shipment back to the United States for analysis and the items that were received at the US Army Chemical Research, Development and Engineering Center.[140]

2. Our Investigation

Interviews with the Fox vehicles commander and the MM-1 operator and a review of the inventory of items sent to the United States for testing eliminated the confusion surrounding what the Fox vehicles’ commander packaged and sent to the United States for analysis. The MM-1 operator cut some samples from the coveralls to send to higher headquarters. When he packaged his protective gear, the Fox vehicles’ commander included these swatches from PFC Fisher’s coveralls, PFC Fisher’s flak jacket, and other material after he and his team concluded their testing for contamination. A US Army Technical Escort Unit team eventually transported this material to the Analytical Research Division of the Research Directorate at CRDEC. The Analytical Research Division analyzed the materials on March 11, 1991. The package contained PFC Fisher’s flak jacket, cloth cut from PFC Fisher’s coveralls, the protective clothing jacket the Fox company commander wore, a gauze pad used to cover PFC Fisher’s blisters, Fox sampling wheels, and a printout from the Fox vehicle, as well as an envelope with additional printouts of the coveralls test on March 2, 1991, and the flak jacket tests on March 4, 1991.

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