During and after the Gulf War, people reported that they had been exposed to chemical warfare agents. To investigate these incidents and to determine if chemical weapons were used, the DOD developed a methodology for investigation and validation based on work done by the United Nations and the international community where the criteria include:

• A detailed written record of the conditions at the site.
• Physical evidence from the site such as weapons fragments, soil, water, vegetation or human/animal tissue samples.
• A record of the chain of custody during transportation of the evidence.
• Testimony of eyewitnesses.
• Multiple analyses.
• Review of the evidence by experts.

While the DOD methodology (Tab D) for investigating chemical incidents is based on these protocols, the passage of time since the Gulf War makes it difficult to obtain certain types of documentary evidence, and physical evidence was often not collected at the time of an event. Accordingly, our methodology is designed to provide a thorough, investigative process to define the circumstances of each incident and determine what happened. Alarms alone are not considered to be certain evidence of chemical agent presence, nor is a single individual’s observation sufficient to validate a chemical agent presence.

By following our methodology and accumulating anecdotal, documentary, and physical evidence, and by interviewing eyewitnesses and key personnel, and analyzing the results, the investigator can assess the validity of the presence of chemical warfare agents on the battlefield. Because information from various sources may be contradictory, we have developed an assessment scale (Figure 1) ranging from "Definitely" to "Definitely Not" with intermediate assessments of "Likely," "Unlikely," and "Indeterminate." This assessment is tentative, based on facts available as of the date of the report publication; each case is reassessed over time based on new information and feedback.

Figure 1. Assessment of Chemical Warfare Agent Presence

The standard for making the assessment is based on common sense: do the available facts lead a reasonable person to conclude that chemical warfare agents were or were not present? When insufficient information is available, the assessment is "Indeterminate" until more evidence can be found.

On March 1, 1991, PFC David A. Fisher was exposed to a chemical agent while exploring enemy bunker complexes. PFC Fisher developed blister symptoms roughly eight hours following exposure. Medical evaluation and treatment diagnosed the exposure as liquid mustard chemical warfare agent. Fox reconnaissance vehicle readings of the bunker and PFC Fisher’s clothing alarmed for mustard agents, and the testing of a urine sample gave positive results for a mustard breakdown product. Although later analysis of physical evidence did not confirm the exposure, experts concluded that PFC Fisher’s skin injuries were most likely caused by exposure to mustard agent. PFC Fisher received a Purple Heart for his injuries. The assessment for this incident is that chemical warfare agent exposure is "Likely." No other reports of similar blisters were made by PFC Fisher’s unit or other units in the area. Likewise, no other symptoms of exposure to liquid mustard chemical warfare agent were reported.

A single incident of exposure to mustard liquid occurred on March 1, 1991, in southeastern Iraq near the Iraq-Kuwait border. The location of the bunker was reported to be in the vicinity of geographical coordinates 29� 56’ N 47� 6’ E as well as Universal Transverse Mercator (UTM) coordinates QU053072, or 29� 49’ N 47� 4’[2] indicated in Figure 2.

Figure 2. Kuwait Theater of Operations: Mustard Exposure

This incident was documented at the time of its occurrence by COL M. A. Dunn,[3 an expert in chemical warfare agents who testified before the Presidential Advisory Committee (PAC).[4] PFC Fisher later corroborated the facts in telephone interviews.[5] Further confirmation of the events was provided by correspondence with a member of the Fox reconnaissance vehicle crew that examined PFC Fisher’s clothing.[6] This incident has also been reported by veterans to the Gulf War Illnesses Incident Reporting Line,[7] and is cited in numerous documents on GulfLINK and elsewhere. No other reports of similar blister agents were made by PFC Fisher’s unit or other units in the area. Likewise, no other symptoms of exposure to liquid mustard chemical warfare were reported. A CIA information report documenting this incident in March 1991 states: "There has been only one instance in which a soldier may have been, and by indication was, exposed to chemical agents."[8]

The following is from COL Dunn’s information paper:

PFC David Allen Fisher... is assigned to Scout Platoon, HTT, 4/8 Cavalry, 2nd Bde, 3d Armored Division, as a cavalry scout, MOS 19D. His exposure to mustard liquid occurred on 1 March 1991 on the objective of 4/8 Cav in northwestern Kuwait[9] ... PFC Fisher’s mission on 1 March included exploring enemy bunker complexes for intelligence materiel and personnel, and demolition of enemy fighting vehicles. On that day he wore Nomex tanker coveralls and a ballistic protective vest. While exploring numerous bunkers, he remembers coming into contact with many surfaces in tight passages, resulting in the soiling of his clothing and equipment. He participated in demolition of ZSU-23 antiaircraft systems, BRDM vehicles, and T55 tanks only. He specifically states that he was not in contact with tube or rocket field artillery systems.[10]

Inside one bunker, which he entered by squeezing through the doorway and passage, PFC Fisher saw crates and many loose artillery projectiles. These appeared in disarray, possibly due to an earlier bombing. He noted a "skull and crossbones" on at least one of the crates, took this as a danger sign, and immediately left the bunker. Exiting, he again brushed up against the wall and doorway.[11]

COL Dunn's information paper continues: 

PFC Fisher completed his mission at about 1700 on 1 March, returned to his platoon area, and experienced no symptoms for 8 hours until he started radio watch at 0100 on 2 March. At that time he felt stinging pain on the skin of his left upper arm, saw that the skin had a red sunburned appearance without blisters, and thought that it felt like a spider bite. He slept from 0300 to 0400, woke for stand-to,[12] and felt more stinging pain on his arm. At this time there were blisters on the upper arm and more reddened skin on the lower arm. At 0800 his company medic checked him, thought he might have a heater burn, and had him return at 1600, when more blisters had formed on the lower arm. At that time he was seen by CW2 Ahmed and CW3 Wildhelm at the 4/8 Cavalry aid station. They suspected he might be a blister agent casualty, decontaminated him with 0.5% chlorine solution, applied a local dressing and evacuated him to C Co., 45th Support Bn.[13]

Several veterans have also reported this incident to the Incident Reporting Line. One such report was given by a chemical officer who was involved in the identification of the exposure: 

I was working at the tactical operation center of the cavalry. We had a soldier reporting he was biten [sic] by a spider. I personally saw the soldier, I looked at the wound and he had blisters on it. I am a chemical officer, so I asked to see his clothing, he had on a tanker’s jacket, on his jacket he had a wet spot. I took the jacket to the [Fox reconnaissance] vehicle... I did a reading and it came positive for blister agent. I did a second reading and it became positive again. After that I basically notified the commander and division HQ [Headquarters]... I used chemical warning to report the incident. He was referred for medical treatment as a chemical casualty... After a week or two he was given a purple heart and sent back to the U.S."[14]

COL Dunn documented PFC Fisher's medical treatment in his information paper: 

At C Co, 45th Support Bn, PFC Fisher was treated by MAJ DeClew, who confirmed the clinical diagnosis of blister agent exposure, photographed the blisters,[15] applied a topical antibiotic and gauze dressing, and returned him to duty with follow-up at his unit. PFC Fisher remains in full duty status. I examined him and interviewed CW2 Ahmed and CW3 Wildhelm on 3 March at 1100. PFC Fisher had 2 blisters, about 2 cm diameter each, on the left upper arm, and another 2 blisters, 1 to 2 cm diameter, on the lateral left forearm, each surrounded by a narrow margin of erythema, or reddening. The roof of one upper arm blister had broken and the other three remained fluid-filled. PFC Fisher felt fine except for mild local pain that did not interfere with his duty performance. The skin area was photographed and a urine sample was saved in preservative for later analysis for thiodiglycol, a mustard breakdown product.... [16]

The blisters described by COL Dunn are consistent with known effects of mustard agent.[17] In addition to the injuries documented by COL Dunn, PFC Fisher noted during a March 1996 interview that he has "scars" on one of his legs from the blisters. These scars are not mentioned in any of the medical reports.[18]

Physical evidence collected in this case consists of: 

• the photographs of the blisters,
• a urine sample,
• samples of PFC Fisher’s clothing, and
• Fox reconnaissance vehicle readings of the clothing and bunker believed to be the location of the exposure.

During PFC Fisher’s evacuation, the medics were assisted by NBC (Nuclear, Biological, Chemical) personnel, who monitored PFC Fisher’s clothing and equipment with the spectrometer of a Fox reconnaissance vehicle.[19] Initial readings of the clothing’s soiled areas showed weak positive spectra suggesting possible lewisite[20] or phosgene oxime[21] contamination.[22] (Lewisite and phosgene oxime are both blister agents.) A later reading of a soiled area on the ballistic vest left upper shoulder pad alarmed for HQ, sesqui mustard. A subsequent Fox survey of the bunker was positive for distilled mustard, HD, but no chemical munitions were found in the bunker.[23]

The crew member contacted by the IAD through electronic mail gave an account of the Fox readings: 

Day 1 - A scout from 2nd Brigade 3rd Armored Division (PFC Fischer) [sic] complains of a severe rash and burning after a day of reconning Iraq bunkers. I do not know the exact location, but it was approximately 15-20 kilometers inside Iraq, 150-200 kilometers north of Saudi border. The 3AD was straddling the Iraq-Kuwait border at that time. Fischer [sic] developed a large blister on his arm and the Brigade Chemical Officer stated that it appeared to be a blister agent burn. At that time the soldier was taken to the two Fox reconnaissance vehicles which were attached to the 2nd Brigade. [My platoon sergeant] and [my second squad leader] were in charge of the two Fox vehicles located with that brigade. [My platoon sergeant] directed his MM1 mobile mass spectrometer operator... to attempt to get a contamination reading from PFC Fischer's Nomex jump suit. After close to an hour of testing, [his MM1 mobile mass spectrometer operator] got readings and was able to print a mass spectrum for an unusual blister agent (HQ). The test took so long because of the high concentration of sweat, oil and other petroleum based products in the suit. [His mobile mass spectrometer operator] had to attempt various temperature ranges in the capillary column before he was able to obtain good separation between the agent and the oil products (which registered as FAT, OIL, WAX on the MM1.) Division Chemical was notified of the results of the testing.[24] A Medical Service Corps Colonel who was one of the military's top experts on chemical agent casualties was flown in to examine PFC Fischer. His preliminary findings after examining the soldier were that the burns had the appearance of a blister agent. He also took blood and urine samples for analysis elsewhere. I never saw the lab reports from these tests, but I was later informed by Division Chemical personnel that the blood test had confirmed the presence of HQ mustard. [25]

Day 2 or 3. I received an order from Division Chemical to use another Fox to confirm the MM1 readings from [the first Fox] vehicle. PFC Fischer's Nomex jumpsuit was no longer available since it had been buried as contaminated waste,) [sic] but we still had his Kevlar flak vest. I took my Fox and [the first] Fox to an open area in the desert approximately 5 kilometers inside of Iraq. (These two vehicles had been attached to 3rd Brigade 3AD, but had been released after the cessation of ground combat back to 22nd Chemical Company, which was attached to 3AD DISCOM and was located in the Kuwaiti portion of the division sector.) I used my MM1 operator... on my vehicle and temporarily replaced [the first Fox's] MM1 operator... with... my most experienced and skilled MM1 operator. We used both MM1's to analyze the flak vest. Both MM1's "alarmed" (i.e. registered) high readings of HQ mustard as well as faint readings of Lewisite (which I was later told is a component of HQ.)[26] We were unable to obtain a spectrum of HQ because the concentration of FAT, OIL, WAX was always higher than the concentration of HQ. The MM1 will only take the mass spectrum of the highest concentration present. [The operator in the first Fox vehicle] filmed this procedure, including the MM1 screen, with his video camera.[27] Protective masks were NOT worn durning [sic] the sampling because I had been informed that HQ remains a soil [sic] until approx. 90 degrees F, and does not vaporize until almost 180 degrees F. I did wear a MOPP protective suit and protective gloves. I was the only member of my platoon to handle the vest. After testing, we placed the vest, my protective gear, and a set of sample wheels from the Fox (which we had unsuccessfully used trying to extract agent from the vest,) into plastic trash bags and triple bagged the samples. I then passed the samples along with the original mass spectrum for HQ and the "alarm" readings from the other two MM1's to Division Chemical.

Day 4 +. It was further discussed that we should attempt to locate the bunker in which PFC Fischer contacted the agent. Testing was done around the exteriors of all bunkers using [my second squad leader's] Fox, but no chemical was detected. Through a process of elimination (which I no longer remember) it was determined that one bunker in particular was most likely the source of contamination. [My second squad leader] took his Fox back to the suspected bunker, rammed a hole into the side of the bunker with the armored bow of his Fox, then lowered his MM1 probe into the hole. His crew was unable to get a reading for chemical agent, which is not surprising since there should not be a vapor hazard at that temperature. I coordinated with Division Chemical to go back out to the bunker the following day. I would get into complete MOPP4 protective gear, enter the bunker, and remove all boxes, supports, and removable equipment. I also intended to scrape samples off of walls and surfaces that PFC Fischer might have brushed up against. We would then attempt to get an MM1 reading by direct contact with the items and samples I removed. Approximately 20 minutes prior to beginning this operation, I received a call from Division Chemical stating the... Commanding General, 3d AD... had personally canceled the mission. I was told that he did not want to risk the personal safety of any of his soldiers since we had already confirmed the presence and nature of the contamination. Since the bunker was in Iraq, it was not militarily essential that we confirm the exact site of contamination.

That is the full synopsis of events involving the PFC Fischer case as I remember them.[28]

Although copies of the photographs showing the blisters have been examined in this investigation, they are of extremely poor quality and no analysis of the blisters could be made based on these photographs.

Army Central Command (ARCENT) Chemical analyzed the urine sample on March 3, 1991, and "the specimen was tested positive."[29] However, later testing of the urine sample--within a month of the sample’s collection--was negative. In testimony to the Presidential Advisory Committee, COL Dunn reported: "The urine sample I obtained showed no evidence of the mustard breakdown product, thiodiglycol, on analysis at my Institute’s laboratory [the US Army Medical Research Institute of Chemical Defense]. We expected this analysis to be negative as well, based on the low level of exposure."[30]

Fox spectra printouts and samples of the coverall sleeve and ballistic vest were retained by Nuclear, Biological, Chemical (NBC) personnel for analysis and were transported back to the US. The package was received on March 7, 1991 by the US Army Chemical Research, Development and Engineering Center, and then forwarded to the Analytical Research Division, Research Directorate for analysis on March 11, 1991. A videotape of a Fox spectrum reading of the clothing was also analyzed. (This reading was taken by a different Fox than the one that printed the tape. Both readings involving the printout and the videotape are discussed in the account given by the Fox crew member above.) "No evidence of any known CW [chemical warfare] agent or agent degradation product was found" during analysis of the clothing.[31] A subject matter expert at the US Army Chemical and Biological Defense Command (CBDCOM) examined the Fox spectra printouts and the videotape. The subject matter expert determined them to be inconclusive evidence for the detection of mustard (although the subject matter expert was able to draw a conclusion based on additional information, as discussed below).[32]

At the time of the incident, COL Dunn, who is an expert in chemical warfare agents, 33] concluded: 

PFC Fisher’s skin injury was caused by exposure to liquid mustard chemical warfare agent. The complete sequence of events is consistent with this conclusion. In particular, the latent period of 8 hours between exposure and first symptoms is characteristic of mustard exposure. No other corrosive or skin-toxic chemical compound that could reasonably be expected to have been present on the battlefield shows this latent period. The confirmatory Fox alarms are also consistent. It seems more likely that PFC Fisher’s exposure occurred during bunker exploration rather than during vehicle demolition because of the positive Fox result in the bunker complex and the lack of established chemical capability of the vehicle types he encountered.[34]

Later, the CBDCOM expert also concluded that the incident was an exposure to mustard agent: 

I reviewed a copy of [the printer tape] and belve [sic] it was a real mustard detection for these reasons: physical evidence (burn, medically diagnosed); plausible scenario of mustard in a bunker; detections at fairly high response levels (3.5 to 4.9 initially, then dropping off over several minutes); crews seemed well versed in MM-1 operation and applied correct procedures. Even though the spectra taken did not verify the agent alarms (they were reported as Fats Oils, waxes or "Unknown"), the high amount of oil/grease on the clothing could have caused this. I have just seen the videotape... it shows the MM-1 taking a spectrum, and verifying the detected material as HD. The questions I have though, are due to the reported detections of HQ, a mixture of HD and Q. If HQ was detected, both HD and Q should have been detected, with the HD being more likely to be detected since it is more volatile than the Q component. This may have been the case in [the] videotape, we can’t really tell... but that was NOT the case in the MM-1 printer tape which came back with the clothing samples for analysis.[35]

Finally, in his testimony to the Presidential Advisory Committee, COL Dunn stated: 

I conclude that the soldier may well have been exposed to a low level of mustard during his exploration of the bunker complex. The exposure clearly did not appear to me to represent intentional use of a chemical warfare agent by Iraq, which in my own experience with Iran-Iraq Gulf War casualties, as well as the experience of others, would have produced far more exposed persons and more severe effects, as it did on every occasion when it was used by Iraq in that conflict. Without solid chemical evidence to prove that the exposure was in fact to mustard, the strongest indication to support mustard as the cause was the 8 hour delay between the time of exposure and first symptoms. A later exposure, that the soldier might not have noticed, to one of many other rapidly corrosive or skin-injuring compounds remains as an alternative possibility in the absence of chemical confirmation.[36]

The assessment for this incident is the chemical warfare agent exposure is "Likely." This assessment is based on the following facts: 

• Two doctors trained to identify chemical warfare agent effects examined PFC Fisher and diagnosed his injuries to be caused by exposure to mustard. One of these doctors--COL Dunn--was a medical expert in chemical warfare agents. Although COL Dunn later qualified his initial diagnosis, he consistently maintains that PFC Fisher "may well have been exposed" to mustard agent.
• Various soldiers involved in the incident consistently reported the same exposure scenario. Accounts of this incident--provided by PFC Fisher, the chemical officer, the Fox crew member, as well as COL Dunn--report that PFC Fisher developed blister symptoms after a day of exploring Iraqi bunkers.
• Physical evidence from inside the bunker, which could have confirmed the presence of chemical agents, was not collected. (Recall the Fox crew member's statement that his mission to return to the bunker for further testing was canceled because the Commanding General, 3d AD "did not want to risk the personal safety of any of his soldiers since we had already confirmed the presence and nature of the contamination. Since the bunker was in Iraq, it was not militarily essential that we confirm the exact site of contamination.") Although the Army Central Command (ARCENT) Message cites that a Fox reconnaissance vehicle did alarm for mustard agents in one bunker, the alarm was not confirmed by a spectrum analysis. As indicated in the Fox Reconnaissance Vehicle Information Paper, the Fox's design results in many false positive alarms and requires a full spectrum analysis to confirm a detection.
• The fact that PFC Fisher was the only casualty is consistent with the overall scenario because his exposure was due to reconnaissance in Iraqi bunkers, which he entered alone, and not related to intentional use of chemical weapons against US and coalition troops.
  As stated in COL Dunn's information paper and testimony, the latent period of eight hours between exposure during bunker exploration and development of symptoms is consistent with effects of exposure to mustard agent.
• The in-theater analysis of PFC Fisher's clothing by Fox reconnaissance vehicles gave positive spectra for the presence of mustard agent, not just alarms. While the subsequent analysis of the clothing samples performed by the US Army Chemical Research, Development and Engineering Center (CRDEC) did not find evidence of chemical warfare agent contamination, it is possible that the sections of the clothing selected for testing were not contaminated sections. (The portions tested are listed on the first page of Memorandum for Record, Subject: Analysis/Evaluation of Clothing and Gauze Samples, US Army Chemical Research, Development and Engineering Center, March 1991.)
• The urinalysis performed by ARCENT Chemical "tested positive." Because the later urinalysis performed in the US is negative, the validity of the ARCENT Chemical result is called into question. However, COL Dunn reported that he did not expect a positive result based on the low level of exposure. Therefore, the lack of a positive urinalysis does not necessarily indicate negative confirmation of exposure.
• The injured soldier was awarded a Purple Heart after contemporaneous investigation.

To summarize, PFC Fisher probably acquired his injuries in the bunker complex in southeastern Iraq even though only one Fox alarmed to chemical warfare agents there and this could not be corroborated by a second Fox. Collection of additional materials for testing within the bunkers did not occur so as not to put troops at risk. Positive detections of mustard agent were made in-theater from analysis of Fisher's clothing and urine. Though these results were not replicated in US laboratories later, the medical assessment of trained and expert doctors was that PFC Fisher may "well have been exposed" to mustard agent.

Taking all these points into consideration within their total context, the assessment of this incident is that chemical warfare agent exposure is "Likely."

This case is still being investigated. As additional information becomes available, it will be incorporated. If you have records, photographs, recollections, or find errors in the details reported, please contact the DOD Persian Gulf Task Force Hot Line at 1-800-472-6719.

ARCENT Army Central Command

BRDM Soviet Armored Personnel Carrier

CBDCOM Chemical and Biological Defense Command

CIA        Central Intelligence Agency

CMAT        Case Management Action Team

COL        Colonel

CRDEC Chemical Research, Development and Engineering Center

CSTA       Combat Systems Test Activity

CW      Chemical Warfare

DIA                       Defense Intelligence Agency

DISCOM      Division Support Command

DOD      Department of Defense (U.S.)

H              Sulfur Mustard

HD     Distilled Sulfur Mustard

HHT             Headquarters and Headquarters Troop

HQ             Sesqui Mustard

IAD     Investigation and Analysis Directorate

MAJ             Major

MOPP     Mission Oriented Protective Posture

NBC      Nuclear, Biological, Chemical

PAC     Presidential Advisory Committee

PFC     Private First Class

RAM    Reliability and Maintainability 

UTM    Universal Transvers Mercator

3d AD   Third Armored Division

• 4/8 Cavalry, 2nd Brigade, 3rd Armored Division
• Fox Reconnaissance Vehicle Crews, 2nd Brigade, 3rd Armored Division
• C Company, 45th Battalion Support

• ARCENT Message, Subject: Chemical Casualty Update.
• Callback Results, CMAT No. 1996330-009, dated February 10, 1997.
• Callback Results, CMAT No. 1996334-004, dated February 28, 1997.
• Callback Results, CMAT No. 1997111-0000024, dated April 28, 1997.
• Callback Results, CMAT No. 1997149-0000056, dated May 29, 1997.
• CIA Information Report, Subject: CW Requirements Response, March 1991.
• COL M. A. Dunn’s Information Paper, GulkLINK, http://www.dtic.mil:80/gulflink/db/otsg/ 092496_sep96_decls1_0001.html.
• "Convention on the Prohibition of the Development, Production, Stockpiling, and Use of Chemical Weapons and on Their Destruction," April 29, 1997.
• Electronic Message from [Fox reconnaissance vehicle crew member], June 5, 1997, CMAT Control # 1997157-0000-037.
• Electronic message from Richard A. Vigus, US Army Chemical and Biological Defense Command, December 7, 1993.
• Fox Reconnaissance Vehicles, Office of the Special Assistant for Gulf War Illnesses, June 1997.
• Fox Spectra Printouts of Clothing, March 3, 1991.
• Incident Report 6330-009 dated November 25, 1996.
• Interview with COL Dunn, 1992.
• Investigation Team Testimony to Presidential Advisory Committee on 16 April 1996.
• Lead Sheet 585, March 6, 1996.
• Memorandum, Results of the Combat Systems Test Activity (CSTA) MM1 Excursion Test, July 14, 1993.
• Memorandum for Record, Subject: Analysis/Evaluation of Clothing and Gauze Samples, US Army Chemical Research, Development and Engineering Center, March 1991.
• NBC Operations Summary, Appendix 2, VII Corps, ARCENT, March 2-3, 1991.
• Transcript of COL Dunn’s testimony, GulfLINK, http://www.dtic.mil:80/gulflink/testimony/ pacwit.html.
• Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries, US Army Field Manual 8-285, December 22, 1995.
• Wade, Lt Col John V., Gum, Maj Robert M., Dunn, Col Michael A., "Medical Chemical Defense in Operations Desert Shield and Storm." The Journal of the US Army Medical Department PB 8-92-1/2, (January/February 1992): 34-36.
  
   

The DOD requires a common framework for our investigations and assessments of chemical warfare agent incident reports, so we turned to the United Nations and the international community which had experience concerning chemical weapons. Because the modern battlefield is complex, the international community developed investigation and validation protocols[37] to provide objective procedures for possible chemical weapons incidents. The standard that we are using is based on these protocols that include:

• A detailed written record of the conditions at the site.
• Physical evidence from the site such as weapons fragments, soil, water, vegetation, or human or animal tissue samples.
• A record of the chain of custody during transportation of the evidence.
• Testimony of eyewitnesses.
• Multiple analyses.
• Review of the evidence by an expert panel.

While the DOD methodology for investigating chemical incidents (Figure 3) is based on these protocols, the passage of time since the Gulf War makes it difficult to obtain certain types of documentary evidence, and physical evidence was often not collected at the time of an event. Accordingly, the methodology is designed to provide a thorough, investigative process to define the circumstances of each incident and determine what happened. The major efforts in this methodology are:

• Substantiate the incident.
• Document the medical reports related to the incident.
• Interview appropriate people.
• Obtain information available to external organizations.
• Assess the results.

Alarms alone are not considered to be certain evidence of chemical agent presence, nor is a single individual’s observation sufficient to validate a chemical agent presence.

To substantiate the circumstances surrounding an incident, the investigator searches for documentation from operational, intelligence, and environmental logs. This focuses the investigation on a specific time, date, and location, clarifies the conditions under which the incident occurred, and determines whether there is "hard" as well as anecdotal evidence. Additionally, the investigator looks for physical evidence that might indicate that chemical agents were present in the vicinity of the incident, including samples (or the results of analyses of samples) collected at the time of the incident.

The investigator searches the medical records to determine if personnel were injured as a result of the incident. Deaths, injuries, sicknesses, etc. near the time and location of an incident may be telling. Medical experts should provide information about alleged chemical casualties.

Figure 3. Chemical Incident Investigation Methodology 

Interviews of incident victims (or direct observers) are conducted. First-hand witnesses provide valuable insight into the conditions surrounding the incident and the mind-set of the personnel involved, and are particularly important if physical evidence is lacking. NBC officers or personnel trained in chemical and biological testing, confirmation, and reporting are interviewed to identify the unit’s response, the tests that were run, the injuries sustained, and the reports submitted. Commanders are contacted to ascertain what they knew, what decisions they made concerning the events surrounding the incident, and their assessment of the incident. Where appropriate, subject matter experts also provide opinions on the capabilities, limitations, and operation of technical equipment, and submit their evaluations of selected topics of interest.

Additionally, the investigator contacts agencies and organizations that may be able to provide additional clarifying information about the case. These would include, but not be limited to:

• Intelligence agencies that might be able to provide insight into events leading to the event, imagery of the area of the incident, and assessments of factors affecting the case.
• The DOD and Veterans’ clinical registries, which may provide data about the medical condition of personnel involved in the incident.

1. Investigation Team Testimony to Presidential Advisory Committee on 16 April 1996.
2. CIA Information Report, Subject: CW Requirements Response, March 1991 and NBC Operations Summary, Appendix 2, VII Corps, ARCENT, March 2-3, 1991, respectively. Note that these coordinates are approximately 10 miles apart; however, the UTM coordinates cited in the NBC Operations Summary were reported with only 6-digit precision (of a possible 9-digits), and it is possible that the discrepancy is due to mismatched precision.
3. COL M.A. Dunn's Information Paper dated March 5, 1991 has been posted on GulfLINK.
4.  A transcript of COL Dunn's testimony has been posted on GulfLINK. COL Dunn discussed these events in a 1992 interview, and also referred to the incident in the article: Wade, Lt Col John V., Gum, Maj Robert M., Dunn, Col Michael A., "Medical Chemical Defense in Operations Desert Shield and Storm." The Journal of the US Army Medical Department PB 8-92-1/2, (January/February 1992): 34-36.
5. Interviews with PFC Fisher are documented in Lead Sheet 585, dated March 6, 1996 and Callback Results, CMAT No. 1997149-0000056, dated May 29, 1997.
6. The IAD is contacting the crews of the Fox reconnaissance vehicles involved in this incident. One crew member was contacted through electronic mail and provided a synopsis of these events as he remembers them. Electronic Message from [Fox reconnaissance vehicle crew member], June 5, 1997, CMAT Control # 1997157-0000-037 .
7. Two such reports are documented in Callback Results, CMAT No. 1996334-004, dated February 28, 1997; and Callback Results, CMAT No. 1997111-0000024, dated April 28, 1997.
8.  CIA Information Report, Subject: CW Requirements Response, March 1991.
9. Although COL Dunn locates the exposure in northwestern Kuwait in his original paper, he later corrected the location to be southeastern Iraq, in concert with the CIA Information Report, NBC Operations Summary, and Fox crew member's account (quoted below).
10.  COL M. A. Dunn's Information Paper, GulfLINK.
11. Lead Sheet 585 dated March 6, 1996.
12.  "Stand-to" occurs approximately a half hour before daybreak in which soldiers man their defensive positions. This defensive procedure is also used as an accountability formation.
13. COL M. A. Dunn's Information Paper, GulfLINK.
14.  Incident Report 6330-009 dated November 25, 1996. See also Callback Results, CMAT No. 1996330-009, dated February 10, 1997.
15.  Copies of the photographs examined by the IAD are of poor quality and have not been included in this package.
16.  COL M. A. Dunn's Information Paper has been posted on GulfLINK.
17.  Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries, US Army Field Manual 8-285, December 22, 1995.
18.  Lead Sheet 585 dated March 6, 1996; Callback Results; CMAT No. 1997149-0000056, dated May 29, 1997.
19.  A description of the Fox and the detection capabilities of its mass spectrometry chemical detection system is found in Fox Reconnaissance Vehicles, Office of the Special Assistant for Gulf War Illnesses, July 1997.
20.  For a description of lewisite, see Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries, US Army Field Manual 8-285, February 28, 1990.
21.  For a description of phosgene oxime, see Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries, US Army Field Manual 8-285, December 22, 1995.
22.  In a July 1993 Reliability and Maintainability (RAM) test of Fox reconnaissance vehicle chemical detection, false positive readings for lewisite were displayed. These readings were found to be due to the presence of silicone polymer and/or silicone grease substance in the sampling wheels. A new sampling wheel has been introduced into the Fox vehicle system to correct the problem. Memorandum, Results of the Combat Systems Test Activity (CSTA) MM1 Excursion Test, July 14, 1993.
23. COL M. A. Dunn's Information Paper previously posted on GulfLINK.
24. The copy of the Fox spectra printout transcribed in Tab E. Tab E corresponds to this reading. This tape printout was examined by a subject matter expert at CBDCOM, as discussed below.
25. Note that COL Dunn reported only that urine samples were taken. It is likely that no blood samples were taken, and that the Fox crew member was mistaken. ARCENT Chemical results of an urinalysis were reported, as discussed below.
26. Lewisite is not a component of HQ, although both are blister agents.
27. This videotape was examined by a subject matter expert at CBDCOM, as discussed below.
28. Electronic Message from [Fox reconnaissance vehicle crew member], June 5, 1997, CMAT Control # 1997157-0000-037. Please note that PFC Fisher's name is misspelled throughout this quotation as "Fischer."
29. ARCENT Message, Subject: Chemical Casualty Update, p.2. This document also summarizes the events of PFC Fisher's exposure.
30. COL Dunn reported these results in his testimony before the Presidential Advisory Committee. A transcript of COL Dunn's testimony has been posted on GulfLINK. COL Dunn also discussed the negative result in an 1992 interview in which he stated, "I had my doubts at the time that I took the urine sample that it would come up positive because the level of exposure the soldier had as I say was pretty mild, just four very small blisters."
31. Memorandum for Record, Subject: Analysis/Evaluation of Clothing and Gauze Samples, US Army Chemical Research, Development and Engineering Center, March 1991.
32. Electronic message from Richard A. Vigus, US Army Chemical and Biological Defense Command, December 7, 1993. A copy of the Fox spectra printout for clothes was transcribed and is discussed in Tab E.
    
    
33. COL Dunn was the commander of the US Army Medical Research Institute of Chemical Defense at Aberdeen Proving Ground, MD, from April 1987 to July 1991.
34.  COL M. A. Dunn's Information Paper previously posted on GulfLINK. Vehicles PFC Fisher encountered are listed above, as quoted from COL Dunn's Information Paper.
35. Electronic message from Richard A. Vigus, US Army Chemical and Biological Defense Command, December 7, 1993.
36. A transcript of COL Dunn's testimony has been posted on GulfLINK.
37. "Convention on the Prohibition of the Development, Production, Stockpiling, and Use of Chemical Weapons and on Their Destruction," April 29, 1997. This Chemical Weapons Convention was opened for signature in Paris, France, on January 13, 1993. It has been signed by 165 States and ratified by 93 States (as of June 1997). It was signed by the U.S. on Jan 13, 1993 and ratified on April 25, 1997. Part XI of the Convention, "Investigations in Cases of Alleged Use of Chemical Weapons," details some of the procedures. [http://www.unog.ch/frames/disarm/distreat/chemical.htm]