The U.S. Army site that shipped live anthrax around the nation and the world was run by "complacent" leaders who overlooked rigged data and slipshod lab work, according to an Army investigation released Friday.
The Article 15-6 investigation under service regulations did not use the word "cover-up," but said that leadership at the Army's Dugway Proving Ground in Utah for more than a decade glossed over serious deficiencies in the testing and handling of deadly agents.
"Despite multiple safety-related incidents and mishaps in the laboratories and involving shipments to external customers, Dugway leadership and Life Sciences Division management failed to take action," the investigation by Army Maj. Gen. Paul Ostrowski said.
Rather than investigating themselves or ordering disciplinary action, the Dugway leaders instead "blamed external entities or downplayed the seriousness of the incidents in reports to higher headquarters," the investigation said.
Ostrowski's investigation did not assess culpability but recommended that the office of the Secretary of the Army hold the appropriate Dugway personnel "accountable for their failures to eliminate the culture of complacency."
As a result of the investigation, Dugway's role in producing biological agents for shipment to participating labs and contractors for the development of detection devices and vaccines was being eliminated, said Lt. Gen. Thomas W. Spoehr, head of the Army's Office of Business Transformation.
"That production mission will no longer be done at Dugway," but production will be continued at other military labs, said Spoehr, who led a bio-safety task force of 84 staffers and more than two dozen organizations on reforming how the military tests and manages deadly agents.
At a Pentagon news conference to discuss the investigation, Ostrowski stressed that "no single event, no single individual, no groups of individuals are directly responsible for the inadvertent shipment of small amounts of active anthrax."
However, his 157-page investigation singled out Army Brig. Gen. William E. King IV, who was in command at Dugway as a colonel from July 2009 to July 2011.
When problems emerged at Dugway, King "attempted to minimize the events," the investigation said. In reports to the Army's Testing and Evaluation Command, King repeatedly "downplayed the seriousness of the shipping errors" that resulted in the transport of live spores.
"These responses, when considered holistically, show that Col. King was unwilling to take a deeper look at the operations he commanded and ultimately perpetuated a complacent atmosphere," the investigation said.
"Col. King had personal knowledge" of the indicators of Dugway's shortcomings and "as a commander had a duty to think strategically about how these indicators are related and to investigate and remedy problems accordingly," the investigation said. "Col. King failed in these duties."
In a statement to USA Today, which received an advance copy of the investigation, King declined comment on the investigation but said that the safety of the soldiers in his command was of the "utmost importance" to him.
King, now commander of the 20th Chemical, Biological, Radiological, Nuclear, Explosive Command at the Army's Aberdeen Proving Ground in Maryland, said he remains "concerned about the seriousness of the circumstances surrounding" the Dugway anthrax scandal and "will continue to fully cooperate with and assist the Army in its ongoing investigation."
In the course of his investigation of Dugway, Ostrowski said, "We saw failures to take action. We saw best practices by lab technicians not being used." He declined comment on possible disciplinary action but said the "chain of command will take a look at the actions of these individuals and adjudicate."
King and at least 11 other individuals at Dugway could possibly face disciplinary action, according to the investigation.
Despite the "serious breach of regulations" in the shipment of live anthrax, the investigation concluded that there was no threat to the health of the public or those involved in handling the agents.
"Over the years, significant safeguards effectively ensured that the inadvertent shipments were not a threat," the investigation said.
However, as the investigation progressed, at least 30 Defense Department and lab personnel were treated with antibiotics as a precaution. None developed symptoms.
Dugway was the military's primary testing facility for the Army's chemical and biological defense programs, but had on the roster a biosafety officer who lacked the proper education and training credentials for the post, the investigation found
Ostrowski's report also found that some of the Dugway staff "regularly manipulated data" on sample shipment records to show that pathogens were inert.
The military's testing and storage of anthrax and other deadly agents, and the security of facilities, have been the subject on numerous critical government reports and congressional hearings going back to the 1990s, but the anthrax shipment issue only came to a head last May when a Maryland lab found live spores in a supposedly irradiated and inert sample from Dugway.
The list of labs that had received live anthrax shipments kept growing as Deputy Defense Secretary Robert Work ordered a Pentagon-wide review of the military's testing of pathogens.
At last count, live anthrax samples were sent to at least 194 labs and contractors in all 50 states and nine foreign countries, plus the U.S. Virgin Islands, Puerto Rico and Guam. The Centers for Disease Control and Prevention said the total shipments to the 184 labs and contractors numbered 575.
However, Lt. Gen. Spoehr said he could not rule out that additional labs would be found that had received live anthrax shipments, but he had "high confidence" that the list was complete.
The Defense Department stopped shipments of anthrax and other pathogens when the scandal broke last May, but Spoehr said the program would likely continue in about a year when his task force completes its work.
The problems at Dugway underscored the need for more research on methods of irradiation to make sure that supposedly inert samples did not contain live spores, Ostrowski said.
"With respect to the gaps in science, we have a lot to do," Ostrowski said. "We must investigate the irradiation process, which is the preferred method of inactivating anthrax. We are lacking in terms of the amount of information" that is available on various aspects of the spore-killing process, he said.
-- Richard Sisk can be reached at Richard.Sisk@Military.com