As of October 31, 2000, the Board had reviewed fourteen original case narratives and nine revised case narratives that OSAGWI and its follow-on, OSAGWIMRMD, have released (see Appendix F). The primary purpose of the case narratives is to provide a summary of events surrounding a possible or reported nuclear, biological, chemical (NBC) attack/exposure and to assess how likely it is that the attack/exposure actually occurred. The Board did not review information papers because they do not address potential exposures and are intended to provide a nontechnical summary of issues or equipment closely associated with OSAGWI investigations.

The Board noted in its Interim Report that OSAGWI did not reach its case narrative assessments based on its stated standard. Instead, OSAGWI employed a preponderance of evidence approach. Although the Board did not disagree with this approach, the Board believed that OSAGWI should have clearly specified in its reports what evidence carried the greatest weight and why certain other evidence could be dismissed or discounted.

OSAGWI subsequently modified its stated methodology in both Section I and Tab D of each case narrative to conform to actual practice. The Board believes that the revised methodology fully reflects OSAGWI procedures and, more important, provides the most accurate method for assessing whether chemical warfare agent exposures may have occurred in the Gulf.

The Board recommended in the Interim Report that OSAGWI develop a policy for determining when and by what criteria interim reports would become final. OSAGWI and the Board have since agreed that reports will be finalized once the Board determines that the case narrative contains a sufficient explanation of the incident(s), accounts for contrary evidence, and does not require additional investigation. The Board bases its determinations on internationally accepted protocols and guidelines and the reasonable man concept used in the U.S. legal system.

The Board found that in all of its case narratives, OSAGWI made assessments regarding the presence of chemical and biological warfare agents that were consistent with available evidence. In the one interim case narrative, the Kuwaiti Girls' School, the Board concurred with the assessment that chemical warfare agent was definitely not present in a storage tank but disagreed that the liquid therein was definitely inhibited red fuming nitric acid. The Board noted shortcomings that did not affect the quality of the assessments in only four interim case narratives: Al Jaber Air Base, Czech/French Detections, Fox Detections in an ASP/Orchard, and Reported Mustard Agent Exposure I.

Case Narrative: 11^th Marines, October 30, 1998. This report addresses eighteen incidents that occurred in the area of operations of the 11^th Marines, an artillery regiment assigned to 1^st Marine Division, during the air and ground campaigns. The incidents generally consisted of unit alerts followed by chemical testing and/or unmasking procedures that did not confirm the presence of chemical warfare agents (CWA). OSAGWI assessed the possibility of CWA being present during any of the incidents as being "unlikely."

The Board found each of OSAGWI's eighteen assessments that it was "unlikely" that CWA was present to be consistent with the available evidence.

The Board recommended that OSAGWI revise the original case narrative to explain more fully several incidents, to ensure the accuracy of all references, and to correct minor editorial oversights prior to releasing it as a final report.

Case Narrative: Al Jaber Air Base, September 22, 1997. This report addresses six alleged detections of chemical warfare agents in the 1^st Marine Division during ground operations against Iraqi units near Al Jaber Air Base, Kuwait. Marine units encircled Al Jaber Air Base on the night of February 24-25, 1991. On five occasions marines near the division forward command post received oral "gas alerts." No unit reported any alerts, and M256 detector kit tests all proved negative. On February 25 a Fox crew reported detecting a lethal concentration of mustard agent, a qualitative capability that the vehicle does not possess. The 1^st Marine Division NBC section reviewed the tape and considered it a false alarm. No marines reported injuries consistent with mustard exposure, and no artillery or air attacks could be associated with the alleged detection. An inspection of Iraqi ammunition abandoned at Al Jaber revealed no CWA munitions. OSAGWI assessed the possibility of CWA being present during any of the incidents as being "unlikely."

The Board found each of OSAGWI's six assessments that it was "unlikely" that CWA was present to be consistent with the available evidence.

The Board recommended that OSAGWI revise the original case narrative to explain more fully several incidents, to ensure the accuracy of all references, and to correct minor editorial oversights prior to releasing it as a final report.

Case Narrative: An Nasiriyah Southwest Ammunition Storage Point, July 30, 1998; revised and reissued on January 13, 2000; further revised and reissued on September 28, 2000. This case narrative addresses the possible presence of chemical warfare agents, chemical weapons (CW), and biological weapons (BW) at the An Nasiriyah Southwest Ammunition Storage Point in Iraq. U.S. precision-guided munitions struck the ammunition supply point (ASP) during the air war, and U.S. troops occupied the site following the cease-fire to destroy all remaining ammunition. Units found no chemical weapons, no biological weapons, and no contamination during the occupation and demolition operations. OSAGWI assessed the presence of chemical weapons, biological weapons, or bulk chemical agents at the site during the U.S. occupation to be "unlikely."

The Board found the OSAGWI assessment to be consistent with available evidence.

The Board recommended that OSAGWI revise the original case narrative to ensure the accuracy of all references and reissue it as a final report. The revised version incorporated the Board's comments and updated the narrative to reflect improved methodology and new information. A third version addressed a Board comment that a possible dual-purpose bomb pictured in the case narrative was likely a conventional munition.

Case Narrative: Reported Detection of Chemical Agent Camp Monterey, Kuwait, May 15, 1997; revised and reissued on January 13, 2000. This report addresses a post-Gulf War incident that occurred at a U.S. Army installation in Kuwait. On September 16, 1991, two soldiers became sick after spilling white powder from a small metal can. Explosive ordnance disposal (EOD) personnel identified the powder as CS, a riot control agent, and two Fox vehicles conducted full-spectrum testing that confirmed the EOD team's assessment. OSAGWI assessed the possibility of CWA being present at Camp Monterey as "definitely not."

The Board agreed with OSAGWI's conclusion that the complete spectrum analyses of the suspect agent by the Fox vehicles identified the compound in question as the riot control agent CS and not a CWA.

The Board recommended that OSAGWI reissue the case narrative as a final report after ensuring the accuracy of its quotations and references. The revised version incorporated the Board's comments and updated the narrative to reflect improved methodology and new information.

Case Narrative: The Cement Factory, April 15, 1999; revised and republished on September 28, 2000. This narrative addresses the possible presence of chemical warfare agents at a Kuwaiti cement factory that Iraqi military units had once occupied. A Fox vehicle conducted a reconnaissance and alarmed for CWA. A second Fox vehicle sent to the factory alarmed for an unknown substance. Subsequent analysis of the Fox tapes indicated that no CWA had been detected. Soil samples also tested negative, but improper sealing of the soil containers compromised the definitiveness of the evaluation. Other attempts to confirm the presence of CWA at the factory proved negative. OSAGWI assessed the presence of CWA at the Cement Factory as "unlikely."

The Board found the OSAGWI assessment that it was "unlikely" that CWA was present to be consistent with the available evidence.

The Board recommended that OSAGWI revise the original case narrative to correct minor editorial oversights and reissue it as a final report. The revised version incorporated the Board's comments and updated the narrative to reflect improved methodology and new information.

Case Narrative: Czech and French Reports of Possible Chemical Agent Detections, July 29, 1998. This case narrative addresses reports by Czech and French units of seven detections or incidents (numbered 1 through 7) of nerve or blister agents in northern Saudi Arabia during the air campaign in late January 1991. No individuals reported any symptoms consistent with the two CWAs, and the detections cannot be related to attacks on Iraqi chemical sites. Since little information existed to prove or disprove five of the incidents, OSAGWI assessed those detections as "indeterminate" for the presence of nerve or blister agents. OSAGWI did not use its own criteria to assess the remaining two incidents (No. 1: the presence of nerve agent; and No. 6: the presence of blister agent). Instead, it concurred with CIA and Defense Intelligence Agency assessments that the two detections were valid and credible.

The Board withheld its recommendation concerning the final disposition of the case narrative to permit OSAGWI to evaluate chemical detection incidents 1 and 6 using its own assessment scale. The Board also found that OSAGWI did not submit for external review changes to its assessments of incidents 2, 3, 4, 5, and 7. However, the Board found that the published assessments of those five incidents are consistent with available evidence.

The French Minister of Defense informed the Secretary of Defense in a June 3, 1999, letter that French units "had no positive results" and "only false alarms occurred, without positive confirmations." In addition, the Czech Ministry of Defense reevaluated incidents where Czech units had reported and confirmed as positive only the detections associated with incident 6 (the contaminated sand; an incident that could only have occurred by liquid mustard agent being poured or spilled on the ground).

OSAGWIMRMD is completing a revised report that will address Board concerns and new information.

Case Narrative: Fox Alerts in the 24^th Infantry Division, February 22, 2000; revised and republished on October 26, 2000. This case narrative addresses a number of Fox vehicle tapes that showed alerts for the presence of chemical warfare agents during the period February 1 through 27, 1991. A Gulf War veteran provided these tapes to the Persian Gulf Illnesses Investigation Team and the Presidential Advisory Committee because he felt that the tapes presented clear evidence that his Fox vehicle had encountered chemical warfare agents. Mass spectroscopy experts analyzed the tapes and determined that the tapes did not indicate the presence of CWA. OSAGWI assessed the likelihood of any CWA being detected as "unlikely."

The Board found that OSAGWI'S assessment of "unlikely" is consistent with available evidence and recommended that the case narrative be reissued as a final report.

The Board recommended that OSAGWI revise the original case narrative to explain how the Fox operator obtained false relative intensity values on one tape and reissue the narrative as a final report. The revised version incorporated the Board's comments and updated the narrative to reflect improved methodology and new information.

Case Narrative: Fox Detections in an ASP/Orchard, September 25, 1997. This report addresses the possible presence of chemical warfare agents at an ammunition supply point in Kuwait that U.S. forces occupied at the end of the ground war. A Marine Corps task force directed its Fox vehicle to inspect the ASP for potential chemical weapons and chemical warfare agents. The Fox alerted for three agents within 100 meters of one another during its February 28, 1991, inspection. Of the three agents (two blister agents-HD and HT-and benzyl bromide, a tearing agent), the Iraqis are known to have possessed only HD. The Fox crew attempted unsuccessfully to reconfirm the HD detection during their reconnaissance even though that chemical warfare agent is persistent. The task force NBC officer conducted a dismounted reconnaissance later that day using chemical agent monitors (CAM) but detected no CWAs. An EOD team inspected the ASP on March 1, 1991, and found no chemical weapons or CWA. At no time during the occupation of the supply point did any task force personnel report symptoms consistent with any of the three chemical agents. After the war, the U.S. contractor responsible for dismantling the ASP found no chemical weapons. OSAGWI assessed the likelihood of CWA being present as "unlikely."

The Board found that OSAGWI's assessment that it is "unlikely" that chemical weapons or chemical warfare agents were present at the ASP during the U.S. occupation in 1991 is consistent with available evidence.

The Board recommended that OSAGWI should consider the investigation complete and change the interim case narrative to read "Final."

Case Narrative: Possible Chemical Warfare Agent Incident Involving a United States Marine, March 16, 2000. This report addresses the possibility that testing of captured Iraqi personal equipment exposed a marine to Lewisite, a blister agent. Following the cease-fire, a marine tested Iraqi equipment with his Fox vehicle and then decontaminated himself with bleach and later with a chemically treated swab from his M258 skin decontamination kit. The marine developed skin blisters shortly thereafter and received medical treatment both in theater and upon his return to the United States. The blisters eventually healed after six months. Based on medical opinion, the lack of other casualties, no unit alerts, and the absence of Lewisite from the Iraqi inventory, OSAGWI assessed the possibility of the marine being exposed to a blister or other chemical warfare agent as "unlikely."

The Board found that OSAGWI's assessment that the marine was "unlikely" to have been exposed to chemical warfare agents is consistent with available evidence.

The Board recommended that OSAGWI should consider the investigation complete and change the interim case narrative to read "Final."

Case Narrative: Kuwaiti Girls' School, March 11, 1998. This report addresses the liquid contents of a storage tank that was discovered next to an outside wall of a school building in Kuwait City, Kuwait, in early August 1991. EOD personnel examined a tank that was emitting a red vapor jet and had positive test results for the CAM and M18A2 chemical agent detector kit. A joint U.S.-United Kingdom team obtained liquid samples for on-site Fox testing and for laboratory analysis in the United Kingdom (UK). The full-spectrum analyses of the two Fox vehicles did not detect any chemical warfare agent, and the British laboratory at Porton Down confirmed the absence of any CWA and determined that the properties of the liquid were consistent with nitric acid. Inhibited red fuming nitric acid (IRFNA), a variant of nitric acid, is the oxidizer portion of the fuel for the Silkworm missiles found at the Kuwaiti Girls' School. OSAGWI assessed the tank's content as "definitely not" CWA and "definitely" IRFNA.

The Board initially found that OSAGWI's assessments were consistent with the best available evidence that chemical warfare agent was "definitely not" present at the Kuwaiti Girls' School and that the storage tank in question "definitely" contained IRFNA. The Board recommended that OSAGWI should consider this investigation complete and that the interim report should be changed to read "Final Report."

Subsequently, the Board discovered, while preparing to review the anticipated final report, additional information that cast some doubt on whether the liquid actually was IRFNA and also suggested that other Fox tapes existed. The Board and OSAGWI closely examined and researched these issues and reconfirmed that the liquid in the tank was "definitely not" CWA. The limitations of retrospective investigations prevented the Board and OSAGWI from definitively determining the liquid's identity, although it was likely a nitrogen-based acid. OSAGWI is revising the narrative to incorporate the newly acquired information.

Case Narrative: Possible Chemical Agent on SCUD Missile Sample, August 13, 1997; revised and reissued on July 27, 2000. This case narrative addresses the possible presence of a chemical warfare agent on a metal fragment purported to be from a SCUD missile. The PAC received the fragment during a meeting in Charlotte, North Carolina. An unidentified individual had obtained the metal from a soldier who claimed it came from a SCUD that a PATRIOT missile had hit over King Fahd Military Airport on January 19, 1991. The U.S. Army Edgewood Research and Development Engineering Center tested the fragment and found no chemical warfare agents. The Missile and Space Intelligence Center determined that the metallurgical qualities of the fragment were consistent with those of a SCUD missile. Since an accurate chain of custody could not be established, OSAGWI assessed the presence of a CWA on the fragment to be "unlikely" (instead of "definitely not").

The Board agreed with OSAGWI's conclusion that it was "unlikely" that CWA could be found on the missile fragment to be consistent with available evidence.

The Board recommended that OSAGWI reissue the case narrative as a final report. OSAGWI updated the narrative to reflect improved methodology and new information.

Case Narrative: Possible Chemical Agent Release at Ukhaydir Ammunition Storage Depot, June 16, 2000. This report addresses the possibility that during the air war U.S. troops may have been exposed to mustard agent released by coalition air strikes on the Ukhaydir Ammunition Storage Depot. Coalition forces struck the storage depot on January 20, 1991, and again on February 13 and 14, 1991. No evidence substantiates the release of chemical agent in the January air strike, and modeling indicates that any chemical agent that survived the fire would not have reached the most forward-based U.S. units. Available information cannot confirm that the February strikes resulted in a chemical release, but modeling demonstrated that any resulting CWA plume would not have reached any U.S. personnel. OSAGWI assessed the possibility of a chemical release from the January and February air strikes as "indeterminate" and the possibility that a release would have resulted in chemical agent exposures to U.S. troops as "unlikely."

The Board found both OSAGWI assessments to be consistent with available evidence and recommended that OSAGWI reissue the case narrative as a final report.

Case Narrative: Reported Mustard Agent Exposure Operation Desert Storm, August 27, 1997; revised and reissued on October 26, 2000. This report addresses the possible postwar exposure of a U.S. Army soldier to mustard agent. PFC David Fisher developed blisters after exploring bunkers in northern Kuwait on March 1, 1991. Medics initially thought that spider bites had caused the blistering, but a senior medical officer diagnosed the blisters as resulting from exposure to mustard agent. OSAGWI assessed this soldier's blisters as "likely" caused by a chemical warfare agent.

The Board agreed with OSAGWI's assessment even though much of the evidence presented in the case narrative was circumstantial. However, the Board notes that Col. Michael Dunn, a medical doctor and an expert in chemical warfare agents who commanded the U.S. Army Research Institute of Chemical Defense during Gulf War operations, diagnosed Private Fisher's blisters as having resulted from exposure to mustard agent.

The Board also found that OSAGWI did not fully research or investigate all possible evidence in connection with this incident. In particular, OSAGWI did not interview Colonel Dunn or obtain copies of the photographs that he took of Private Fisher's burns.

The Board notes that the investigation of this incident began before OSAGWI was established and that OSAGWI's investigation was primarily limited to reviewing available field correspondence and testimony. The Board also believes that OSAGWI's investigation process matured after this case narrative was published. The Board acknowledges that the General Accounting Office also found weaknesses in OSAGWI's investigation of this case and relayed its concerns to OSAGWI.

The Board recommended that OSAGWI update and amend the case narrative using the Board's findings and the GAO report (GAO/NSIAD-99-59) and reissue the report.

Several agencies have since identified additional information that materially changed the OSAGWI assessment. The only test of Private Fisher's urine for mustard agent breakdown products proved negative. Second, analysis of videotape taken during a Fox vehicle test of Private Fisher's flak jacket showed that the vehicle had false alarmed for mustard agent (the full-spectrum analysis did not support the presence of any CWA). Third, the diagnosing physician stated that he could not rule out the possibility that the blisters resulted from insect bites or some other irritant. Fourth, the recovered MM-1 printout tape from the coverall test did not indicate the presence of mustard agent. Based on this and other information, OSAGWI reassessed the likelihood that Private Fisher was exposed to mustard agent from "likely" to "indeterminate."

The Board found that OSAGWI's assessment of "indeterminate" that PFC Fisher was exposed to chemical warfare agents is consistent with available evidence.

The Board recommended that OSAGWI should consider the investigation complete and change the interim case narrative to read "Final."

Case Narrative: Tallil Air Base, Iraq, October 30, 1997; revised and reissued on May 25, 2000. This case narrative addresses the possible presence of chemical weapons or chemical warfare agents at an air base that U.S. troops occupied in Iraq. U.S. aircraft had bombed the air base during Operation Desert Storm, and U.S. ground forces occupied the site following the cease-fire. During the occupation, U.S. troops discovered chemical warfare defensive gear but no chemical weapons or chemical warfare agents. OSAGWI assessed that the presence of CW and CWA at Tallil during the U.S. occupation was "unlikely."

The Board found that OSAGWI's assessment that it was "unlikely" that chemical weapons and chemical warfare agents were present at the air base during the U.S. occupation is consistent with available evidence.

The Board recommended that OSAGWI review the narrative to ensure its quotations and references were accurate and then reissue it as a final report. The revised version incorporated the Board's comments and updated the narrative to reflect improved methodology, new source documents, and an added lessons learned section.

Case Narrative: US Marine Corps Minefield Breaching, May 25, 2000. This report addresses the possible detection of chemical warfare agents when the 1^st and 2^nd Marine Divisions breached the forward Iraqi minefields on February 24, 1991. A Fox vehicle in each division reported detecting CWA in its one assigned breaching lane. In addition, the Fox crew in the 2^nd Marine Division reported detections with a CAM and with M9 chemical detection paper later that day.

The Board found that OSAGWI's assessment that it is "unlikely" that U.S. forces were exposed to chemical warfare agents in each of the incidents is consistent with the best evidence available. The Board recommended that OSAGWI should consider the investigation complete and change the interim case narrative to read "Final."

The General Accounting Office reviewed the original version of this case narrative, dated July 29, 1997, and had expressed concerns with OSAGWI's assessment. The Board found that the current version fully addresses each of the GAO's concerns.