This Section contains several key lessons learned while investigating Kuwait’s oil well fires. These lessons learned do not reflect other governments’ or US departments’ or agencies’ opinions or positions. Where appropriate we have recommended courses of action to address or otherwise correct noted discrepancies or shortcomings.

A General Accounting Office report says that "DoD took reasonable steps to safeguard the health of US troops stationed in the Persian Gulf who were exposed to potentially dangerous smoke."^[222] Information developed during this investigation, however, has identified shortcomings (both discrete events and systemic deficiencies) in how DoD and the individual military Services responded to the oil well fires. This Section lists these findings and observations, and offers recommendations as applicable.

The formal military "Lessons Learned" process distinguishes between "system failures" and "individual failures" or deviations from established policies and procedures. While both types of failures are important to recognize and correct, the "system failures" are more significant, since they may require fundamental changes to current DoD policies and across the readiness domains of doctrine, organizations, training, materiel, and leadership development. OSAGWI’s Lessons Learned Implementation Division is working with the Services and Joint Staff Lessons Learned programs to identify and implement necessary corrective measures to better protect the health of deployed US personnel.

Our findings and observations apply to the following deployment health surveillance and protection functional areas:

• Health risk assessment;
• Medical readiness and force health protection;
• Environmental and occupational exposure surveillance;
• Risk management; and
• Information management.

Accordingly, these areas serve as the organizing framework for the observations, findings, and recommendations presented here.

Health risk assessment evaluates the risks from identified hazards using current intelligence from sources such as the Armed Forces Medical Intelligence Center (AFMIC). Once the probability of occurrence has been assigned (ranging from "frequent" to "unlikely"), the health risks (ranging from "extremely high" to "low") are determined in accordance with the operative DoD, Joint Staff, and Service risk management guidance.

Contrary to Intelligence estimates that Iraq had the resources to sabotage "only" 150 oil wells, the actual number was 4 to 5 times higher. The reasons for the lower estimate are unclear, since Saddam Hussein clearly had the motive and means to devastate Kuwait’s oil pumping infrastructure if it appeared that Coalition forces were going to eject Iraqi’s forces from Kuwait.

In addition, it does not appear that the appropriate agencies properly collected, evaluated, analyzed, or disseminated the available indications and warnings. Nor was any concerted effort apparently made to assess how such mass sabotage would affect friendly operations, or to formulate a coordinated health, safety, and environmental-occupational response.

FINDING: Operational and Medical Intelligence assessments underestimated Iraq’s preparations, capability, and intent to systematically sabotage Kuwait’s oil pumping infrastructure.

OBSERVATION: A myriad of DoD and Service offices, agencies, and authorities with preventive or occupational medicine roles and responsibilities issued various advisories regarding the potential health hazards presented by oil well fires. However, no coordinated, centrally managed effort was undertaken by the Unified, Component, or supporting commands, or their supporting medical readiness and preventive medicine centers, to:

1. Forecast the potential hazard from oil well smoke exposures of the magnitude encountered;
2. Determine a risk value, e.g., "low" or "moderate;"
3. Obtain baseline data by sampling and monitoring the environmental media (i.e., air, soil, and water) at the various locations where US forces were concentrated; and
4. In accordance with standing DoD, Joint Staff, and Service risk management policies and guidance:

• ensure that risk management information, including risk assessments and countermeasures, was properly collected, reported, and disseminated to the appropriate health, safety, and environmental authorities; or to
• ensure that these authorities advised tactical unit commanders and troops on the nature of the risk and appropriate countermeasures.

Medical surveillance is the collection of accurate, objective data relating to potential exposures, health risks, and health effects or clinical manifestations in the populations of concern (i.e., unit personnel).

A primary purpose of medical surveillance is to give operational commanders a means of recognizing risks and hazards to their personnel. Aside from concerns about individual servicemembers’ safety, health, and well-being, the requirement to prevent or minimize disease and non-battle injuries (DNBI) is an operational imperative. Thus, medical surveillance is a key component of a robust, responsive risk management program. Additionally, comprehensive medical surveillance data is essential for updating risk assessments, developing countermeasures, tailoring and improving the medical response, and collecting data for retrospective exposure investigations and analyses.

The difficulty in pinpointing the causes and effects of the undiagnosed symptoms reported by some Gulf War veterans made it clear that improvements were needed in the way the DoD and Services recognized and addressed potential health risks to deployed forces. These actions were absent in the Gulf War deployment:

• Continuous, real-time, or comprehensive medical and environmental surveillance;
• Systematic collection and reporting of medical or exposure events; and
• Central analysis and monitoring of such information and reports.

Such actions were directed, to varying degrees, by existing DoD and Service guidance, but implementing guidance or procedures, especially under operational conditions, did not ensure that such actions were actually performed. In addition, higher headquarters apparently did not have or did not use standard systems, procedures, and protocols to disseminate assessments and advisories to reporting units or to the field.

FINDING: The Gulf War highlighted shortcomings in the way the DoD identified, assessed, monitored, tracked, and recorded individual and population risk factors and exposures that could potentially lead to adverse health outcomes.

FINDING: DoD, Joint Staff, and Service policies, doctrine, and requirements concerning medical surveillance lacked uniformity, and did not adequately address deployment medical surveillance requirements (including the timely collection, reporting, processing, evaluation, dissemination, and archiving of essential data and information).

C. Risk Management

DoD Instruction 6055.1, "DoD Safety and Occupational Health (SOH) Program," (August 19, 1998) defines ‘risk management’ as:

The Department of Defense's principal structured risk reduction process to assist leaders in identifying and controlling safety and health hazards and making informed decisions. Risk management is a cyclical process that involves:

• Identifying hazards;
• Assessing hazards to personnel, equipment, and mission;
• Developing controls;
• Making risk decisions to eliminate all unnecessary risks. Determining which risks are acceptable and unacceptable from the standpoint of balancing benefit against the potential for accidental losses or harm (severity, likelihood of occurrence). The standard for risk management is leadership at the appropriate level of authority making an informed decision to either control hazards or accept risks. In those circumstances where local resources are not available to control residual risks, leaders will make a conscious decision to either accept the risk or elevate the risk decision to the next higher level of leadership;
• Implementing controls; and
• Supervising and evaluating the appropriateness of established controls and making adjustments where necessary.

The heart of risk management is making informed, appropriate risk decisions. In most cases Gulf War planners and decision-makers had little choice but to "accept" the risk of oil well smoke, due to the operational imperative of engaging and defeating Iraq’s military units, many of them deployed in or near the burning oilfields. In addition, the assessed risk appeared unlikely to produce a level of injury, illness, or mission degradation that would force a reassessment of friendly plans and operations. In effect, US health, safety, and environmental authorities had to focus on preventing needless exposures and mitigating unavoidable risks. Their options in doing so were limited, requiring these elements:

• Real-time monitoring and forecasting to assess the extent and severity of the hazard;
• Alerting medical caregivers;
• Implementing a medical, safety, and environmental alert system; and
• Developing recommendations for tactical commanders to institute protective measures among their personnel.

As stated, the deployed preventive medicine (PM) resources were insufficient to fully meet these requirements. The sampling effort, as noted, did not really get underway until March. At the operational unit level, there was no system to ensure that tactical commanders and their PM staffs received continuously-updated information regarding potential environmental hazards such as oil smoke, and recommended countermeasures. While unit PM staffs might have been aware of the risks presented by oil smoke, their ability to recommend protective measures was limited. Hazard avoidance was not always feasible, and beyond recommending the use of issue items such as goggles and cravats to cover their eyes and airways, there were few other countermeasures at the troops’ disposal. Surgical masks, when available, quickly became saturated and useless in heavy smoke environments. The chemical protective mask could not be recommended, because such usage would quickly degrade the efficiency of the filters and leave troops unprotected against chemical or biological warfare agents. Given these constraints, the range of protective measures that PM personnel could recommend was limited.

A key component of risk management is risk communication, intended to educate and inform personnel and leaders regarding about factors and give them the knowledge they need to prevent or minimize needless exposures. It appears that anticipatory guidance was not widely (or centrally) disseminated, and that risk communication channels and content were largely dependent on the initiative of individual PM personnel.

FINDING: It appears that risk communication efforts were sporadic and ad hoc, and in general were not carried out in accordance with the instructions and intent of guidance such as DoD Instruction 6050.5, "DoD Hazard Communication Program," and implementing Service guidance.

Ideally the appropriate action offices and addressees would have centrally collected, reported, processed, evaluated, analyzed, and then disseminated medical and environmental surveillance data the Services, Unified Commands, and Joint Task Forces collected. This information was needed to update health risk assessments; improve the medical, safety, and environmental response to identified risks; and aid retrospective investigations and analyses or medical research.

Unfortunately, the lack of data and information on in-theater personnel and unit locations and movements, compounded by the lack of medical and health surveillance data and exposure reporting and record-keeping, has seriously hindered post-war retrospective assessments of these events and their health and medical significance. The data that was collected and reported too often has been "lost in the system."

FINDING: Information Management and record-keeping deficiencies resulted in incomplete, often inaccurate data and information collection and reporting. These deficiencies have impaired retrospective efforts to characterize the risks of Gulf War service and conduct research or provide follow-up assistance to veterans and populations at risk.

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