A newly-released Army inquiry determined there was no single cause for the service’s accidental shipments of live Anthrax spores to 88 different laboratories in several countries. But one factor was a “culture of complacency” at Dugway Proving Ground that allowed safety mishaps to go unaddressed for years, investigators said.

The review, known as a 15-6 investigation, recommended that the secretary of the Army consider disciplinary measures against a dozen current and former employees at the Utah facility, including two previous installation commanders and other supervisors who “routinely failed to take appropriate steps or actions that could have limited the inadvertent shipment of viable” Anthrax.

But the investigation did not draw a conclusive connection between Dugway management lapses and the errant shipments from its Anthrax production facility, where the shipments were supposed to have been “inactivated” with blasts of gamma radiation, but included live spores instead.

Rather, broader institutional failures across DoD were part of the mix, as was a lack of understanding in the larger scientific community about what’s necessary to reliably ensure Anthrax spores are  no longer harmful before being shipped elsewhere for further research, said Maj. Gen. Paul Ostrowski, who led the investigation.

“With respect to the gaps in science, we have a lot to do,” said Ostrowski, the deputy for acquisition and systems management in the office of the assistant secretary of the Army for acquisition, logistics and technology. “We must investigate the irradiation process, which is the preferred method of inactivating Anthrax. We are lacking in terms of the amount of information we’ve had on spore counts and how that affects irradiation, purity and the type of spore itself. We also need to do additional research with respect to the way that we test for whether or not a spore is active.”

Over time, different DoD labs had developed different protocols for that testing. As part of a corrective action plan, the Army announced on Friday, a panel of DoD and outside scientists will create a common set of procedures for all military labs to use when working with biological agents and toxins.

Officials said they would also establish more rigorous oversight for determining which outside laboratories have a bona fide need to work with potentially deadly biotoxins, and if not, to offer them alternative agents that suit their research needs.

The Army will also create a centralized IT system to track all outside requests for samples of dangerous biological agents and monitor their status — something it hasn’t had until now.

Officials have also removed Dugway from the control of the Army Test and Evaluation Command and placed it under the Army Research and Development Command, a step suggested by previous DoD inquiries that found the Anthrax mishaps were partially caused by the fact that too many research labs were reporting to too many different commanders.

Also, Dugway will no longer be allowed to produce Anthrax samples for distribution to outside organizations, though it will still grow spores for Army-specific needs such as testing soldier protection equipment to ensure it can defend against the bacteria.

Officials did not detail their reasons for taking the lab out of its former role of “exporting” samples to other researchers, but the 15-6 investigation found numerous instances in which biological agents sent to other facilities had been mislabeled or mishandled. In some cases, labels misidentified batches of Anthrax from which the samples were drawn. In another, a shipping container was labeled “KILLER ORGANISM ON DRY ICE” because of a clerical error. It should have read “KILLED ORGANISM” instead.

Altogether, if the Army facility had been a private lab, it could have been fined $2.5 million by the Department of Health and Human Services for a series of documented safety violations, the Army investigation found. The HHS IG declined to pursue monetary penalties given that the lab is run by another branch of the federal government.

Army officials said they have found no evidence that any workers were ever harmed by the inadvertent Anthrax shipments. That’s because the employees who dealt with the samples at Dugway constantly wore biohazard equipment to protect them from exposure. And they said secondary lab workers who mistakenly received live samples were never in any real danger because the bacteria was not in its powdered form.

“Number one, it was shipped by a very secure means — as secure as we can make it for an invirulent or inactive strain — and second, it was shipped in  liquid vials,” said Ostrowski. “This was not aerosol. Anthrax  is mostly lethal when it’s aerosolized.”

Last May, after a private laboratory first notified the Army that it had detected live Anthrax in a sample that was supposed to have been inactivated, subsequent DoD investigations found 194 labs in the U.S. and nine other countries had received live samples as well — some directly from Dugway and some from other labs who’d sent them onto other researchers. Then-Army Secretary John McHugh ordered a moratorium on production of the bacteria at all four Army labs that do so.

The other three will be allowed to continue producing Anthrax for outside researchers, but within the next year, officials said, DoD and CDC will develop a single governmentwide protocol to verify that the samples are truly inactivated, said Maj. Gen. Brian Lein, the commander of the Army Medical Research and Material Command.

Anthrax continues to be a topic of interest for the military and for agencies in charge of homeland defense because of its potential use as a biological weapon by other nations and terrorist groups.

But the recent Dugway episode brought to light how little is known about the proper procedures to kill the bacteria and ensure “injured” spores do not reactivate themselves  and become dangerous again in research settings: If too little gamma radiation is applied, the spores remain deadly and can’t be safely sent to lower-level facilities for further research. If too much is applied, the samples are rendered useless.

“If you irradiate something too much, it destroys the cell, it destroys the proteins, it destroys the markers, so then if you try and test for that live agent, it’s not there,” Lein said. “If you use it too little, then you have live agents. We need to look at potential, newer tools that are out there, including freezing or other types of radiation. That’s going to all be part of this in-depth research that we are doing in conjunction with the CDC to develop a national standard. And we’re not going to do this with just Anthrax. The requirement on us is to do all of our biologic select agents and toxins, anything that we’re going to be shipping out, we’ve got to validate and determine what’s the mechanism we’re going to use to inactivate it to a level of surety that we can provide to the public and to everybody else that it’s safe if it’s inadvertently spilled or the specimen is lost.”

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