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 DODs 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. GAOs 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 soldiers 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 .
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 Soldiers Clothing
[T]he results of the tests conducted on March 2, 1991 (the first day of testing), for mustard agent on the soldiers clothing cannot be confirmed with the available documentation, and OSAGWI did not interview some key officials involved in the case about the tests.
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 Fishers coveralls and his flak jacket.
Over the course of three days, Fox vehicles tested PFC Fishers clothing and flak jacket on two occasions. On March 2, 1991, one Fox vehicles crew tested his coveralls; on March 4, 1991, two Fox crews working simultaneously examined PFC Fishers flak jacket.
Using electronic mail, the company commander of the crews who conducted the Fox vehicle tests of PFC Fishers 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 Iraqs 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 Fishers 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 Iraqs 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.
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 Fishers coveralls, PFC Fishers 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 Fishers flak jacket, cloth cut from PFC Fishers coveralls, the protective clothing jacket the Fox company commander wore, a gauze pad used to cover PFC Fishers 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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