One prominent hypothesis about illnesses among Gulf War veterans is that some of the reported symptoms are the result of exposure to chemical warfare agents. During and after the Gulf War, some veterans reported that they had been exposed to chemical warfare agents. To investigate these incidents, and to assess the likelihood that chemical warfare agents were present in the Gulf, the Department of Defense developed a methodology for investigation and validation based on work done by the United Nations and the international community. 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;
• The testimony of witnesses;
• Multiple analyses; and
• A review of the evidence by experts.

While the methodology (Tab D) used to investigate suspected chemical warfare agent 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. Therefore, we cannot apply a rigid template to all incidents, and each investigation must be tailored to its unique circumstances. Accordingly, we designed our methodology to provide a thorough, investigative process to define the circumstances of each incident and to determine what happened. Alarms alone are not considered to be certain evidence of chemical warfare agent presence, nor is a single observation sufficient to validate the presence of a chemical warfare agent.

After following our methodology and accumulating anecdotal, documentary, and physical evidence; after interviewing witnesses and key servicemembers; and after analyzing the results of all available information, the investigator assesses the validity of the presence of chemical warfare agents on the battlefield. Because we do not expect to always have conclusive evidence, we have developed an assessment scale (Figure 1) ranging from Definitely Not to Definitely, with intermediate assessments of Unlikely, Indeterminate, and Likely. This assessment is our best judgement, 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 2, 1991, U.S. Army medical personnel diagnosed Pfc. David A. Fisher as having been exposed to liquid mustard chemical warfare agent while exploring enemy bunkers along the Kuwait-Iraq border. He was medically evacuated from the Kuwait theater of operations and awarded a Purple Heart for his injuries.

Pfc. Fisher began developing blisters on his upper left arm roughly eight hours after a search-and-destroy mission in enemy bunkers on March 1, 1991. Medics and physician’s assistants in his unit examined Pfc. Fisher’s injury. Medical personnel evaluated, diagnosed, and treated his blisters as a chemical warfare injury. The doctors who diagnosed his injury as blister agent exposure were trained to identify chemical warfare agent casualties. Furthermore, one of them was a leading expert in this field.

Pfc. Fisher provided a urine sample to the doctors who diagnosed his injury as an exposure to liquid mustard chemical warfare agent. One of the doctors took this urine sample to the United States for analysis at the U.S. Army Medical Research Institute of Chemical Defense. The urinalysis results were negative for thiodiglycol, a mustard agent breakdown product usually found in the urine of persons exposed to mustard agent.

Two Fox Nuclear, Biological, Chemical reconnaissance vehicles attempted to locate the bunker in which Pfc. Fisher might have been exposed. Pfc. Fisher did not accompany these vehicles to the bunker complex, and it is not known if the crews located the correct bunker. One Fox crew, believing they had found the bunker, tested for chemical warfare agent and reported they detected a mustard agent, but we have no physical evidence to corroborate this report. The accompanying Fox also tested for chemical warfare agent but yielded negative results.

Two Fox vehicle crews tested Pfc. Fisher’s coveralls and body armor (more commonly called a flak jacket) with MM-1 mobile mass spectrometers to determine if a chemical warfare agent was present. While three separate tests (one test of Pfc Fisher’s coveralls and two of his flak jacket) indicated a possible presence of a mustard agent, only one of the flak jacket tests provided high confidence for mustard presence.

Pfc. Fisher’s flak jacket and pieces of cloth from his coveralls were sent to the U.S. Army Chemical Research, Development, and Engineering Center for laboratory analysis. The analysis showed no evidence of chemical warfare agent or chemical warfare agent degradation byproducts.

It is difficult to conclude whether Pfc Fisher was exposed to chemical warfare agent residue while searching bunkers along the Iraq-Kuwait border on March 1, 1991. Among the strongest evidence supporting the conclusion he was exposed to a chemical warfare agent are statements from the well-trained medical personnel who diagnosed and treated his injury as mustard exposure. The medical personnel who examined Pfc. Fisher believed his blisters resulted from chemical warfare agent exposure. However, even the doctor who was a leading expert in the field of chemical warfare agent casualties stated that something other than mustard agent could have caused the blisters. But he further stated that all of the information at the time of the incident led him to a clinical diagnosis of mustard exposure.

The urinalysis failed to detect the mustard breakdown product, thiodiglycol. This result was inconsistent with the diagnosis, but, in the leading medical expert’s opinion, not unexpected because of the low level of exposure.

The nuclear, biological, chemical soldiers who tested Pfc. Fisher’s coveralls and flak jacket with the Fox MM-1 remembered detecting sulfur mustard and sesqui-mustard. However, the surviving physical evidence does not agree with their recollections; in fact, sesqui-mustard was not in Iraq’s chemical warfare agent inventory. During our previous investigation of this incident in 1997, we believed one operator had obtained a spectrum providing a high degree of confidence of mustard’s presence on the flak jacket. We had based this conclusion on a videotape of a spectrum showing the MM-1 spectrometer analysis of a spot on the flak jacket that indicated sulfur mustard presence. However, a review of the data on the operator’s screen cast doubt on the presence of mustard agent—the sample was missing critical ions of mustard. Also, the subsequent laboratory testing of the coverall cloth samples and the flak jacket at the U.S. Army Chemical Research, Development, and Engineering Center showed no evidence of chemical warfare agent or chemical warfare agent degradation byproducts.

Pfc. Fisher’s reported exposure occurred 100 miles from Iraq’s nearest chemical warfare agent storage facility, according to the Central Intelligence Agency and United Nations Special Commission. The Central Intelligence Agency and United Nations Special Commission have reported no evidence Iraq moved any chemical warfare agents south of Khamisiyah. Consequently, we do not know where the mustard would have come from to cause this reported exposure.

In summary, the information about this incident is conflicting. The medical diagnosis by trained doctors and the videotape of an apparent spectrum lead to the conclusion an exposure occurred. On the other hand, the analysis of the data extracted from the videotaped Fox spectrum showed critical ions were missing from the spectrum. In addition, other causes of blisters exist, we have no evidence of chemical weapons in that area of the Kuwait theater of operations, and laboratory testing in the United States failed to identify any chemical warfare agent on the flak jacket or coveralls material. Therefore, because of the conflicting evidence, we have reassessed this chemical warfare agent exposure incident as indeterminate.

On August 27, 1997, the Special Assistant for Gulf War Illnesses published the original narrative detailing the circumstances surrounding the possible exposure to liquid mustard chemical warfare agent of a U.S. soldier during the Gulf War.[2] Since then the Presidential Special Oversight Board for Department of Defense Investigations of Gulf War Chemical and Biological Incidents (PSOB) and the General Accounting Office (GAO) have reviewed the narrative and provided comments to the Special Assistant. Both the PSOB and the GAO agreed with the original assessment based on information presented that an exposure to a chemical warfare agent was likely; however, both recommended additional investigation.

We investigated further as the PSOB and GAO suggested. New information about this incident includes reports on the location of the suspected bunker and when it was constructed. In the original investigation of this incident, we interviewed 11 people. For this follow-up investigation, we re-interviewed four people and conducted 20 new interviews. We identified seven additional people to interview, but were unable to locate them. For the original narrative, we telephonically interviewed Col. Dunn, the physician who examined Pfc. Fisher and diagnosed the injury as an exposure to a chemical warfare agent; we interviewed him in person for this version. This narrative incorporates additional information obtained from Pfc. David Fisher.[3] It also includes information obtained during interviews with medical and chemical warfare agent experts as well as with the soldiers who conducted the search and destroy mission with Pfc. Fisher.[4]

According to a VII Corps message,[5] Pfc. Fisher’s reported exposure to liquid mustard chemical warfare agent occurred on March 1, 1991, in a bunker located near the Iraq-Kuwait border.[6] Figure 2 shows the general area where the bunker reportedly was located.

Figure 2. Location of reported mustard exposure incident

Reports on the bunker’s location vary, making its exact location difficult to determine; however, at the time of the incident, most of the reported locations were on Kuwait’s side of the border near Universal Transverse Mercator (UTM) coordinates QU 050 072. Figure 3 shows this location and others in detail. A VII Corps casualty report records another location for the bunker—on the Iraq-Kuwait border at UTM coordinates QU 003 023.[7] We found no other information to support this location.

Figure 3.  Locations associated with the reported mustard exposure

Pfc. Fisher’s unit conducted a search-and-destroy mission centered on UTM coordinates PU 995 047.[8] A VII Corps report to US Army Central Command (ARCENT) listed the location of the incident in Iraq "W [west] of PU 995 047."[9] The unit’s mission was to destroy enemy vehicles and bunkers located within an area five kilometers east and west of UTM coordinates PU 995 047 and four kilometers north and south of the same coordinates—an 80 square kilometer area, shown as the shaded portion of Figure 3.[10] PFC Fisher related he had checked out some 30 bunkers over three days before the diagnosis of his blister agent injury.[11]

After medical personnel diagnosed Pfc. Fisher’s blisters as a chemical warfare agent exposure, two Fox vehicles went to find the bunker suspected of being the point of exposure. Although VII Corps reported to ARCENT that Pfc. Fisher would accompany the Fox vehicles to the suspect bunker[12] when they searched the area, Pfc. Fisher did not accompany them to identify bunkers he had searched. ARCENT directed him not to accompany the vehicles, but rather to wait for a special chemical medical casualty team to examine him.[13] The Fox vehicles searched the suspected area; one reported traces of distilled sulfur mustard and mustard-T mixture blister agent[14] at a bunker located in Kuwait at UTM coordinates QU 050 072[15] . The second Fox failed to detect the presence of any chemical warfare agent at the same location.[16] An after action report noted the bunker at UTM coordinates QU 053 072.[17] A VII Corps journal entry concerning this activity noted a Fox vehicle had a weak HD [sulfur mustard] reading at the suspected bunker at UTM coordinates QU 053 027,[18] which may have been a transposition of the "072" portion of the coordinates.

According to an intelligence report, the suspected bunker was in an area recently occupied by Iraq’s 52nd Infantry Division[19] at geographic coordinates 29 56N 047 06E (UTM coordinates QU 031 136). At the time of the reported exposure, an officer who served with the 9th Battalion, 227th Aviation Regiment, was located at a tactical assembly area at geographic coordinates 29 57 06N 047 05 02E (UTM coordinates QU 010 150). He reported the bunker where Pfc. Fisher was exposed was one kilometer northeast of the tactical assembly area.[20] We found no other information to support this statement.

Pfc. Fisher’s initial treatment by the medics in the 4th Battalion, 8th Cavalry Regiment (4-8th Cavalry) aid station did not focus on his injury as chemical warfare-related. Pfc. Fisher himself originally thought a spider bite might have caused his arm’s redness and soreness. At 1 a.m., March 2, 1991, he awakened for guard duty and radio watch and noticed redness on his upper left arm. He went to sick call at 8 a.m.; the medic diagnosed the blister as a possible heater burn and told Fisher to return to sick call in the afternoon.[21]

• His company medic checked him, thought he might have a heater burn, and had him return at 4 p.m., when more blisters had formed on the lower arm. At that time he was seen by CW2 [Chief Warrant Officer 2] Ahmed and CW3 [Chief Warrant Officer 3] Widhalm[22] at the 4-8th 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. [Company], 45th Support Bn [Battalion].[23]

CW2 Ahmed related Fisher came to him with "a big blister on the deltoid of his arm,"[24] which CW2 Ahmed said he treated with calcium hypochlorite. CW3 Widhalm examined Pfc. Fisher’s blisters and stated, "It was a textbook picture straight from the photos shown in the chem school."[25]

• The assistant non-commissioned officer in charge (NCOIC) of the 4-8th Cavalry aid station and another medic working there took Pfc. Fisher through the decontamination procedures. The assistant NCOIC indicated he knew of no urine or blood tests taken while Pfc. Fisher was at the aid station.[26] Medical personnel evacuated Pfc. Fisher to the 45th Support Battalion for further treatment.

At C Company, 45th Support Battalion, Pfc. Fisher was treated by [the senior medical officer], Maj. DeClue, who confirmed the clinical diagnosis of blister agent exposure, photographed the blisters, 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.[27]

Before hostilities, three two-man teams of medical experts had deployed to the Kuwait theater of operations from the U.S. Army Medical Institute of Chemical Defense. One team each was assigned to VII Corps, XVIII Airborne Corps, and the US Marines in-theater. Col. (Doctor) Michael Dunn and another doctor, a pulmonary specialist, made up the VII Corps team.[28] On Pfc. Fisher’s diagnosis and treatment as a chemical warfare agent casualty, Col. Dunn’s team was notified to examine Pfc. Fisher’s injury.[29]

• I examined him and interviewed CW2 Ahmed and CW3 Widhalm on 3 March at 11 a.m. Pfc. Fisher had two blisters, about two centimeters (cm) diameter each, on the left upper arm, and another two blisters, one to two cm in 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 [agent] breakdown product.[30]

When confronted with this apparent chemical warfare agent exposure, Col. Dunn reviewed Pfc. Fisher’s activities before his first symptoms appeared. Col. Dunn indicated in several interviews Pfc. Fisher’s blisters could have been caused by something other than mustard, such as poison ivy or other "skin sensitizing contact dermatitis provokers."[31] However, in the absence of these causes and with the possibility that U.S. soldiers might encounter chemical warfare agents in Iraq, he agreed with the clinical diagnosis of blister agent exposure.

When Col. Dunn interviewed Pfc. Fisher to determine where and when his exposure might have occurred, he learned Pfc. Fisher had entered several bunkers on a search-and-destroy mission. Pfc. Fisher entered one particular bunker by squeezing through the doorway and passageway[32] , where he recalled contacting many surfaces in the tight passages, thus soiling his clothing and equipment.[33] Exiting the bunker, he again brushed against the wall and doorway.[34]

Col. Dunn concluded an exposure to liquid mustard chemical warfare agent while exploring enemy bunkers caused Pfc. Fisher’s skin injury. Col. Dunn believed the sequence of events was consistent with this conclusion, particularly the eight hours between exposure and the first symptoms’ appearance. He concluded no other corrosive or skin-toxic chemical compounds that reasonably could be expected to be on the Gulf War battlefield show this eight-hour latent period between exposure and blisters’ appearance.[35]

In a 1995 interview, Col. Dunn reviewed the possible causes of Pfc. Fisher’s injury. He stated there were two possibilities. One possibility was Pfc. Fisher may have gotten into something on the battlefield other than mustard, for example, waste products usually associated with motor pools or possibly rocket fuel. All sorts of things might have caused blistering. Alternatively, Pfc. Fisher was, in fact, exposed to mustard chemical warfare agent. Col. Dunn concluded that all of the information available at the time led to the diagnosis that the injury was clinically consistent with a mustard exposure, but that it was unproven and unconfirmed.[36]

In a 1999 discussion with Col. Dunn of possible causes for Pfc. Fisher’s blisters, he stated

• I was also asked could this represent exposure to something other than mustard … and I said, "Yes." [T]here [are] several other things that can cause skin blisters after a symptom-free latent period of many hours. The commonest one … is poison ivy and there are a few other skin sensitizing contact dermatitis provokers …. So, in the absence of any of these other well known potential causes of skin blisters after a latent period of time and with a hint of the positive Fox vehicle spectrum, we concluded that on clinical grounds this appeared to be a mustard exposure.[37]

Col. Dunn went on to explain that the universe of things that can cause skin to redden and blister six to eight hours after exposure is rather limited. Chemical warfare agents, some skin sensitizing agents and some plants like poison ivy can cause blisters such as Pfc. Fisher’s. In the absence of evidence for other things that seem likely, given the location, he believed mustard was the most likely, especially considering the latent period.[38]

Helpful physical evidence collected and examined in the investigation into this incident included:

• Fox reconnaissance vehicle paper printouts and a videotape obtained during the testing of Pfc. Fisher’s coveralls and his body armor (more commonly called a flak jacket);
• A urine sample;
• Photographs of the blisters; and
• Chemical Research, Development, and Engineering Center test results of a swatch cut from the coveralls, medical gauze used to cover Pfc. Fisher’s injury, and the flak jacket.

1. The Fox Tests

a. Fox Sampling Procedures

The primary chemical warfare agent detection system in the Fox is the MM-1 mobile mass spectrometer with an air/surface sampler. The system is primarily a liquid chemical agent detector. The MM-1 continuously monitors samples passing through it to check for the presence of chemical warfare agents identified on a pre-selected target list of 1 to 22 chemical compounds, primarily chemical warfare agents. This target list consists of a four-ion "fingerprint" for each compound. During the initial identification step, the MM-1 fragments each sample into a unique ion pattern and then compares each four-ion fingerprint on the target list against the sample, searching for a match.[39]

If the MM-1 makes an approximate, initial match and the four-ion intensity[40] is higher than a specific level (unique for each agent), an alarm is sounded, displayed on the MM-1 operator’s screen, and printed on a paper tape. This initial alarm, however, does not verify the presence of a chemical warfare agent because many chemical compounds have ions of the same or similar weight as the compounds on the chemical warfare agent target list and can cause a false positive alarm for chemical warfare agents.[41] The initial alarms continue until either the ion intensity level falls below the alarm level or the MM-1 operator changes sampling methods or modes.[42]

To improve confidence the system has detected a chemical warfare agent, the MM-1 operator must perform a spectrum analysis. The operator reduces the sample line temperature from 180� Celsius (C) to 120� C (356� Fahrenheit (F) to 248� F) for better ion separation, discontinues using the sample wheels, cleans the sample probe to remove residual ion activity (contamination), and lowers the probe to within three to five centimeters of the source of the alert allowing the MM-1 to acquire a better-prepared sample. The MM-1 then searches its 60-compound chemical library of four-ion-peak fingerprints, compares them to this improved sample, and attempts to match the chemical warfare agent fingerprints with it.[43]

Using proper procedures, it takes several minutes to collect a good sample and obtain sufficient ion spectrum readout and analysis. This process is necessary to evaluate the sample properly for any suspected chemical warfare agent. Although an MM-1 operator can produce a spectrum in other ways, this is the proper, most accurate method.[44] The MM-1 operator also should print a paper tape as a hard-copy historical record to save spectrum details.[45]

If the properly performed spectrum procedure identifies a chemical warfare agent, the MM-1 operator and the Fox commander can be more confident the agent is present. Conversely, if the spectrum analysis does not identify one of the chemical warfare agents in the MM-1 60-compound chemical library, the MM-1 operator and the Fox commander can be confident the chemical warfare agent displayed during the initial alarm is not present. Field-testing can provide only high confidence, not confirmation, of agent presence. Further analysis of the spectrum printout tape by a mass spectrometry expert comparing the spectrum results to an established database of compounds can increase confidence in the detection.  Only a laboratory analysis of a sample can confirm agent presence. Comparing a spectrum not only increases confidence in a detection, it can also determine a false positive alarm. Additionally, MM-1 operators are taught to collect a specimen of the contamination (e.g., a soil sample) to provide further confidence of the presence of the substance by thorough laboratory analysis.[46]

b. Test of Coveralls and Flak Jacket

Over three days, Fox vehicle MM-1s twice tested Pfc. Fisher’s clothing and flak jacket: on March 2, 1991, one Fox vehicle crew tested his coveralls, and on March 4, 1991, two Fox crews working simultaneously examined the flak jacket.

The company commander of the Fox vehicle crews who analyzed Pfc. Fisher’s coveralls and flak jacket recalled these events. His platoon sergeant directed his MM-1 mobile mass spectrometer operator to attempt to get a contamination reading from Pfc. Fisher's Nomex jump suit.[47] After close to an hour of testing, the MM-1 operator got readings and was able to print a mass spectrum for an unusual blister agent (sesqui-mustard). The test took so long because of the high concentration of sweat, oil, and other petroleum based products in the suit. He said the MM-1 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 MM-1. Division Chemical was notified of the results of the testing.[48]

We have transcribed the Fox printout of the March 2, 1991, test of Pfc. Fisher’s coveralls; the transcription appears in Tab F. Although the company commander recalled his MM-1 operator printing a mass spectrum for sesqui-mustard, the tape does not show any initial alarms or spectrum for sesqui-mustard but only initial alarms for phosgene oxime, thiophosgene, lewisite, and S-mustard (sulfur mustard [HD] ). Of these agents, Iraq’s inventory contained only sulfur mustard agent.[49]

The 22nd Chemical Company MM-1 operator who tested Pfc. Fisher’s coveralls told us that analysis indicated the clothing contained sweat, oil, and a lewisite HQ/HD mixture. He said he cut sections off of his nomex coveralls and sent the samples up the chain to higher headquarters, then marked the site and buried the nomex coveralls. According to the operator, Headquarters called later and wanted additional readings from the nomex coveralls, but the coveralls had been buried and the agent on the samples had evaporated by then.[50]

The company commander received an order from division chemical to use another Fox vehicle to confirm the MM-1 readings from Pfc. Fisher’s coveralls. The coveralls were no longer available since they had been buried as contaminated waste, but the 22nd Chemical Company still had his flak jacket.

The company commander used two Fox vehicles to analyze the flak jacket[51] and reported both MM-1s alarmed for sesqui-mustard as well as faint readings of lewisite. Again, Iraq had neither of these chemical warfare agents in its inventory. In addition, distilled sulfur mustard is more volatile—quicker to vaporize—than sesqui-mustard; any alert for sesqui-mustard normally includes an alert for sulfur mustard. The company commander related they were unable to obtain a sesqui-mustard spectrum because the concentration of "Fat, Oil, Wax" was always higher than the concentration of sesqui-mustard. While the two Fox vehicles worked simultaneously, one of the vehicle commanders filmed this procedure, including the MM-1 screen, with his video camera.[52]

The videotape is the only record of a spectrum of a sample initially suspected to contain a chemical warfare agent. We have never located the printout tape from the Fox vehicle in which the videotape was made and none of the data on the surviving MM-1 printout tape from the other Fox vehicle indicates the presence of any chemical warfare agent known to be in Iraq’s inventory. However, the videotape of the MM-1 operator’s screen shows a spectrum indicating the presence of sulfur mustard.

After testing, the company commander put his own protective gear, Pfc. Fisher’s flak jacket, and a set of Fox sample wheels with which they had unsuccessfully attempted to extract agent from the flak jacket, into plastic trash bags and triple-bagged the articles. He then passed the bagged articles, along with three MM-1 printouts (from the March 2, 1991 coveralls test and the two March 4, 1991 flak jacket tests) to division chemical personnel who subsequently sent the three Fox printouts with the other bagged articles to the US Army Chemical Research, Development, and Engineering Center (CRDEC).[53]

Tab F shows a reproduction of the printout of the Fox’s coveralls test; Tab G shows one of the printouts from the March 4, 1991, flak jacket test. The second printout, the one produced by the MM-1 that was videotaped, was not available. According to the MM-1 operator who obtained the spectrum, he kept a copy of this printout after the war, but lost it in a household move before December 1993.[54, 55]

During our investigation, we transcribed the spectrum data shown on the videotape (Tab H) and gave it to spectrometry experts to examine. Although National Institute of Standards and Technology and U.S. Army Soldier and Biological Chemical Command (SBCCOM) subject matter experts initially thought mustard may have been present based on the videotaped spectrum,[56, 57] the Central Intelligence Agency (CIA) presented convincing evidence that a critical ion was missing from the spectrum, indicating mustard was not present on the flak jacket at the spot the MM-1 examined. Based on this new information, SBCCOM concluded the presence of mustard on the flak jacket was possible but improbable.[58]

2. Urinalysis

During Col. Dunn’s examination, Pfc. Fisher provided a urine sample, which was saved in preservative for later analysis for thiodiglycol, a mustard breakdown product.[59]

After Col. Dunn treated Pfc. Fisher, the VII Corps chemical officer drafted a message to ARCENT summarizing the incident. The message indicated, "A urine sample was taken from Pfc. Fisher and analyzed for thiodiglycol, a breakdown product of mustard. Per ARCENT Chemical, the specimen was tested positive."[60] This message caused some confusion because it refers to an in-theater urinalysis and states ARCENT Chemical indicated the specimen was positive. In 1999, the officer who drafted this message said he based the statement about a positive urinalysis on hearsay information he had received from ARCENT Chemical. He does not remember who specifically provided the information. Everything in his message was based on reports others provided to him at the time.[61]

The 3rd Armored Division’s assistant chemical officer drafted a memorandum for the record documenting this incident. The memorandum stated the division surgeon "confirmed that the urine test was positive."[62] In 1999 when asked the basis of this statement, the 3rd Armored Division division surgeon said he could not recall the source of the information, although he may have talked with Col. Dunn. He believed Colonel Dunn told him the urinalysis test was unreliable. The division surgeon also believed that it was discussed that although the test was positive, "it had breakdown products (possibly from POL [petroleum, oil, lubricant] supplies) that could have contaminated it."[63] Although the division surgeon recalled discussing a positive urinalysis in-theater, Col. Dunn stated he took only one urine sample from Pfc. Fisher, was not aware of anyone else conducting a urinalysis, and did not have any knowledge of any in-theater laboratory that would have had that capability.[64]

Col. Dunn took the urine sample back to the United States where the U.S. Army Medical Research Institute of Chemical Defense (USAMRICD), Aberdeen, Maryland, analyzed it with negative results for thiodiglycol.[65] In testimony to the Presidential Advisory Committee, Colonel Dunn reported:

• Later testing to confirm the exposure as mustard by analysis of clothing samples at an analytical laboratory in the United States was negative …. The urine sample I obtained showed no evidence of the mustard breakdown product, thiodiglycol, on analysis at my Institute’s laboratory [U.S. Army Medical Research Institute of Chemical Defense]. We expected this analysis to be negative as well, based on the low level of exposure.[66]

Col. Dunn also discussed the negative result in a 1995 interview in which he said, "I had my doubts at the time that I took the urine sample that it would come up positive because the level of exposure … was pretty mild, just four very small blisters."[67]

3. Photographs

Dr. DeClue, the senior medical officer, C Company, 45th Support Battalion, 3rd Armored Division, photographed Pfc. Fisher’s injuries during his examination. Figure 4 is Dr. DeClue’s photograph. Col. Dunn also photographed Pfc. Fisher’s blisters, shown as Figures 5 and 6. Pfc. Fisher’s blisters are apparent in these pictures. Although these photos by themselves do not identify the blisters’ source, they constitute a formal record of Pfc. Fisher’s injuries.

Figure 4. Pfc. blister injury - Dr. DeClue photo

Figure 5. Pfc. Fisher blister injury - Dr. Dunn photo 1

Figure 6.  Pfc. Fisher blister injury - Dr. Dunn photo 2

4. Chemical Research, Development and Engineering Center Tests of Coverall Cloth and Flak Jacket

The Fox company commander packaged his own protective gear (a Nomex shirt), Pfc. Fisher’s flak jacket, and other material after he and his team tested for contamination. A U.S. Army Technical Escort Unit team eventually transported this material to the Analytical Research Division of the Research Directorate at CRDEC for analysis on March 11, 1991. In addition to Pfc. Fisher’s flak jacket and the company commander’s Nomex zippered shirt (his protective gear), the package contained a piece of olive material marked "coveralls," a gauze pad that had covered Pfc. Fisher's blisters, Fox sampling wheels, a printout from the Fox vehicle, and an envelope with the printouts made during the March 2, 1991 coverall examination and the March 4, 1991 flak jacket test. While it is evident from this shipment’s inventory that the Fox printout tapes were sent to CRDEC, the final disposition of all these printout tapes is unknown today. After analyzing the company commander’s Nomex shirt, Pfc. Fisher’s flak jacket, the gauze that had covered Pfc. Fisher’s injury, and the material cut from his coveralls, CRDEC’s overall conclusion was "No evidence of any known CW [chemical warfare] agent or agent degradation product was found."[68]

1. Medical

At the time of the incident, Col. Dunn 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 eight 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. … It seems … likely that Private Fisher’s exposure occurred during bunker exploration….[69]

Later, in his testimony to the Presidential Advisory Committee on Gulf War Veterans’ Illnesses five years after the incident, 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. … 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 eight 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.[70]

We contacted an expert (a medical doctor) and asked him to review the circumstances surrounding Col. Dunn’s diagnosis. He read the original narrative and viewed electronic copies of the photographs of Pfc. Fisher’s blisters, which the original case narrative did not include. He concluded

• The differential diagnoses for this type of injury would include military vesicant exposure; primary irritant contact dermatitis; allergic contact dermatitis; contact urticaria syndrome; and, thermal burns.[71]

Based principally on Col. Dunn’s clinical presentation of the incident, this medical expert believed the diagnosis of chemical warfare agent exposure was the most consistent with the information he reviewed. He stated the inconclusive nature of the urinalysis and MM-1 tests did not detract from the strong clinical chronology suggestive of a mustard exposure. While other causes cannot be completely ruled out, the expert stated that Col. Dunn had suggested no likely candidates for further exploration. Taking all of this into consideration, including how the blisters appeared in the photographs, he concluded it is more likely than not, to a reasonable degree of medical certitude, Pfc. Fisher sustained an exposure to a sulfur or nitrogen mustard-type vesicant on March 1, 1991.[72]

2. MM-1 Mobile Mass Spectrometer

In 1993, a Chemical and Biological Defense Command[73] subject matter expert reviewed a copy of the MM-1 printout made during the Fox vehicle company commander’s test of Pfc. Fisher’s flak jacket. He reported the MM-1’s detections were at fairly high response levels and believed although the spectra taken did not verify the agent alarms, the high amount of oil and grease on the clothing may have prevented acquiring an actual spectrum for mustard chemical warfare agent. He concluded the incident was a mustard detection.[74]

He also reviewed the videotape and concluded it showed a spectrum verifying the alarm as HD (sulfur mustard).[75] Figure 7 [76] shows the spectrum data on the MM-1 screen as recorded on videotape. The MM-1 was in the surface monitor mode and had identified the blister agent, S-Mustard. "S-Mustard (HD)" is visible on the screen.

Figure 7.  MM-a screen showing spectrum for S-Mustard (HD)

In February 2000, we again asked this expert to review the videotape and ion relative intensity data we had extracted from it.[77] The analyst reviewed both and, believing the data showed the presence of sulfur mustard, stated:

• The video says S-Mustard [HD]. The correct mass ions are all there...[T]hree [ion] peaks fall in line for HD in the presence of Fats/Oil/Wax. ... [W]e still believe that HD was present at some time on the vest.[78]

After reviewing the videotape and associated ion relative intensity data, the CIA concluded mustard chemical warfare agent was not present on Pfc. Fisher’s flak jacket based on the absence of critical ions. They pointed out that several ions of medium-high intensity from a standard sulfur mustard spectrum are not present in the spectrum obtained from testing PFC Fisher’s flak jacket. For example, ion 59, ion 63, and ion 73 are missing. The absence of ions is a good indicator a target substance is not present. Of these missing ions, ion 63 is the most critical. Its presence is usually one-half to one-third the intensity of the most intense ion. Since ion 63 was not detected, the CIA concluded no detectable amount of mustard was found by the MM-1.[79]

1. Likelihood of Chemical Agents in the Area 

Is it reasonable to believe that a chemical warfare agent would be present in a bunker along the Iraq-Kuwait border?

The United States knew Saddam Hussein’s army had used chemical weapons in the Iran-Iraq war, knew his army had chemical weapons in its inventory in 1990, and expected to encounter these weapons on the battlefield.

In the underground bunker where he squeezed through a narrow doorway, PFC Fisher reported seeing ammunition—crates and many loose artillery projectiles in disarray, possibly due to earlier bombing.[80] PFC Fisher told one of the Fox vehicle commanders, "Everything inside the bunker looked like it had been deliberately messed up with broken items and everything in shambles."[81] However, he did not identify the munitions as chemical weapons and we found no evidence Iraq moved chemical weapons or chemical warfare agent into this area of the theater of operation.

In a 1995 interview,[82] Colonel Dunn speculated PFC Fisher might have encountered chemical warfare agent residue from weapons stored in bunkers (also called revetments) during the Iran-Iraq war because mustard is a very persistent agent. However, intelligence sources revealed the bunkers PFC Fisher’s unit searched were built in late 1990 after Iraq invaded Kuwait[83] and long after the Iran-Iraq war. Consequently, if PFC Fisher was exposed to liquid mustard while searching bunkers along the Iraq-Kuwait border, he encountered chemical warfare agent deployed in late 1990 or early 1991, not something left over from an earlier war.

However, in testimony to the Presidential Advisory Committee on Gulf War veterans’ Illnesses in July 1997, the Special Assistant to the Director of Central Intelligence for Persian Gulf War Illnesses Issues, discussed the possibility chemical weapons may have been present at 17 weapons storage sites along the Iraq-Kuwait border. He commented the CIA had assessed that Khamisiyah and An Nasiriyah were the only two sites within the Kuwait theater of operations where chemical weapons were stored during Desert Storm.[84] (PFC Fisher was never near either of these sites). The United Nations Special Commission echoed this testimony before the same committee. When asked if chemical weapons had been moved into Kuwait, the UN official, Charles Duelfer, stated, "We have seen no evidence of that and Iraqis have said that no movements took place…."[85]

During post-war munitions clearance operations in Kuwait, no chemical weapons were reported found in the US sector or indeed anywhere in Kuwait. According to the Defense Intelligence Agency, "During the three-year post-Gulf War ordnance clearing operations in Kuwait, chemical warfare agents were never detected."[86]

2. Location of Possible Chemical Exposure 

How confident are we regarding the location of the bunkers where PFC Fisher was possibly exposed to liquid mustard chemical warfare agent?

The bunkers PFC Fisher explored on March 1, 1991, are located approximately 100 miles south-southeast of the Khamisiyah-An Nasiriyah area. Based on the area covered by his unit’s search-and-destroy mission (80 square kilometers overlapping the Kuwait-Iraq border), it is possible they could have been in either Iraq or Kuwait, although reporting at the time of the incident consistently placed the suspected bunker on the Kuwait side of the border.

No one can pinpoint the exact location or time of PFC Fisher’s reported exposure to the chemical that caused his blisters. By his own estimate, PFC Fisher investigated more than 30 bunkers during the three-day search-and-destroy mission.[87] Reconstructing the details of the mission’s activities with Colonel Dunn after his diagnosis of exposure to a chemical warfare blister agent, the two narrowed the possibility to a bunker where PFC Fisher squeezed through tight passages, brushing against the bunker walls and doorways. Although PFC Fisher’s experience in that particular bunker seemed the most logical explanation for his exposure, it is simply his and the doctor’s best guess as to when and where the exposure could have occurred.

We have information about the two Fox vehicles sent to investigate the suspected bunker. A message from VII Corps to ARCENT indicated PFC Fisher was "OK…[and would] return to [the] scene to assist Foxes locate [the] site of possible chemical agent."[88] However, PFC Fisher did not accompany the Fox vehicles because higher headquarters wanted him available for Colonel Dunn’s examination.[89] The Fox vehicles reported they "found a bunker [with] traces of HD."[90] Because PFC Fisher was not with the Fox vehicles, we cannot be certain if they found the particular bunker he believed was the site of his exposure. Additionally, we have no confirming evidence, such as MM-1 printouts, about the Fox vehicle reports of HD in the suspect bunker.

3. Medical Expertise 

How well were the medical personnel trained regarding the identification and treatment of chemical warfare agent-related injuries?

Colonel Dunn’s credentials identify him as an expert in chemical warfare agent-related injuries. During Desert Shield/Desert Storm, Colonel Dunn was the US Central Command chemical casualty consultant, responsible for research and instructing US and allied physicians and medical personnel in chemical casualty care and medical protection against chemical warfare agents.

During peacetime, the Medical Research Institute of Chemical Defense conducts a Medical Management of Chemical Casualties Course at Aberdeen Proving Grounds, Maryland. The curriculum involves five days of classroom and field instruction on recognition and medical management of chemical casualties. The course trains medical personnel (doctors, nurses, physician’s assistants, clinical scientists, and senior enlisted medical specialists). When Operation Desert Shield started, the Institute increased its course instruction at Aberdeen and at posts in the United States and Europe for units identified as ones about to deploy to the Middle East. Colonel Dunn testified he was certain course graduates were assigned at every location where a US unit was stationed.[91] It is reasonable to believe all the medical personnel involved in this incident were adequately trained to recognize and correctly treat this type of injury.

4. Factors Affecting an Accurate Diagnosis 

Even with adequate training, could the medics and doctors who attended to PFC Fisher have made a hasty or incorrect diagnosis?

The medical personnel who examined and treated PFC Fisher did not rashly diagnose him as a chemical warfare agent casualty. During his first sick call visit, they apparently did not suspect his injuries might have been related to chemical warfare agent—"heater burn" was the first diagnosis. This changed on his second sick call visit; the medics eventually thought the blisters were characteristic of a chemical warfare agent exposure. At that point, they decontaminated PFC Fisher and called in an expert, Colonel Dunn, to confirm or refute their diagnosis. By this time, two medics, two physician’s assistants, and a medical doctor had seen PFC Fisher. Colonel Dunn concurred exposure to liquid mustard chemical warfare agent had caused PFC Fisher’s injury. Based on interviews with the medical personnel involved in this incident, it appears they made their diagnosis carefully and deliberately. The photographs provide a historical record of the injury but shed no light on its cause. Although they are insufficient to conduct a detailed analysis, they confirm the blisters’ existence.

5. Absence of Thiodiglycol 

Could the diagnosis have been incorrect, since the urinalysis was negative for thiodiglycol, a mustard breakdown product?

Colonel Dunn was not surprised by thiodiglycol’s absence in the urine. He believed PFC Fisher’s exposure was so mild that the lack of a mustard breakdown product was not surprising. In addition, more than 40 hours passed from the time of the possible exposure to the time PFC Fisher provided a urine sample. If PFC Fisher had been exposed to liquid mustard, he probably would have eliminated through urination any trace of thiodiglycol from his system during that period. Thus, the absence of physical evidence, i.e., thiodiglycol in his urine, does not imply PFC Fisher had not been exposed to liquid mustard.

6. Discrepancies in Test Results 

How do we account for the apparent positive results from the Fox tests completed in Iraq and the negative results for those completed at the Chemical Research, Development, and Engineering Center (CRDEC) in the US? Were the tests conducted properly?Two positive spectra for chemical warfare agent were reported: the MM-1 test of PFC Fisher’s coveralls and the two tests on his flak jacket. In the first case, the coveralls test printout conflicts with the Fox vehicle company commander’s recollection of the event. He recalled his MM-1 operator printed a spectrum for sesqui-mustard. The tape refutes this. No spectrum was obtained to provide high confidence of the presence of any of the chemical agents for which the MM-1 alarmed.

In the second case, while the company commander reported his Fox alerted for sesqui-mustard and lewisite on the flak jacket, the MM-1 spectrum did not indicate the presence of any type of chemical warfare agent, evident on the paper printout produced at the time (Tab G).[92] The second Fox, however, apparently obtained a spectrum for sulfur mustard. While a paper printout documenting this test is unavailable, the event was videotaped. According to the Fox Vehicle Program Management Office, the videotaped spectrum revealed that the presence of mustard on the flak jacket was only possible, but not probable. Data extracted and transcribed from the videotape showed the Fox spectrum did not contain a number of critical ions necessary to indicate mustard presence.

Finally, laboratory testing at CRDEC did not detect chemical warfare agent on either the flak jacket or the coverall swatch sent from Iraq.[93] However, it is possible the small amount of liquid mustard that might have been present on these articles dissipated through improper packaging or mishandling before CRDEC conducted the tests.

It is difficult to conclude whether Pfc. Fisher was exposed to chemical warfare agent residue while searching bunkers along the Iraq-Kuwait border on March 1, 1991. Among the strongest evidence supporting the conclusion he was exposed to a chemical warfare agent are statements from the well-trained medical personnel who diagnosed and treated his injury as mustard exposure. A subject matter expert in chemical warfare exposure as well as a medical doctor, Col. Dunn examined this injury contemporaneously and concurred with a diagnosis of chemical warfare agent injury. Although Col. Dunn stated something other than liquid mustard could have caused Pfc. Fisher’s injury (e.g., poison ivy, or some caustic chemical), he found no other cause present. In both his 1995 statements and 1999 interview, Col. Dunn stated that other causes could explain Pfc. Fisher’s blisters. But in both instances, he focused on the latent period between exposure and first appearance of symptoms as well as the absence of other common causes in the area. While Col. Dunn may not have found another cause to override his diagnosis, the nature of the injury leaves open the possibility of another cause. Also, the medical expert we contacted agreed with Col. Dunn’s diagnosis, noting that although additional causes were possible, given the latent period between exposure and symptom appearance, mustard agent was the likely cause of Pfc. Fisher’s blisters.

The nuclear, biological, chemical soldiers who tested Pfc Fisher’s coveralls and flak jacket with the Fox MM-1 remembered detecting sulfur mustard and sesqui-mustard. However, the surviving physical evidence, namely the MM-1 printout tapes from the coverall and flak jacket tests, does not agree with their recollections. Also, sesqui-mustard was not in Iraq’s inventory. Until recently, we believed one operator had obtained a spectrum providing a high degree of confidence of mustard’s presence on PFC Fisher’s flak jacket. We had based this conclusion on a review of the videotape because we were unable to find the paper tape printout of this spectrum. The videotape showing the operator’s screen during the MM-1 spectrometer analysis of a spot on the flak jacket indicated sulfur mustard presence, a known component of Iraq’s chemical warfare inventory; however, further review of this incident, particularly of the ion data from the videotape, casts doubt on the presence of mustard agent. The spectrum revealed the sample was missing critical ions necessary for mustard. Pfc Fisher’s reported exposure occurred 100 miles from Iraq’s nearest chemical warfare agent storage facility, according to the CIA and UNSCOM. The CIA and UNSCOM have reported no evidence Iraq moved any chemical warfare agents south of Khamisiyah. Consequently, we do not know where the mustard would have come from to cause this reported exposure.

The urinalysis failed to detect thiodiglycol, a mustard breakdown product. This result was inconsistent with the diagnosis, but, in Col. Dunn’s opinion, not unexpected because of the low level of exposure. Laboratory tests in the United States on the flak jacket and coverall swatch were negative for chemical warfare agent or any degradation byproducts.

Taking all the facts surrounding this incident into consideration, the medical diagnosis by trained doctors and the videotaped MM-1 operator’s screen of an apparent spectrum lead to the conclusion an exposure may have occurred. On the other hand, the analysis of the data extracted from the videotaped Fox spectrum showed critical ions were missing from the spectrum. In addition, other causes of blisters exist, we have no evidence of chemical weapons in that area of the Kuwait theater of operations, and laboratory testing in the United States failed to identify any chemical warfare agent or chemical warfare agent breakdown products on the flak jacket or coveralls material. Therefore, because of the conflicting evidence, we have reassessed this chemical warfare agent exposure incident as indeterminate.

This case still is being investigated. If additional information becomes available, we will incorporate it into a revised narrative. If you have records, photographs, or recollections or find errors in the details reported, please call 1-800-497-6261.

AD Armored Division

ARCENT U.S. Army Central Command

CBDCOM Chemical and Biological Defense Command

CIA Central Intelligence Agency

cm centimeter

CRDEC Chemical Research, Development, and Engineering Center

CW chemical warfare

CWA chemical warfare agent

DCI Director of Central Intelligence

DIA         Defense Intelligence Agency

DOD Department of Defense

MAJ major

NBC nuclear, biological, chemical

NCOIC non-commissioned official in charge

NIST National Institute of Standards and Technology

OSAGWI Office of the Special Assistant for Gulf War Illnesses

POL petroleum, oil, lubricants

SBCCOM Soldier and Biological Chemical Command

UNSCOM United Nations Special Commission

US  United States 

USA AMRICD U.S. Army Medical Research Institute of Chemical Defense

UTM Universal Transverse Mercator

Allergic

(Immunology) Pertaining to, caused by, affected with or of the nature of allergy.[94]

Blister agent

A blister agent is a chemical warfare agent that produces local irritation and damage to the skin and mucous membranes, pain and injury to the eyes, reddening and blistering of the skin, and when inhaled, damage to the respiratory tract. Blister agents include mustards, arsenicals like lewisite, and mustard and lewisite mixtures. Blister agents are also called vesicants or vesicant agents.[95, 96]

Chemical and Biological Defense Command (CBDCOM)

CBDCOM was a US Army command with a mission to provide research, development, and acquisition for nuclear, biological, chemical (NBC), and obscurant equipment for the US Forces; to act as the Army NBC defense commodity command; to provide management of joint service NBC defense material; to provide US chemical stockpile management and safe storage; to provide installation management; to prepare for and respond to chemical biological emergency events/accidents; provide weapons of mass destruction (chemical or biological) domestic preparedness support; to conduct emergency remediation/restoration actions at chemical sites; to provide successful planning, management, and execution of treaty responsibilities; and to provide demilitarization support. The Chemical and Biological Defense Command merged with the Soldier Support Command to form the US Army Soldier and Biological Chemical Command.[97]

Chemical warfare agent

 A CWA is a chemical substance excluding riot control agents, herbicides, smoke, and flame, used in military operations to kill, seriously injure, or incapacitate through its physiological effects. Included are blood, nerve, blister, choking, and incapacitating agents.[98]

Contact Dermatitis 

(Pathology) A type of immune-mediated inflammatory skin rash that results from an allergy to a particular substance (for example jewelry dermatitis, poison ivy, neomycin ointment, etc.).[99]

Dermatitis 

(Pathology) Inflammation of the skin.[100]

Distilled Sulfur Mustard

 A blister agent known as HD
Chemical name: Bis-(2-chloroethyl) sulfide[101]

Fox Nuclear, Biological, Chemical (NBC) Reconnaissance Vehicle

The Fox vehicle is a six-wheeled, light armored vehicle designed primarily for reconnaissance of liquid chemical warfare agent hazards. On-board chemical warfare agent detection capabilities include the MM-1 mobile mass spectrometer, which is the primary detection device, the M43A1 chemical agent detector, which is an integral component of the M8 alarm system, and the M256A1 chemical agent detector kit. The Fox is also equipped with two radiation detectors. The Fox does not provide any biological warfare agent detection capability, but it does protect the crew from biological hazards, and it allows the crew to mark areas of potential hazard and safely take samples for laboratories to analyze for biological hazards.[102]

H-series blister agents 

A series of persistent blister agents that includes levinstein (sulfur) mustards (H), distilled sulfur mustard (HD), nitrogen mustards (HN), a mustard-lewisite mixture (HL), a mustard T mixture (HT), a sulfur-mustard/sesqui-mustard mixture (HQ), and sesqui-mustard (Q)[103, 104]

HD

• A blister agent known as distilled sulfur mustard
• Chemical name: Bis-(2-chloroethyl) sulfide[105]

HQ 

• A blister agent mixture of sulfur-mustard or distilled sulfur mustard and sesqui-mustard
• Chemical names:
  • HD: Bis-(2-chloroethyl) sulfide
  • Q: 1,2-Bis (2-chloroethylthio) ethane[106]

HT

• A blister agent known as mustard-t mixture
• Chemical name:
  • HDs: Bis-(2-chloroethyl) sulfide
  • T: Bis [2(2-chloroethylthio) ethyl] ether[107]

Irritant 

This refers to any substance that causes inflammation following immediate, prolonged, or repeated contact with skin or mucous membranes.[108]

L

• A blister agent known as lewisite
• Chemical Name: Dichloro-(2-chlorovinyl)arsine[109]

MM-1 mobile mass spectrometer

The MM-1 mobile mass spectrometer is the primary chemical warfare agent detector in the Fox reconnaissance vehicle. During Operation Desert Storm, the MM-1 monitored against a target list of approximately ten selected chemical warfare agents most likely to be present, based on intelligence reports of the suspected chemical warfare agent threat. To speed the initial search, the sampling probe operates at 180� C and the MM-1 looks for only four ion peaks of each detected chemical warfare agent and attempts to match the target list of chemicals against the pattern and ratio of these peaks. If an initial match is made with these four ion peaks at a pre-determined intensity and relationship, the MM-1 sounds an alarm. However, this first alarm does not confirm the presence of a chemical warfare agent, since there are many chemicals that have similar ion peaks and many combinations of chemicals that may yield ion patterns similar to those in the target list. Consequently, the MM-1 can falsely indicate the presence of dangerous chemical warfare agents. To more conclusively determine what chemical is present, the operator must lower the sampling probe temperature to 120� C, re-acquire a sample of the suspected substance, and run a spectrum analysis with the MM-1 against all the detection algorithms stored in the MM-1 chemical library. For more detailed analysis later, the complete ion spectrum of the suspected sample can be printed on a paper tape.[110]

Q

A blister agent, known as sesqui-mustard, Q is a more effective chemical warfare vesicant than sulfur mustard. It produces symptoms consistent with blister type agents, with about five times stronger skin activity than distilled mustard (HD). The fact that it is in solid form at room temperature with a very low vapor pressure hinders its effective use as a chemical warfare agent. Combining sesqui-mustard (Q) with distilled mustard (HD) to form sulfur-mustard/sesqui-mustard (HQ) helps to eliminate this problem.

Chemical names:

• Ethylene-Bis-(2-Chloroethylthio) sulfide or
• 1,2-Bis (2-chloroethylthio) ethane[111]

Soldier and Biological Chemical Command (SBCCOM)

Headquartered at Aberdeen Proving Ground, Maryland, SBCCOM has a broad research, development and acquisition mission to ensure the decisive edge and maximum protection for the United States. SBCCOM develops, acquires, and sustains soldier, soldier support, and nuclear, biological, and chemical defense technology, systems, and services. SBCCOM also provides for safe storage, treaty compliance, and destruction of chemical materiel.[112]

Syndrome 

A set of signs or series of events occurring together that often point to a single disease or condition as the cause. [113]

Universal Transverse Mercator Grid (UTM)

UTM is a coordinate system used for creating maps. The UTM system projects a series of intersecting grid lines on the Earth's surface, extending from 84 degrees north to 80 degrees south latitudes. Also called UTM Grid.[114]

Urticaria 

(Dermatology) A transient condition of the skin, usually caused by an allergic reaction, characterized by pale or reddened irregular, elevated patches and severe itching, hives.[115]

Vesicant 

(Chemistry, Pharmacology) Refers to a chemical or agent that causes blisters. [116]

• U.S. Central Command 
• U.S. Army Central Command 
• VII Corps 
• 3rd Armored Division, VII Corps
• 2nd Brigade, 3rd Armored Division, VII Corps 
• 4th Battalion, 8th Cavalry (4-8th Cav), 2nd Brigade, 3rd Armored Division
• Fox reconnaissance vehicle crews, 22nd Chemical Company 
• C Company, 45th Support Battalion, 3rd Armored Division 
• 227th Aviation Regiment

3rd Armored Division Battle Control Center Journal Entry, Subject: "Release of Commander’s Report of Chemical Casualty," 06:15 AM, March 5, 1991.

3rd Armored Division fact sheet, Subject: "Chemical Casualty occurring during ‘Bunker Search and Destroy Mission’ within the 3AD Area of Operation," undated. 3rd Armored Division memorandum for the commanding general, Subject:

"Significant Events for 3AD Following the Cease-fire," April 4, 1991.

3rd Armored Division message, Subject: "Chem Casualty Update," 6:15 AM, March 3, 1991.

3rd Armored Division NBC-4 Report, 3:20 PM, February [sic] 3, 1991.

3rd Armored Division Spot Report, Subject: "Chem Casualty," 8:55 PM, March 13 [sic], 1991.

3rd Armored Division Spot Report, Subject: "NBC-4 Report," 9:30 AM, March 3, 1991.

VII Corps Battle Control Center Journal Entry, Subject: "Chem. Cas Evidence Pickup at 3 AD," 07:10 PM, March 5, 1991.

VII Corps Battle Control Center Journal Entry, Subject: "Chem. Casualty in 3 AD," 12:00 PM, March 3, 1991.

VII Corps Battle Control Center Journal Entry, Subject: "Chem Casualty Update," 11:21 AM, March 3, 1991.

VII Corps Battle Control Center Journal Entry, Subject: "Chemical Casualty Follow-Up," 5:15 AM, March 3, 1991.

VII Corps Battle Control Center Journal Entry, Subject: "Chemical Casualty Guidance from CENTCOM," 6:05 AM, March 3, 1991.

VII Corps Battle Control Center Journal Entry, Subject: "Chemical Casualty Update #3," 6:10 AM, March 3, 1991.

VII Corps Battle Control Center Journal Entry, Subject: "Confirmed Chemical Casualty," 2:45 AM, March 3, 1991.

VII Corps Battle Control Center Journal Entry, Subject: "Msg from CENTCOM CINC," 11:10 PM, March 4, 1991.

VII Corps Battle Control Center Journal Entry, Subject: "Pick Up Contaminated Garments 3AD," 05:15 AM, March 5, 1991.

VII Corps Battle Control Center Journal Entry, Subject: "Ref. Material on HQ & Fox Tapes," 09:00 AM, February [sic] 3, 1991.

VII Corps Battle Control Center Journal Entry, Subject: "Strike Serial for Contaminated Site," 1:45 PM, March 3, 1991.

VII Corps Casualty Management Team, "Operation Desert Shield/Desert Storm, Briefing Information," March 23, 1991.

VII Corps Command Chemical Report (extract), undated.

VII Corps, Desert Shield/Desert Storm After Action Report, Enclosure A (Main) to Appendix 2 (Daily Log Summary) to Tab H (NBC Operations).

VII Corps, Desert Shield/Desert Storm After Action Report Extracts, March 1-6, 1991.

VII Corps message, Subject: "Chemical Casualty Update," undated.

XVIII Airborne Corps message, Subject: "Captured Chemical and Biological Munitions," 270845Z Feb 91.

XVIII Airborne Corps message, Subject: "Commander’s Guidance for Disposition of Captured Chemical and Biological Munitions," 090442Z Mar 91.

XVIII Airborne Corps message, Subject: "Suspected Chemical Agent Contamination," 031015Z Feb 91.

ARCENT Conversation Record, Subject: "Possible Chemical Casualty in ARCENT Area," 4:12 AM, March 3, 1991.

ARCENT Spot Report, Subject: "Chemical Casualty," 2:45 AM, March 3, 1991.

ARCENT Spot Report, Subject: "Confirmed Chemical Casualty per [name redacted]," undated.

ARCENT Spot Report, Subject: "Large Cache of Suspected Chemical Munitions - 152mm w/Skull & Crossbones," 12:45 PM, March 7, 1991.

ARCENT Telephone or Verbal Conversation Record, Subject: "Blister Agent Casualty," 9:50 PM, March 3, 1991.

ARCENT Telephone or Verbal Conversation Record, Subject: "(Update) Possible Blister Casualty in 3AD Sector," 5:40 AM, March 3, 1991.

Central Intelligence Agency, Information Report, Subject: "CW Requirements Response," March 1991.

Central Intelligence Agency, Memorandum, Subject:  "Comments on Reported Mustard Exposure Operation Desert Storm Case Narrative (U)," (SECRET) April 14, 2000.

Chemical and Biological Defense Command, e-mail message, Subject: "[name redacted]: Response to Action 3 --- From CPT [name redacted], OSD, 02 Dec 93 14:32," December 7, 1993 @ 1659.

Chemical and Biological Defense Command, mission statement, web site www.sbccom.army.mil/hooah/pubs/cbdcom98.pdf (as of September 2, 1999).

"Convention on the Prohibition of the Development, Production, Stockpiling, and Use of Chemical Weapons and on Their Destruction," April 29, 1997.

Defense Intelligence Agency, e-mail message, Subject: "Gulf War Illness," November 11, 1999 @ 9:42 AM.

Defense Intelligence Agency, Intelligence Information Report 7-717-0082-97, "Iraqi Ordnance Clean-up Operations in Kuwait (U),"  June 1997.

Defense Intelligence Agency message, Subject: "Response to RII 2093, Location of All Iraqi CW/BW Contamination Sites and Ammo Storage Areas in the KTO (U)," 071120Z Feb 91.

Department of the Army, Headquarters, 3rd Armored Division (Spearhead), Operation Desert Storm, APO NY 09760-1000, Permanent Order 28-16, March 28, 1991.

Department of Defense, Joint Publication 1-02, "Dictionary of Military Terms," April 6, 1999, web site www.dtic.mil/doctrine/jel/doddict/data/u/06599.html (as of November 4, 1999).

Dunn, Colonel Michael A., Information Paper, Subject: "Chemical Agent Exposure Operation Desert Storm," March 5, 1991.

General Accounting Office, Report to the House of Representatives, Committee on Veterans Affairs, "Gulf War Illnesses; Procedural and Reporting Improvements Are Needed in DOD’s Investigative Processes," February 1999.

Handbook for the Investigation of Allegations of the Use of Chemical or Biological Weapons, Department of External Affairs, Department of National Defence, Health and Welfare Canada, and Agriculture Canada, November 1985.

Interview of Colonel Dunn for "60 Minutes," March 1, 1995.

Lead Sheet 402, Interview of US Army Medical Research Institute of Chemical Defense pulmonary specialist, December 11, 1995.

Lead Sheet 585, Interview of Private First Class David Allen Fisher, March 6, 1996.

Lead Sheet 1051, Interview of corps tactical operations officer, VII Corps, October 16, 1996.

Lead Sheet 7834, Interview of chemical officer, 513th Military Intelligence Brigade, December 3, 1997.

Lead Sheet 7921, Interview of battalion S2, 4th Battalion, 18th Regiment, 3rd Armored Division, April 7, 1997.

Lead Sheet 8775, Interview of nuclear-biological-chemical reconnaissance specialist, 22nd Chemical Company, 3rd Armored Division, November 29, 1996.

Lead Sheet 9008, Interview of brigade chemical officer,4-8th Cavalry, 2nd Brigade, 3rd Armored Division, November 25, 1996.

Lead Sheet 10674, Interview of brigade commander, 2nd Brigade, 3rd Armored Division, April 21, 1997.

Lead Sheet 10903, Interview of Fox vehicle company commander, 22nd Chemical Company, May 7, 1997.

Lead Sheet 10905, Interview of Fox vehicle company commander, 22nd Chemical Company, June 6, 1997.

Lead Sheet 10906, Interview of Fox vehicle crew member, May 7, 1997.

Lead Sheet 10907, Interview of Fox MM-1 operator, 22nd Chemical Company, May 7, 1997.

Lead Sheet 11121, Interview of Private First Class David A. Fisher, May 29, 1997.

Lead Sheet 11123, Interview of aviation logistician, 9th Battalion, 227th Aviation Regiment, October 20, 1999.

Lead Sheet 11124, Interview of Fox MM-1 operator, 22nd Chemical Company, May 29, 1997.

Lead Sheet 11125, Interview of Fox vehicle commander, 22nd Chemical Company, August 13, 1998.

Lead Sheet 11127, Interview of Fox MM-1 operator, 22nd Chemical Company, May 29, 1997.

Lead Sheet 13383, Interview of surgical physician’s assistant, 4-8th Cavalry, 3rd Armored Division, May 21, 1998.

Lead Sheet 13735, Interview of MM-1 operator, 22nd Chemical Company, August 20, 1999.

Lead Sheet 13991, Interview of Fox vehicle crew member, December 24, 1997.

Lead Sheet 14025, Interview of chief, US Army Medical Research Institute of Chemical Defense, January 5, 1998.

Lead Sheet 14074, Interview of assistant NCOIC, 4-8 th Aid Station, August 3, 1999.

Lead Sheet 14358, Interview of physician’s assistant, 4-8th Cavalry, 3rd Armored Division, February 5, 1998.

Lead Sheet 14979, Interview of chief medical officer, 45th Support Battalion, 3rd Armored Division, February 10, 1998.

Lead Sheet 16879, Interview of division chemical officer, 3rd Armored Division, August 24, 1999.

Lead Sheet 17491, Interview of Fox vehicle crew member, June 25, 1998.

Lead Sheet 17496, Interview of Fox vehicle crew member, June 25, 1998.

Lead Sheet 17949, Statement by Charles Duelfer, United Nations Special Commission official, at Presidential Advisory Committee, July 29, 1997.

Lead Sheet 18491, Interview of dermatologist, US Army Medical Research Institute of Chemical Defense, August 12, 1998.

Lead Sheet 18558, Interview of Fox vehicle crew member, August 13, 1998.

Lead Sheet 18569, Interview of Fox vehicle crew member, August 13, 1998.

Lead Sheet 18570, Interview of Fox vehicle crew member, August 13, 1998.

Lead Sheet 18580, Interview of MM-1 operator, 22nd Chemical Company, August 14, 1998.

Lead Sheet 18585, Interview of US Army Medical Research Institute of Chemical Defense pulmonary specialist, August 17, 1998.

Lead Sheet 21670, Interview of division surgeon, 3rd Armored Division, August 6, 1999.

Lead Sheet 22711, Interview of brigade chemical officer,2nd Brigade, 3rd Armored Division, April 26, 1999.

Lead Sheet 22840, Interview of medic,4-7th Cavalry, 3rd Armored Division, April 29, 1999.

Lead Sheet 23181, Meeting with Fox subject matter experts, May 6, 1999.

Lead Sheet 24533, Interview of NBC officer, 3rd Armored Division, July 29, 1999.

Lead Sheet 24537, Interview of Fox vehicle crew member, July 30, 1999.

Lead Sheet 24550, Interview of medic,4-8th Cavalry, 3rd Armored Division, August 3, 1999.

Lead Sheet 24552, Interview of chemical officer, 3rd Armored Division, August 3, 1999.

Lead Sheet 24553, Interview of dermatologist, US Army Medical Research Institute of Chemical Defense, August 3, 1999.

Lead Sheet 24761, Interview of NCO, 4-8th Cavalry, 3rd Armored Division, August 27, 1999.

Lead Sheet 24761, Interview of battalion commander, 4-8th Cavalry, 3rd Armored Division, August 6, 1999.

Lead Sheet 24842, Interview of platoon sergeant, 4-8th Cavalry, 3rd Armored Division, September 24, 1999.

Lead Sheet 24873, Interview of battalion executive officer, 4-8th Cavalry, 3rd Armored Division, September 20, 1999.

Lead Sheet 24906, Interview of service member, 4-8th Cavalry, 3rd Armored Division, September 28, 1999.

Lead Sheet 24923, Interview of operations officer, 4-8th Cavalry, 3rd Armored Division, September 30, 1999.

Lead Sheet 25122, Interview of service member, 4-8th Cavalry, 3rd Armored Division, October 25, 1999.

Lead Sheet 25153, Interview of service member, 4-8th Cavalry, 3rd Armored Division, October 27, 1999.

Lead Sheet 27004, Interview of chemical officer, 3rd Armored Division, June 5, 2000.

Letter from National Institute of Standards and Technology fellow, Mass Spectrometry Data Center, Physical and Chemical Properties Division, April 16, 2000.

Memorandum for Record, 3rd Armored Division, Subject: "Chemical Casualty Occurring During ‘Bunker Search and Equipment Destruction Mission’ Within the 3AD Area of Operation," June 10, 1991.

Memorandum for Record, US Army Chemical Research, Development and Engineering Center, Subject: "Analysis/Evaluation of Clothing and Gauze Samples," March 1991.

Memorandum from assistant chief of staff, G3, Headquarters XVIII Airborne Corps, Subject: "Chemical Casualty Care," January 1, 1991.

Memorandum from Chemist, Applied Pharmacology Branch, US Army Medical Research Institute of Chemical Defense, Subject: "Documentation on Analysis of Persian Gulf War Samples by US Army Medical Research Institute of Chemical Defense (USAMRICD)," March 3, 1995.

Memorandum from medical subject matter expert, Subject: "Expert Report on Potential Exposure of PFC David A. Fisher," May 4, 2000.

Memorandum from US Army Intelligence Center, Combat Support Branch, Subject "MM1 Chemical Agent Detector Printout," December 15, 1993.

Memorandum from US Army Office of the Project Manager for NBC Defense Systems, Subject: "Review of Case Narrative (draft) - Reported Mustard Exposure Operation Desert Storm - Final Report," May 23, 2000.

"Methodology and Instrumentation for Sampling and Analysis in the Verification of Chemical Disarmament," The Ministry for Foreign Affairs of Finland, Helsinki, Finland, 1985.

Office of the Secretary of Defense memorandum, Subject: "Information on the Fox MM-1 Mass Spectrometer and Gulf War CW Detection Reports," December1993.

On-Line Medical Dictionary web site www.graylab.ac.uk/cgi-bin/omd (as of August 25, 2000).

Soldier and Biological Chemical Command, e-mail message, Subject: "Question about video of MM-1," February 23, 2000 at 1807.

Soldier and Biological Chemical Command mission statement, web site www.sbccom.army.mil/about/mission.htm (as of September 2, 1999).

Special Assistant for Gulf War Illnesses, Interview of Colonel Michael A. Dunn, M.D., July 13, 1999.

Special Assistant for Gulf War Illnesses, transcript, Subject: "Discussion concerning the Fox MM-1 spectrum associated with the Reported Mustard Exposure, Operation Desert Storm," April 26, 2000.

Special Assistant for Gulf War Illnesses, "The Fox NBC Reconnaissance Vehicle" (Information Paper), July 29, 1997.

Special Assistant for Gulf War Illnesses, "Reported Mustard Agent Exposure Operation Desert Storm" (Case Narrative), August 27, 1997.

Testimony of Colonel Michael Dunn before the Presidential Advisory Committee on Gulf War Veterans’ Illnesses, April 16, 1996.

Testimony of Richard Vigus, Chemical and Biological Defense Command, Fox subject matter expert, before the Presidential Advisory Committee on Gulf War Veterans' Illnesses, May 7, 1997.

Testimony of Robert D Walpole, Special Assistant to the Director, Central Intelligence, for Persian Gulf War Illnesses Issues, Central Intelligence Agency, to the Presidential Advisory Committee on Gulf War Veterans’ Illnesses, July 29-30, 1997.

United Nations, Department of Public Information, The United Nations and the Iraq-Kuwait Conflict, 1990-1996, New York, New York: United Nations Publication, 1996.

US Army Chemical Center, CW Procedural Text for Chemical Corps Field Laboratories, Book 1, Part I, "Chemistry of CW Agents," January 7, 1954.

US Army Chemical Research, Development and Engineering Center chronology, Subject: "FLACK [sic] Jacket - NOMEX Shirt Segment Samples," December 20, 1993.

US Army Chemical Research, Development and Engineering Center message, Subject: "Acknowledgement of Samples Message/Results of Analysis," 181631Z Mar 91.

US Army Field Manual 3-4, US Marine Corps Fleet Marine Force Manual 11-9, "NBC Protection," February 21, 1996.

US Army Field Manual 3-9, US Navy Publication P-467, US Air Force Manual 355-7, "Potential Military Chemical/Biological Agents and Compounds," December 12, 1990.

US Army Field Manual 3-101-2, "NBC Reconnaissance Squad/Platoon (FOX) Operations - Tactics, Techniques, and Procedures," August 10, 1994.

US Army Field Manual 8-285, US Navy Medical Publication P-5041, US Air Force Joint Manual 44-149, US Marine Corps Fleet Marine Manual 11-11, "Treatment of Chemical Agent and Conventional Military Chemical Injuries," December 22, 1995.

US Army Field Manual 19-20, "Law Enforcement Investigations," November 25, 1985.

US Army Material Safety Data Sheet on HQ Mustard, Aberdeen Proving Ground, MD, June 30, 1995.

US Army Technical Manual 3-6665-342-10, "Operator’s Manual, Nuclear-Biological-Chemical Reconnaissance Systems (NBCRS), Fox XM93," Change 2, April 21, 1995.

US Central Command Public Affairs Officer Q & A sheet, Subject:  "Response to Queries:  Mustard Agent Exposure," March 1991.

US Central Command Telephone or Verbal Conversation Record, Subject:   "Blister Agent Casualty," 9:40 PM, March 3, 1991.

Verification Methods, Handling, and Assessment of Unusual Events in Relation to Allegations of the Use of Novel Chemical Warfare Agents, Consultant University of Saskatchewan in conjunction with the Verification Research Unit of External Affairs and International Trade Canada, March 1990.

The Department of Defense requires a common framework for our investigations and assessments of chemical warfare agent reports, so we turned to the United Nations and the international community, which had chemical weapons experience (e.g., the United Nations’ investigation of the chemical weapons used during the 1980-88 Iran-Iraq war). Because the modern battlefield is complex, the international community developed investigation and validation protocols[117] to provide objective procedures for possible chemical weapons incidents. The methodology we are using is based on these international protocols and guidelines. The methodology includes:

• 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;
• The testimony of witnesses;
• Multiple analyses; and
• A review of the evidence by an expert panel.

While the methodology used to investigate chemical incidents (Figure 8) 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 often was not collected at the time of an event. Therefore, we cannot apply a rigid template to all incidents, and each investigation must be tailored to its unique circumstances. Accordingly, we designed our methodology to provide a thorough, investigative process to define the circumstances of each incident and determine what happened. The major efforts in our methodology are:

• To substantiate the incident;
• To document available medical reports related to the incident;
• To interview appropriate people;
• To obtain information available to external organizations; and
• To assess the results.

A case usually starts with a report of a possible chemical warfare agent incident, often from a veteran. 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.

Alarms alone are not considered to be certain evidence of chemical warfare agent presence, nor is a single observation sufficient to validate a chemical warfare agent presence. The investigator looks for physical evidence collected at the time of the incident that might indicate that chemical agents were present in the vicinity of the incident. Such evidence might include tissue samples, body fluid samples, clothing, environmental samples of soil or vegetation, weapons parts, and Fox MM-1 tapes with properly documented spectrums.

The investigator searches available medical records to determine if anyone was injured by the incident. Deaths, injuries, sicknesses, etc., near the time and location of an incident are noted and considered. Medical experts are asked to provide information about any alleged chemical warfare agent casualties.

Interviews of those involved in or near the incident (participants or witnesses) are conducted. First-hand witnesses provide valuable insight into the conditions surrounding the incident and the mind-set of those involved, and are particularly important if physical evidence is lacking. Nuclear, biological, and chemical officers or specialists trained in chemical 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 clinical registries of the Departments of Defense and Veterans Affairs which may provide data about the medical condition of those involved in the incident; and
• Agencies capable of computer modeling meteorological and source characterization data in cases where airborne dispersion of agent is suspected.

Once the investigation is complete, the investigator evaluates the available evidence in order to make a subjective assessment. The available evidence is often incomplete or contradictory and thus must be looked at in the total context of what is known about the incident being investigated. Physical evidence collected at the time of the incident, for example, can be of tremendous value to an investigation. Properly documented physical evidence would generally be given the greatest weight in any assessment. The testimony of witnesses and contemporaneous operational documentation is also significant when making an assessment. Testimony from witnesses who also happen to be subject matter experts is usually more meaningful than testimony from untrained observers. Typically, secondhand accounts are given less weight than witness testimony. When investigators are presented with conflicting witness testimony, they look for other pieces of information supporting the statements of the witnesses. Investigators evaluate the supporting information to determine how it corroborates any of the conflicting positions. Generally, such supporting information will fit into a pattern corroborating one of the conflicting accounts of the incident over the others. Where the bulk of corroborating evidence supports one witness more than another, that person's information would be considered more compelling.

Our assessments rely on the investigators’ evaluation of the available information for each investigation. Because we do not expect to always have conclusive evidence, we have developed an assessment scale (Figure 9) ranging from Definitely Not to Definitely, with intermediate assessments of Unlikely, Indeterminate, and Likely. The investigator will use this scale to make an assessment 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 9. 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.

The events surrounding the March 2, 1991, medical diagnosis of Pfc. Fisher’s blisters as an exposure to liquid mustard chemical warfare agent began on March 1, 1991. On that day, elements of Pfc. Fisher’s unit (4th Battalion, 8th Cavalry [4-8th Cav], 2nd Brigade, 3rd Armored Division) conducted a search-and-destroy mission in Iraq near the Kuwait border. The mission was to identify and mark enemy ordnance so demolitions personnel could later destroy it.[118] The mission ended at 5 p.m. and the unit returned to the platoon area.[119].

At 1 a.m., March 2, 1991, Pfc. Fisher awakened for guard duty and radio watch. He noticed redness on his upper left arm and believed it may have been a spider bite. From 3 a.m. to 4 a.m., Pfc. Fisher slept, awakening for "stand-to"[120] at 4 a.m.. He now had blisters on his upper left arm. He went to sick call at 8 a.m.; the medic diagnosed the blister as a possible heater burn and told Fisher to return to sick call in the afternoon.[121]

By 4 p.m., when Pfc. Fisher returned to sick call, he had additional blisters on his upper left arm. The medics examined his arm and suspected a chemical warfare injury.[122].

Between 5:18 and 7:41 p.m., Fox vehicle chemical personnel tested Pfc. Fisher’s coveralls. The MM-1 mobile mass spectrometer alarmed while testing the coveralls for phosgene oxime, thiophosgene, lewisite and sulfur mustard.[123,124] Since Iraq’s chemical warfare inventory did not contain these agents, the MM-1 operator did not obtain a spectrum for any of them.

Acting on the medics’ suspicions that a chemical warfare exposure caused Pfc. Fisher’s injury and the alarms for chemical warfare agents on his coveralls (albeit without a positive spectrum since these agents were not in Iraq’s inventory), the 3rd Armored Division reported a suspected chemical casualty to VII Corps headquarters at 2:45 a.m., March 3, 1991.[125]

Between 7:30 a.m. and noon, two Fox vehicles searched an area seven by ten kilometers around Universal Transverse Mercator (UTM) coordinates PU 995 047, the area where it was believed Pfc. Fisher had been exposed during the previous day’s search-and-destroy mission.[126] The intent was to locate and test the bunker in which they believed Pfc. Fisher had encountered mustard chemical warfare agent. Pfc. Fisher did not accompany this mission to assist in locating the suspected bunker because ARCENT directed him to wait for a special chemical medical casualty team to examine him.[127] At 9:15 a.m., one Fox vehicle alarmed for sulfur mustard (HD) and mustard-T mixture (HT) blister agent at a bunker located in the area where Pfc. Fisher’s unit had operated on March 1, 1991.[128, 129] The second Fox failed to detect the presence of any chemical warfare agent.[130]

At 11 a.m., March 3, 1991, Col. Michael Dunn, a doctor and medical expert in chemical warfare injuries, examined Pfc. Fisher. Col. Dunn concurred with the diagnosis of Maj. DeClue, a doctor with the 45th Support Battalion, who concluded Pfc. Fisher’s injury had resulted from exposure to chemical warfare agent. At this time, both Maj. DeClue and Col. Dunn photographed Pfc. Fisher’s blisters. Pfc. Fisher provided a urine sample to Col. Dunn for later analysis. Col. Dunn concluded Pfc. Fisher’s injury was caused by an exposure to liquid mustard chemical warfare agent.[131]

At 8:30 a.m., March 4, 1991, two Fox vehicles tested Pfc. Fisher’s flak jacket. One Fox vehicle’s test produced alarms for lewisite, sesqui-mustard, and thiophosgene.[132] Iraq’s chemical warfare inventory did not contain these agents; consequently, the MM-1 operator did not generate a spectrum to add confidence in the presence of any of these chemical warfare agents. The second Fox alarmed for similar chemical warfare agents and sulfur mustard. The second Fox’s MM-1 operator apparently produced a spectrum for sulfur mustard. The MM-1 printout tape of this test is unavailable; however, a crewmember videotaped this activity.[133]

The 3rd Armored Division had planned to return to the suspect bunker on March 4, 1991.[134] The Fox vehicle platoon leader intended to enter the suspect bunker in full protective gear and scrape samples from the bunker walls for testing. Twenty minutes before this operation was to start, the division’s commanding general canceled it. With hostilities over, the general did not believe the return to the bunker was worth the risk to his soldiers.[135]

Following convalescent leave, Pfc. Fisher returned to his unit in Germany.[136] He received a Purple Heart for his injury on March 28, 1991.[137]

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 Col. Dunn, the senior medical officer, Pfc. Fisher provided a urine sample. Col. Dunn took the urine sample back to the United States where the U.S. Army Medical Research Institute of Chemical Defense, Aberdeen, Maryland, analyzed it. The results of the urinalysis were negative for thiodiglycol. According to Col. 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 U.S. 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.

Following Presidential Special Oversight Board guidance, we further investigated this incident and rewrote the narrative with new information gathered since this paper’s original publication in August 1997. Changes from the previous version include:

• The location of the suspect bunker appears to be in Kuwait, not in Iraq as reported in the initial investigation.
• The bunkers were built after Iraq’s August 1990 invasion of Kuwait.
• We did not interview Col. Dunn during the original investigation of this incident. In writing the original narrative, we relied solely on Col. Dunn’s written account of the events surrounding his examination of Pfc. Fisher.  However, we did provide him a copy of the narrative to review before we published it, and he provided no comments about the findings. We subsequently interviewed him by telephone after we published the original narrative. For this narrative, we interviewed Col. Dunn in person. He maintained his original diagnosis was correct.
• We contacted and re-interviewed Pfc. Fisher.
• This paper refutes statements in the original narrative about a second urinalysis reportedly accomplished in-theater. This further investigation established Col. Dunn conducted the only urinalysis associated with this incident.
• This narrative includes photographs Maj. DeClue and Col. Dunn took of Pfc. Fisher’s blisters.
• This narrative includes a still photo taken from the videotape of the MM-1 screen showing a spectrum for distilled sulfur mustard (HD) during a Fox test for chemical warfare agent of Pfc. Fisher’s flak jacket.
• We located the MM-1 printout for the coveralls test and transcribed it for inclusion in this narrative in Tab F.
• We transcribed ion intensity data from the videotape showing the spectrum for sulfur mustard (HD) during the test of Pfc. Fisher’s flak jacket. Spectrometry experts examined this transcribed data and commented for this narrative. The transcribed data appears in Tab H.

1. Tab A lists acronyms, abbreviations, and glossary terms.
2. Special Assistant for Gulf War Illnesses, "Reported Mustard Agent Exposure Operation Desert Storm" (Case Narrative), August 27, 1997
3. Lead Sheet 11121, Interview of Private First Class David A. Fisher, May 29, 1997, p. 2-5. We provided a copy of this narrative to Private First Class Fisher and he had no comments.
4. Tab J lists major changes between this and the original narrative.
5. VII Corps message, Subject: "Chemical Casualty Update," undated, p. 1.
6. Tab E contains a detailed chronology of the events surrounding this incident.
7. VII Corps Casualty Management Team, "Operation Desert Shield/Desert Storm, Briefing Information," March 23, 1991.
8. VII Corps message, Subject: "Chemical Casualty Update," undated.
9. ARCENT Spot Report, Subject: "Chemical Casualty," 2:45 AM, March 3, 1991.
10.  ARCENT Telephone or Verbal Conversation Record, Subject: "(Update) Possible Blister Casualty in 3AD Sector," 5:40 AM, March 3, 1991.
11.  Lead Sheet 11121, Interview of Private First Class David A. Fisher, May 29, 1997.
12. ARCENT Telephone or Verbal Conversation Record, Subject: "(Update) Possible Blister Casualty in 3AD Sector," 5:40 AM, March 3, 1991.
13. VII Corps Battle Control Center Journal Entry, Subject: "Chemical Casualty Guidance from CENTCOM" 6:05 AM, March 3, 1991.
14. Tab A's glossary contains information on mustard agents.
15. ARCENT Telephone or Verbal Conversation Record, Subject: "Blister Agent Casualty," 9:50 PM, March 3, 1991.
16. VII Corps message, Subject: "Chemical Casualty Update," undated.
17. VII Corps, Desert Shield/Desert Storm After Action Report Extracts, March 1-6, 1991, p. 45.
18. VII Corps Battle Control Center Journal Entry, Subject: "Chem. Casualty in 3 AD," 12:00 PM, March 3, 1991.
19. Central Intelligence Agency, Information Report, Subject: "CW Requirements Response," March 1991, p. 2.
20. Lead Sheet 11123, Interview of aviation logistician, 9th Battalion, 227th Aviation Regiment, October 20, 1999.
21. Dunn, Colonel Michael A., Information Paper, Subject: "Chemical Agent Exposure Operation Desert Storm," March 5, 1991.
22. CW2 Ahmed and CW3 Widhalm were physician assistants.
23. Dunn, Colonel Michael A., Information Paper, Subject: "Chemical Agent Exposure Operation Desert Storm," March 5, 1991.
24. Lead Sheet 14358, Interview of physician's assistant, 4-8th Cavalry, 3rd Armored Division, February 5, 1998.
25. Lead Sheet 13383, Interview of surgical physician's assistant, 4-8th Cavalry, 3rd Armored Division, May 21, 1998.
26. Lead Sheet 14074, Interview of assistant NCOIC, 4-8th Aid Station, August 3, 1999.
27. Dunn, Colonel Michael A., Information Paper, Subject: "Chemical Agent Exposure Operation Desert Storm," March 5, 1991.
28. Lead Sheet 18585, Interview of US Army Medical Research Institute of Chemical Defense pulmonary specialist, August 17, 1998.
29. Testimony of Colonel Michael Dunn before the Presidential Advisory Committee on Gulf War Veterans' Illnesses, April 16, 1996, p. 3.
30. Dunn, Colonel Michael A., Information Paper, Subject: "Chemical Agent Exposure Operation Desert Storm," March 5, 1991.
31. Special Assistant for Gulf War Illnesses, Interview of Colonel Michael A. Dunn, M.D., July 13, 1999, p. 6.
32. Lead Sheet 585, Interview of Private First Class David Allen Fisher, March 6, 1996.
33. Dunn, Colonel Michael A., Information Paper, Subject: "Chemical Agent Exposure Operation Desert Storm," March 5, 1991.
34. Lead Sheet 585, Interview of Private First Class David Allen Fisher, March 6, 1996.
35. Dunn, Colonel Michael A., Information Paper, Subject: "Chemical Agent Exposure Operation Desert Storm," March 5, 1991.
36. Interview of Colonel Dunn for "60 Minutes," March 1, 1995, p. 2.
37. Special Assistant for Gulf War Illnesses, Interview of Colonel Michael A. Dunn, M.D., July 13, 1999, p. 5, 6.
38. Special Assistant for Gulf War Illnesses, Interview of Colonel Michael A. Dunn, M.D., July 13, 1999, p. 11, 13.
39. Lead Sheet 23181, Meeting with Fox subject matter experts, May 6, 1999, p. 1.
40. Ion intensity measures the amount of ions in a sample compound compared to the amount of ions in a background or normal air sample. The background sample is captured when the Fox MM-1 is started.
41. Special Assistant for Gulf War Illnesses, "The Fox NBC Reconnaissance Vehicle" (Information Paper), July 29, 1997.
42. Testimony of Richard Vigus, Chemical and Biological Defense Command, Fox subject matter expert, before the Presidential Advisory Committee on Gulf War Veterans' Illnesses, May 7, 1997.
43. Special Assistant for Gulf War Illnesses, "The Fox NBC Reconnaissance Vehicle" (Information Paper), July 29, 1997, web site www.gulflink.health.mil/foxnbc/ p. 5; US Army Field Manual 3-101-2, "NBC Reconnaissance Squad/Platoon (FOX) Operations - Tactics, Techniques, and Procedures," August 10, 1994, p. 5-2, 5-3; Lead Sheet 23181, Meeting with Fox subject matter experts, May 6, 1999, p. 1, 5.
44.  Lead Sheet 23181, Meeting with Fox subject matter experts, May 6, 1999, p. 2.
45. Special Assistant for Gulf War Illnesses, "The Fox NBC Reconnaissance Vehicle" (Information Paper), July 29, 1997.
46. Lead Sheet 23181, Meeting with Fox subject matter experts, May 6, 1999, p. 4.
47. This is the 5:18 to 7:41 PM entry for March 2, 1991 in Tab E (Chronology of Events) of this report.
48. Lead Sheet 10905, Interview of Fox vehicle company commander, 22nd Chemical Company, June 6, 1997.
49. United Nations, Department of Public Information, The United Nations and the Iraq-Kuwait Conflict, 1990-1996, New York, New York: United Nations Publication, 1996, p. 656-657.
50. Lead Sheet 13735, Interview of MM-1 operator, 22nd Chemical Company, August 20, 1999.
51. This is the 8:30 AM entry for March 4, 1991 in Tab E (Chronology of Events) of this report.
52. Lead Sheet 10905, Interview of Fox vehicle company commander, 22nd Chemical Company, June 6, 1997.
53. Memorandum for Record, US Army Chemical Research, Development and Engineering Center, Subject: "Analysis/Evaluation of Clothing and Gauze Samples," March 1991.
54. Lead Sheet 13735, Interview of MM-1 operator, 22nd Chemical Company, August 20, 1999.
55. Memorandum from US Army Intelligence Center, Combat Support Branch, Subject "MM1 Chemical Agent Detector Printout," December 15, 1993.
56. Letter from National Institute of Standards and Technology fellow, Mass Spectrometry Data Center, Physical and Chemical Properties Division, April 16, 2000.
57. Soldier and Biological Chemical Command, e-mail message, Subject: "Question about video of MM-1," February 23, 2000 at 1807.
58. Memorandum from US Army Office of the Project Manager for NBC Defense Systems, Subject: "Review of Case Narrative (draft) - Reported Mustard Exposure Operation Desert Storm - Final Report," May 23, 2000, p. 2.
59. Dunn, Colonel Michael A., Information Paper, Subject: "Chemical Agent Exposure Operation Desert Storm," March 5, 1991.
60.  VII Corps message, Subject: "Chemical Casualty Update," undated.
61. Lead Sheet 16879, Interview of division chemical officer, 3rd Armored Division, August 24, 1999.
62. Memorandum for Record, 3rd Armored Division, Subject: "Chemical Casualty Occurring During 'Bunker Search and Equipment Destruction Mission' Within the 3AD Area of Operation," June 10, 1991.
63. Lead Sheet 21670, Interview of division surgeon, 3rd Armored Division, August 6, 1999.
64. Special Assistant for Gulf War Illnesses, Interview of Colonel Michael A. Dunn, M.D., July 13, 1999, p. 7, 8.
65. Memorandum from Chemist, Applied Pharmacology Branch, US Army Medical Research Institute of Chemical Defense, Subject: "Documentation on Analysis of Persian Gulf War Samples by U.S. Army Medical Research Institute of Chemical Defense (USAMRICD)," March 3, 1995.
66. Testimony of Colonel Michael Dunn before the Presidential Advisory Committee on Gulf War Veterans' Illnesses, April 16, 1996.
67. Interview of Colonel Dunn for "60 Minutes," March 1, 1995, p. 5.
68. Memorandum for Record, US Army Chemical Research, Development and Engineering Center, Subject: "Analysis/Evaluation of Clothing and Gauze Samples," March 1991.
69. Dunn, Colonel Michael A., Information Paper, Subject: "Chemical Agent Exposure Operation Desert Storm," March 5, 1991.
70. Testimony of Colonel Michael Dunn before the Presidential Advisory Committee on Gulf War Veterans' Illnesses, April 16, 1996.
71. Memorandum from medical subject matter expert, Subject: "Expert Report on Potential Exposure of PFC David A. Fisher," May 4, 2000.
72. Memorandum from medical subject matter expert, Subject: "Expert Report on Potential Exposure of PFC David A. Fisher," May 4, 2000.
73. The Chemical and Biological Defense Command is now the US Army Soldier and Biological Chemical Command.
74. Chemical and Biological Defense Command, e-mail message, Subject: "[name redacted]: Response to Action 3 --- From CPT [name redacted], OSD, 02 Dec 93 14:32," December 7, 1993 @ 1659.
75. Chemical and Biological Defense Command, e-mail message, Subject: "[name redacted]: Response to Action 3 --- From CPT [name redacted], OSD, 02 Dec 93 14:32," December 7, 1993 @ 1659.
76. This image was extracted from the videotape made when Private First Class Fisher's flak jacket was tested on March 4, 1991.
77.  The Office of the Special Assistant for Gulf War Illnesses, the Central Intelligence Agency, the National Institute of Standards and Technology, and the US Army Chemical and Biological Defense Command reviewed the videotape. Tab H shows the ion relative intensity data each of these organizations extracted and when. Numbers on the chart with an "X" indicate the organization was unable to decipher the complete number while extracting the data.
78.  Soldier and Biological Chemical Command, e-mail message, Subject: "Question about video of MM-1," February 23, 2000 @ 1807.
79.  Central Intelligence Agency, Memorandum, Subject: Comments on Reported Mustard Exposure Operation Desert Storm Case Narrative (U), (SECRET) April 14, 2000, p.5.
80. Lead Sheet 585, Interview of Private First Class David Allen Fisher, March 6, 1996.
81. Lead Sheet 11125, Interview of Fox vehicle commander, 22nd Chemical Company, August 13, 1998.
82. Interview of Colonel Dunn for "60 Minutes," March 1, 1995, p. 3.
83. Defense Intelligence Agency, e-mail message, Subject: "Gulf War Illness," November 11, 1999 @ 9:42 AM.
84. Testimony of Robert D Walpole, Special Assistant to the Director, Central Intelligence, for Persian Gulf War Illnesses Issues, Central Intelligence Agency, to the Presidential Advisory Committee on Gulf War Veterans' Illnesses, July 29-30, 1997, p. 1.
85. Lead Sheet 17949, Statement by Charles Duelfer, United Nations Special Commission official, at Presidential Advisory Committee, July 29, 1997.
86.  Defense Intelligence Agency, Intelligence Information Report 7-717-0082-97, "Iraqi Ordnance Clean-up Operations in Kuwait (U),", June 1997.
87.  Lead Sheet 11121, Interview of Private First Class David A. Fisher, May 29, 1997.
88.  VII Corps Telephone or Verbal Conversation Record, Subject: "(Update) Possible Blister Casualty in 3AD Sector," 5:40 AM, March 3, 1991.
89.  VII Corps Battle Control Center Journal Entry, Subject: "Chemical Casualty Guidance from CENTCOM" 6:05 AM, March 3, 1991.
90.  VII Corps Battle Control Center Journal Entry, Subject: "Chem Casualty Update," 11:21 AM, March 3, 1991.
91.  Testimony of Colonel Michael Dunn before the Presidential Advisory Committee on Gulf War Veterans' Illnesses, April 16, 1996.
92.  The company commander failed to recall that his MM-1 also indicated the presence of thiophosgene, as shown on the transcribed printout at Tab G.
93.  Memorandum for Record, US Army Chemical Research, Development and Engineering Center, Subject: "Analysis/Evaluation of Clothing and Gauze Samples," March 1991.
94. On-Line Medical Dictionary, web site www.graylab.ac.uk/cgi-bin/omd (as of August 25, 2000).
95.  US Army Field Manual 8-285, US Navy Medical Publication P-5041, US Air Force Joint Manual 44-149, US Marine Corps Fleet Marine Force Manual 11-11, "Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries," Glossary, Section II, "Definitions and Terms," December 22, 1995, p. 4-5.
96.  US Army Material Safety Data Sheet on Mustard, HQ, Aberdeen Proving Ground, MD, June 30, 1995.
97. Chemical and Biological Defense Command, mission statement, web site www.sbccom.army.mil/hooah/pubs/cbdcom98.pdf (as of September 2, 1999).
98. US Army Field Manual 8-285, US Navy Medical Publication P-5041, US Air Force Joint Manual 44-149, US Marine Corps Fleet Marine Force Manual 11-11, "Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries," Glossary, Section II, "Definitions and Terms," December 22, 1995, p. 6.
99. On-Line Medical Dictionary, web site www.graylab.ac.uk/cgi-bin/omd (as of August 25, 2000).
100.  On-Line Medical Dictionary, web site www.graylab.ac.uk/cgi-bin/omd (as of August 25, 2000).
101.  US Army Field Manual 3-9, US Navy Publication P-467, US Air Force Manual 355-7, "Potential Military Chemical/Biological Agents and Compounds," December 12, 1990, Chapter 2, p. 31.
102. Special Assistant for Gulf War Illnesses, "The Fox NBC Reconnaissance Vehicle" (Information Paper), July 29, 1997, p. 3.
103. US Army Field Manual 3-9, US Navy Publication P-467, US Air Force Manual 355-7, "Potential Military Chemical/Biological Agents and Compounds," December 12, 1990, p. 30.
104. US Army Material Safety Data Sheet on Mustard, HQ, Aberdeen Proving Ground, MD, June 30, 1995.
105. US Army Field Manual 3-9, US Navy Publication P-467, US Air Force Manual 355-7, "Potential Military Chemical/Biological Agents and Compounds," December 12, 1990, chapter 2, p. 31.
106. US Army Material Safety Data Sheet on Mustard, HQ, Aberdeen Proving Ground, MD, June 30, 1995.
107. US Army Field Manual 3-9, US Navy Publication P-467, US Air Force Manual 355-7, "Potential Military Chemical/Biological Agents and Compounds," December 12, 1990, Chapter 2, p. 37-38.
108. On-Line Medical Dictionary, web site www.graylab.ac.uk/cgi-bin/omd (as of August 25, 2000).
109. US Army Field Manual 3-9, US Navy Publication P-467, US Air Force Manual 355-7, "Potential Military Chemical/Biological Agents and Compounds," December 12, 1990, Chapter 2, p. 38-39.
110. Special Assistant for Gulf War Illnesses, "The Fox NBC Reconnaissance Vehicle" (Information Paper), July 29, 1997, p. 2, 8-9, web site (as of Oct. 14, 1999).
111. US Army Chemical Center, CW Procedural Text for Chemical Corps Field Laboratories, Book 1, Part I, "Chemistry of CW Agents," January 7, 1954, p. 294; US Army Material Safety Data Sheet on Mustard, HQ, Aberdeen Proving Ground, MD, June 30, 1995.
112. Soldier and Biological Chemical Command mission statement, web site www.sbccom.army.mil/about/mission.htm (as of September 2, 1999).
113. On-Line Medical Dictionary, web site www.graylab.ac.uk/cgi-bin/omd (as of August 25, 2000).
114. Department of Defense, Joint Publication 1-02, "Dictionary of Military and Associated Terms," web site www.dtic.mil/doctrine/jel/doddict/data/u/06630.html (as of July 26, 2000).
115. On-Line Medical Dictionary, web site www.graylab.ac.uk/cgi-bin/omd (as of August 25, 2000).
116. On-Line Medical Dictionary, web site www.graylab.ac.uk/cgi-bin/omd (as of August 25, 2000).
117. "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 or acceded to by 106 states as of February 1998. It was signed by the United States on January 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. Other protocols and guidelines were found in Methodology and Instrumentation for Sampling and Analysis in the Verification of Chemical Disarmament, The Ministry for Foreign Affairs of Finland, Helsinki, Finland, 1985; Verification Methods, Handling, and Assessment Of Unusual Events In Relation To Allegations of the Use of Novel Chemical Warfare Agents, Consultant University of Saskatchewan in conjunction with the Verification Research Unit of External Affairs and International Trade Canada, March 1990; and Handbook for the Investigation of Allegations of the Use of Chemical or Biological Weapons, Department of External Affairs, Department of National Defence, Health and Welfare Canada, and Agriculture Canada, November 1985. US Army Field Manual 3-4, US Marine Corps Fleet Marine Force Manual 11-9, "NBC Protection," May 1992; US Army Field Manual 8-285, US Navy NAVMED P-5041, US Air Force Manual 44-149, US Marine Corps Fleet Marine Force Manual 11-11 (adopted as NATO Field Manual 8-285), "Treatment Of Chemical Agent Casualties and Conventional Military Chemical Injuries," December 22, 1995; US Army Field Manual 19-20, "Law Enforcement Investigations," November 25, 1985; and other DoD investigational procedures contributed ideas for developing this methodology.
118. VII Corps message, Subject: "Chemical Casualty Update," undated.
119. Dunn, Colonel Michael A., Information Paper, Subject: "Chemical Agent Exposure Operation Desert Storm," March 5, 1991.
120. "Stand-to," when soldiers take their defensive positions, occurs approximately one-half hour before daybreak. This defensive procedure is also used as an accountability formation.
121. Dunn, Colonel Michael A., Information Paper, Subject: "Chemical Agent Exposure Operation Desert Storm," March 5, 1991.
122. Dunn, Colonel Michael A., Information Paper, Subject: "Chemical Agent Exposure Operation Desert Storm," March 5, 1991.
123. The transcribed Fox test printout at Tab F provides the times and chemical agent alarms for the coveralls test.
124. VII Corps message, Subject: "Chemical Casualty Update," undated.
125. ARCENT Spot Report, Subject: "Chemical Casualty," 2:45 AM, March 3, 1991.
126. VII Corps message, Subject: "Chemical Casualty Update," undated.
127. VII Corps Battle Control Center Journal Entry, Subject: "Chemical Casualty Guidance from CENTCOM" 6:05 AM, March 3, 1991.
128. VII Corps message, Subject: "Chemical Casualty Update," undated.
129. VII Corps, Desert Shield/Desert Storm After Action Report, Enclosure A (Main) to Appendix 2 (Daily Log Summary) to Tab H (NBC Operations).
130. VII Corps, Desert Shield/Desert Storm After Action Report Extracts, March 1-6, 1991.
131. Dunn, Colonel Michael A., Information Paper, Subject: "Chemical Agent Exposure Operation Desert Storm," March 5, 1991.
132. See transcribed Fox test printout at Tab G.
133. Lead Sheet 10905, Interview of Fox vehicle company commander, 22nd Chemical Company, June 6, 1997.
134. VII Corps message, Subject: "Chemical Casualty Update," undated.
135. Lead Sheet 10905, Interview of Fox vehicle company commander, 22nd Chemical Company, June 6, 1997.
136. Lead Sheet 24842, Interview of platoon sergeant, 4-8th Cavalry, 3rd Armored Division, September 24, 1999.
137.  Department of the Army, Headquarters, 3rd Armored Division (Spearhead), Operation Desert Storm, APO NY 09760-1000, Permanent Order 28-16, March 28, 1991.
138. General Accounting Office, Report to the House of Representatives, Committee on Veterans Affairs, "Gulf War Illnesses; Procedural and Reporting Improvements Are Needed in DOD's Investigative Processes," February 1999, p. 25.
139. General Accounting Office, Report to the House of Representatives, Committee on Veterans Affairs, "Gulf War Illnesses; Procedural and Reporting Improvements Are Needed in DOD's Investigative Processes," February 1999, p. 25.
140. General Accounting Office, Report to the House of Representatives, Committee on Veterans Affairs, "Gulf War Illnesses; Procedural and Reporting Improvements Are Needed in DOD's Investigative Processes," February 1999, p. 26.