TAB F – Investigators' Notes on Site-Specific Incidents

Alameda Naval Air Station - February 12, 1999

I.  Site Location Information

Alameda Naval Air Station is located in California, five miles east of San Francisco, in Alameda. The Air Station is on an island next to Oakland, in San Francisco Bay. The NAS was scheduled to be turned over to the city in 1997.

II.  Case Background

A civilian contractor employed by DYNCORP, worked as a packer for the Navy in Alameda during and after the Gulf War. While unpacking the hospital ships Hope and Mercy, This contractor had an adverse health reaction. She reported that she and other co-workers began to have rashes, stomach problems, bouts of depression, weight loss, and many other health problems. After unsuccessfully attempting to gain benefits from her employer, she wrote a letter on behalf of herself and several other employees to her congressman, Mr. Ronald V. Dellums. Congressman Dellums forwarded her letter, along with a request for an investigation, to the Navy’s Fleet Hospital Support Office.[40] A commander was assigned to investigate the issue. After speaking with the contractor, her supervisor at DYNCORP, the fleet hospital staff, and individuals knowledgeable on retrograde equipment at the CHPPM, the Navy sent a response back to a point of contact in Congressman Dellums' office.[41]

III.  Navy Investigation

After an investigation of the contractor’s claim, the commander of the Navy’s BUMED concluded that any illnesses she contracted were not related to her work unpacking retrograde equipment. There are several main points that led the commander to this conclusion. These points are as follows:

The commander no longer has the notes from his investigation. However, he recalls speaking with the following individuals:

The civilian contractor.

IV.  OSAGWI Investigation

The OSAGWI analyst began by asking the OSAGWI legislative representative to contact the point of contact at Congressman Dellums' (retired) office. He did and obtained an update of their current position on the Alameda retrograde equipment case. The contractor’s current thoughts on the case were of particular interest since the Navy investigation is now complete. She was satisfied with the results of the Navy investigation, but does want to know the DoD’s official position on the extent to which civilian contractors can receive benefits (e.g. CCEP eligibility).

OSAGWI currently has copies of all the available investigation files from the commander who investigated. Most of these files are memos to and from Congressman Dellums’ office. OSAGWI has also spoken with the following individuals relating to this case:

V.  Eligibility of Contractors to the CCEP

Civilian contractors are not covered by the Federal Employees Compensation Act. For these personnel, injuries and illnesses incurred incident to employment are covered by State workers compensation laws, which establish obligations for employers to provide medical care and compensation. No provision of federal law entitles contractor employees to care in the Military Health System. However, under 10 U.S.C. 1074(c), the Secretary of Defense and the Secretaries of the Military Departments have authority to extend by regulation eligibility for health care services to persons not eligible by statute if such action would further an authorized DOD interest. This is commonly referred to as "Secretarial designee" authority. It is possible that Secretarial designee authority could be used to extend CCEP eligibility to contractor employees, both those who served in theater and those who did not, who believe they have medical problems caused by their Gulf War related employment.

Anniston Army Depot - February 12, 1999

I.  Site Location Information

Anniston Army Depot (AAD) is located in Alabama, 50 miles East of Birmingham, and 10 miles West of the city of Anniston.  The primary mission at Anniston Army Depot is maintenance, overhaul, modification and repair of tracked vehicles, ammunition, and missile systems. Chemical weapons are among the munitions stored here (7.2% of nation's chemical weapons stockpile), mostly M155 rockets shells with sarin, and VX, and mustard, which are stored in some of the hundreds of earthen igloos at Anniston. The Army would like to build an incinerator to dispose of the material, similar to the recently finished chemical agent incinerator at Tooele Depot in Utah.

II.  Case Background

In the summer of 1991, a large amount of retrograde vehicles were sent to Anniston Army Depot to be brought back up to operational standards. In particular, a number of M1A1 tanks from the Gulf War needed maintenance and replacement of worn parts. One part of these tanks that routinely required attention was the chemical, biological, and radiation (CBR) filter system. Tanks were taken into the disassembly area, where the filters were reworked and replaced under controlled conditions.  The filters of 16 vehicles, to include 6 that had been battle damaged, revealed no presence of chemical agents.

Several DoD civilians who worked in the CBR shop began to complain of various health problems in mid- to late-1991. A local physician, who claimed to be several of these individuals, wrote letters to the Commander of AAD and 3 of his congressmen requesting that the issues surrounding the health problems be investigated. Below is a table of the chain of correspondence relating to the physician’s inquiries.

Table 5. Correspondence concerning the physician





October 19, 1991 The physician The Commander, AAD The physician asked for information concerning whether or not the CBR filters on the retrograde tanks had been tested for any hazardous substance.[42]
November 4, 1993 The physician Sen Richard Shelby; cc: Sen Howell Heflin, Rep Glen Browder The physician requested that the CBR filters be tested.[43]
November 22, 1993 Sen Richard Shelby DA Chief of Legislative Liaison Sen Shelby enclosed The physician letter and asked that the matter of inspecting filters be investigated.[44]
December 21, 1993 Director, Professional Services, Anniston HQDA Sent a reply (not attached) to HQDA for Sen Shelby’s inquiry.[45]
February 22, 1994 Safety Director HQDA POC OTSG All tank filters and other parts tested for DU; results were negative. All filters, formerly steam cleaned or cleaned w/ compressed air, were held in box pallets until final risk assessment could be completed. 16 vehicles (6 of which were battle damaged), were sampled; all results were negative. Employees directly involved in the major disassembly processes have not experienced any illnesses; their only complaint was the dust related to engine air intake assemblies. As a result, they have resumed cleaning the filters. Filter test results are included.[46]
April 25, 1994 The physician CO AAD Points out disparity in information concerning the maintenance that is being done on tank filters that is described in the preceding memos.
April 25, 1994 DA OTSG HQ AAD Enclosing draft response to Sen Shelby. Attachment is not present.
May 4, 1994 Command Surgeon, US Army Material Command CO Walter Reed Army Medical Center Five other AMC depots were queried about workers experiencing similar health problems. No other depot received similar complaints from workers.[47]
  OSTG POC Sen Richard Shelby Official response to Sen Shelby relating to letter from the physician. M1 tanks, none of which were involved in hostile action, have had their filters removed in accordance w/ Army technical guidance. No radiation was detected. No M1A1 (tanks were involved in battle) filters have yet been removed. Several M1A1’s filters will be removed soon and tested for CW.[48]

III.  OSAGWI Investigation

This office began investigating the issues at Anniston Army Depot after 3 individuals contacted VDM through the 800 line. These individuals all had similar complaints; they all had non-specific symptoms and all worked around retrograde tanks. IAD investigators have followed up with these complaints by contacting two of the individuals (the third does not have a phone), as well as several other individuals who worked in the same shop at AAD. In addition, IAD has contacted the physician who treated several individuals and sent letters to AAD and his congressmen.

CBR filters were sampled for radiological and chemical parameters – results for both were negative.

Gun tubes were tested for DU and found to be negative.

Other AMC depots were queried about workers experiencing similar problems. No problems were noted.

A memorandum from the facilities Safety Director (see file) indicates that unserviceable air intake filters on M1 tanks contained chromium and therefore were required to be handled as a hazardous waste. In sensitive individuals, chromium has been known to cause contact dermatitis and therefore may explain the rashes reported by some individuals.

Camp Robinson - February 19, 1999

I.  Site Location Information

Camp Joseph T. Robinson is located in North Little Rock, Arkansas. It is the headquarters of the Arkansas National Guard, 90th Regional Support Command. General phone number: 501-212-5100.

II.  Case Background

In the summer of 1991, a number of vehicles from units of the Arkansas Army National Guard returned to Camp Robinson in Little Rock, Arkansas. A large portion of these vehicles were expected to be brought up to operational, "1020," standards by the maintenance teams at Camp Robinson before being sent out to their respective posts. This work included cleaning, painting, sand blasting, bodywork, and various other vehicle repair work. Several DoD civilians who worked on this retrograde equipment began to complain of various health problems. Symptoms included nosebleeds, eye problems, headaches, or sinus problems. Table 1 shows the sequence of events of the investigation conducted by OSAGWI before the environmental team taking the case.

Table 6. Sequence of investigation events






September 11, 1993 Memorandum for Record. Possible Exposure to Chemical or Other Unknown Agents, DS Equipment 1991 Shop Safety Officer N/A Lists names of people and their health complaints. Also lists units whose equipment came through Camp Robinson.
  1-800 Reported Incident at Camp Robinson N/A OSAGWI Outlines status of OSAGWI’s investigation. Very brief.
September 1, 1995 Civilian mechanic1 1-800 call Civilian mechanic1 N/A The civilian mechanic explained that he and others worked on retrograde equipment at Camp Robinson and got sick.
September 7, 1995 Civilian mechanic2 1-800 call Civilian mechanic2 N/A Civilian mechanic2 explained that he worked on retrograde equipment at Camp Robinson and got sick. Daughter also got sick.
September 11, 1995 Civilian mechanic3 1-800 call Civilian mechanic3 N/A Civilian mechanic3 explained that he and others worked on retrograde equipment at Camp Robinson and got sick.
September 1995   N/A N/A Summary of results of CCEP evaluations of 3 Army reservists from Camp Robinson



December 17, 1995 Memorandum for USA Medical Research and Material Command. Request for information. Director PGIIT USA Medical Research and Material Command Request for analytical reports of all biological and biomedical samples analyzed at Ft. Detrick.[49]
February 22, 1996 Memorandum for Director, PGIIT. RFI. USA Medical Research and Material Command, Fort Detrick Director, PGIIT Reply to 12/17/95 RFI. Results of Ft. Detrick testing.[50]
July 26, 1996 Lead 881. N/A N/A Civilian mechanic3 called in to report health problems. This led to follow-up calls to him and investigation into his comments.
August 19, 1996 Memorandum for US Army Medical Research Institute of Infectious Diseases, Diagnostic Systems Division. Sand sampling relating to GWI. PGIIT US Army Medical Research Institute of Infectious Diseases, Diagnostic Systems Division Memo that accompanies a sand sample, given to PGIIT by Shop Safety Officer, that is set for testing.[51]
October 31, 1996 Memorandum through commander USAMRIID. Request for Biological, Chemical Analysis. USAMRIIDChief, Diagnostic Systems Division USAMRIID As requested, the Diagnostic Systems Division will perform a biological assessment of the sample provided. However, they can no longer provide such services w/out reimbursement due to budget constraints.[52]
December 18, 1997 Lead 8442. N/A N/A Caller called to talk about retrograde experiences at Camp Robinson and his health problems. He listed several other individuals who were involved and said that they could be reached through his work number. Also explains that his group was asked if they wanted to join class action lawsuit against the government.

III.  OSAGWI Investigation

Called a number of the individuals to verify specific information. Results of these interviews revealed the following:

Ft. Bragg / Wilmington Incident - February 12, 1999

I.  Site Location Information

One of the largest and most active military bases in the eastern USA, Fort Bragg is an Army base in south central North Carolina, located 10 miles NW of Fayetteville. The installation consists of 142,125 acres, much of which is used for ground/air training, with a large cantonment area adjacent to Pope Air Force Base, at the eastern end. Simmons Army Airfield is located at the extreme eastern end of the base. Fort Bragg is headquarters for the Special Operations Command (once called the Psychological Warfare Center), and the Special Warfare Center. It is home also to the 82nd Airborne—the short-notice, worldwide Army unit that gained notoriety as one of the major forces in the Gulf War.

II.  Case Background

In the summer of 1991, roughly May through September, ships transported large amounts of equipment from Operation Desert Shield/Storm back to North Carolina. Though the final destination for this equipment was Ft. Bragg, the port used to unload these ships was at Wilmington, North Carolina.

The primary group responsible for ensuring that the equipment was mechanically ready to make the trip back to Ft. Bragg was the Directorate of Logistics, a group of DoD civilians based at Ft. Bragg. A number of individuals from this group spent a few months in the summer of 1991 unloading and fixing the vehicles in Wilmington. Several of these individuals have complained of illnesses that they attribute to working on the retrograde equipment.

III. OSAGWI Investigation

OSAGWI began its investigation by contacting the three veterans who called the 1-800 line. Speaking with these individuals led to obtaining the names of a number of others who worked with retrograde equipment at Wilmington; OSAGWI has spoken with eight total workers to date.

After speaking with eight individuals who worked at Wilmington, several clear trends in their discussions began to stand out. The most obvious trend was that the workers had to climb in, on, and around the retrograde equipment. This fact is not surprising, as the workers were all mechanics. A second trend was that there was a good deal of miscellaneous equipment strewn about the retrograde vehicles. All of the individuals that were interviewed explained that the vehicles were littered with trash, used fatigues, and other assorted personal items. It is important to note, however, that the mechanics were generally not involved with handling this miscellaneous equipment.

Though the explanations of the processes of unloading the equipment and the contents of the vehicles were generally very consistent among workers that were interviewed, the descriptions of the condition of the vehicles varied substantially. While some workers characterized the vehicles as being fairly clean and mud, dirt, and sand free, an equal number of workers described them as being filthy. Thus, it is not clear to what extent the vehicles were cleaned in the Persian Gulf before they were loaded onto the ships.

In addition to discussions with the eight workers at Wilmington, OSAGWI spoke with a nurse at the Ft. Bragg civilian Occupational Health Clinic. She has been on staff at the clinic since before 1991, and explained that there were no real changes in the frequency of total patients or patients with rashes during the summer of 1991. In fact, she does not recall seeing any patients in the clinic relating to exposure to retrograde equipment.

Of the civilian workers who came into contact with retrograde equipment the reported symptoms varied from none to several and included: rashes, fatigue, joint pain, cold-like symptoms, memory loss, mood swings, allergies, Raynaud’s disease, and nerve problems. Clustering was not observed.

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