UMASS/AMHERST.
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THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF THE ATTORNEY GENERAL
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1989
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The Report of the Investigation of
Attorney General James M. Shannon
of the Class 1 2 Experience at the
Edward W. Connelly
Criminal Justice Training Center
Agawam, Massachusetts
October 28, 1988
TABLE OF CONTENTS
SECTION PAGE
I . Introduction 1
II. Scope of Investigation 2
III . Description of Agawam Academy 7
IV. The Massachusetts Criminal Justice Training
Council 11
V. Chronology of Significant Events 41
VI. Narrative 45
VII . Environmental Report 83
VIII. Conclusion 105
I . INTRODUCTION
This is the report of Attorney General James M. Shannon
into the events and circumstances which led to the sudden
illness of cadets in Class 12 at the Western Massachusetts Law
Enforcement Academy in Agawam.
This report has been written and designed to make it as
accessible as possible to those directly concerned with the
events at the Academy and to the public at large. To that end,
the report is structured as follows:
o Scope of the investigation
o A description of the academy building by size,
history, and observation.
o A discussion of the Massachusetts Criminal Justice
Training Council and its relationship to the
troopers/instructors, local police chiefs, and other
relevant parties. Included is a brief description of
and introduction to the officials who play a role in
the normal day-to-day operations of cadet training at
the Agawam academy.
o A chronology of significant events at the academy
beginning Monday, September 19, the first day of
training for Class 12.
o A detailed, chronological narration of what happened
in the first three days of training at the academy.
o A report on environmental and public health factors in
and around the vicinity of the academy.
o Conclusion.
II . SCOPE OF INVESTIGATION
On September 19, 1988, at 7:30 a.m., 50 police trainees
reported to the Edward W. Connelly Center in Agawam. They
comprised the 12th class of recruits in the center's four-year
history. Within a week, every trainee had been diagnosed as
suffering from some degree of muscle deterioration
( rhabdornyolysis) . Several cadets suffered renal failure.
Eleven were hospitalized. At least two underwent kidney
dialysis. One received a liver transplant and remains
hospitalized.
Because the need for swift discovery of facts must not
compromise the thoroughness of an investigation, we confined
our scope of inquiry to the experience at Agawam and to the
relevant facts leading to and from it. The Attorney General
immediately divested his office of any legal matter, current or
future, which might conceivably conflict with the aim of his
investigation.
This report is the result of lengthy interviews with more
than 100 persons, each having direct knowledge of the
experience at Agawam, its aftermath, or relevant events and
circumstances .
There is some confusion about how many cadets were
hospitalized. Based on this investigation, it was determined
that 11 cadets were admitted to hospitals. Some were detained
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for several hours or even overnight, but only for additional
testing .
Those interviewed included the cadets of Class #12 and the
State Troopers and instructors who directed the class. Training
Council Administrators and Staffers who were working on site in
the Academy, and also visiting observers who were there during
the pertinent time period, as well as those who lived or worked
in proximity to the Academy were also interviewed. In short,
an effort was made to speak with anyone who was in a position
to witness the events and happenings that befell Class #12
during its first week of training.
In addition, personnel employed on the ambulance that was
called to the Academy on Septembter 19, 1988 were interviewed.
Where possible, reports of physicians and hospital staffers who
examined, tested and treated cadets who fell ill or were
injured, have been obtained, and, in several instances, doctors
and hospital staffers were interviewed. Dr. George Grady,
State Epidimiologist , of the Department of Public Health, was
interviewed, as was the Commissioner, Dr. Deborah
Prothrow-Stith. They provided us with the methods and results
of Dr. Grady's medical investigation, and cooperated fully with
this investigation.
State Police and Training Council officials who are
responsible for state-wide police training were interviewed.
Finally, a thorough investigation and study was made, under
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the direction of a leading expert on water quality and the
environment, of the water consumed by the cadets and others who
were in the Academy Building during the week of September 19,
1988. The immediate environment of the academy was also
examined in this effort.
Of the 50 cadets who entered Class #12 at 7:30 a.m. on
Septembter 19, 49 were interviewed. Cadet Timothy Shepard has
not been interviewed. Shortly after 4:00 p.m. on
September 19, Mr. Shepard collapsed on the academy running
track. He was taken by ambulance to Baystate Medical Center
and admitted. He was later moved to a hospital in Pittsburgh,
PA, where he underwent a liver transplant.
Forty-seven cadets provided authorization for the Attorney
General to obtain relevant medical records. The remaining did
not .
Attorney Michael Hashim, who represents Mr. Shepard,
declined to cooperate with the Attorney General's request for
access to his client's medical records and treating
physicians. We are, therefore, unable to ascertain whether
this most extreme reaction to the experience at Agawam was in
any manner influenced by a pre-existing health condition or
organic abnormality.
Each cadet interview was conducted by a pair of
investigators, one leading the interview, the other keeping
notes. Most interviews took place in the National Guard Armory
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in Agawarn, where Class 12 has been moved to continue its
training; one was conducted in the private home of a cadet; and
another in the office of the cadet's attorney.
Each interview with the state troopers was conducted by two
investigators. These took place at the State Police Training
facility in Needham, MA, and were done in the presence of their
attorney.
Thirteen highly experienced investigators from the
Department of the Attorney General have worked almost
continuously on this matter. Nine are normally assigned to
Boston. Throughout this investigation, they worked out of the
Springfield Office of the Attorney General. The investigative
team was led by the Chief Investigator of the Criminal Bureau
of the Attorney General's Office, who was detached from that
bureau for the duration of the assignment, and was assisted by
the Chief Investigator of the Public Protection Bureau. The
team was augmented by administrative and secretarial support
from both the Boston and Springfield Offices. Three of the
investigators are attorneys and a fourth has completed law
school. Four of the investigators are former federal agents
with substantial major case experience, three with the Federal
Bureau of Investigation and one with the Internal Revenue
Service .
Attorney General Shannon assigned his First Assistant
Attorney General to bear primary staff responsibility for this
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investigation and he has supervised the preparation of this
report in Springfield. Two other attorneys from the Boston
office also assisted.
In short, no effort was spared to make this investigation
and this report as thorough and as complete as possible within
the constraints of time.
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Ill . DESCRIPTION OF AGAWAM ACADEMY
When the building which now houses the training academy was
constructed in 1916, it was to house the Hampden County Training
School for juvenile offenders. Located on South Westfield
Street in Agawam, the academy sits just six-tenths of a mile
from the Connecticut line in a mixed residential and
agricultural neighborhood. The four-acre parcel abuts a golf
course; nearby is a strawberry farm and a sod farm.
Set well back from the street, the building is centrally
sited on the academy grounds. The Greek Revival brick and
stone structure is largely in various stages of disrepair. The
white wood columns and railing which set off the entrance are
badly peeling. The stone and brick exterior is dirty and water
stained. The windows on the ground-level basement floor are
protected by thick metal screens.
The building served as a juvenile offender facility until
1971, when it was closed. In 1981, rennovations began on the
first floor. By 1983, those were completed. It became the
home of the Academy in 1984.
The construction itself is sturdy with concrete floor
joists on permanent steel beams which transfer the loads to
steel girders and columns. There are also several
load-bearing, masonary cross walls which provide fire
partitions. Interior walls are masonary with cross walls; all
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are surface-coated with plaster on both sides. There are oak
floors throughout. The corridors and stairwells have cement
floors .
Reconstruction of the basement, which is partially below
ground level, is now underway. The basement had so
deteriorated through the decades that it was virtually unfit
for any use, although two rooms served as the lunchroom and
locker room for previous classes. There are no showers for men
or women. The old showers were disconnected from the water
system in the 1981/1982 rennovations . The total reconstruction
will give the academy, among other things: new showers, a new
boiler, an elevator, and classroom and storage space.
Additionally, the water pipes entering the building will be
enlarged from two-inch to four-inch pipe.
In a recent inspection of the building, these observations
were made:
The rooms are large, with tall ceilings and large windows
which let in plenty of sun. On the first floor, the rooms are
lighted with modern fixtures. All floors are steam heated.
While the office space for the Academy director and staff,
as well as the state police, are clean and refurbished, as are
the first floor classrooms and general areas, the rest of the
building is filthy. A visitor is unprepared for the condition
of the upper two floors. The first inclination of the general
decay above is the musty smell and the dirt immediately
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encountered on the way up the stairs. The picture is
striking: paint is peeling in large patches from the ceiling;
the window shades are torn and ragged; the floors are covered
with a layer of grime and dust so thick that walking leaves
footprints; periodically there are piles of broken plaster,
broken glass and dead insects. Class 12 used two rooms on the
second floor. One room became the cadets' locker room, and
another, directly across the hall, was their lunchroom.
The bulky, round, wooden tables in the lunchroom were very
grimy. Double-wooden-slat chairs were grouped around the
tables, many with at least a few slats missing. There were
two, large holes in the walls, with plaster, dirt, wood etc.
piled inside. The window ledges were coated with dirt; flies,
wasps and other insects were milling around or dead on the
sills. Paint chips spotted the floors. The condition of the
locker room and the hallway were similar. In short, both the
second and third floors appeared to have been unattended to for
literally years. Both floors resembled an abandoned building.
The existing interior area breakdown:
Basement 11,228 gross square feet
First Floor 10,838
Second Floor 9,526
Third Floor 3 , 832
Total 35,424 gross square feet
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Figure 1 shows the use allocations on the completed first
floor and Figures 2 through 4 show the basement, second and
third floor plans as they existed and as scheduled for
renovation. (See Appendix.)
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IV. THE MASSACHUSETTS CRIMINAL JUSTICE TRAINING COUNCIL
The Massachusetts Criminal Justice Training Council
(Council) was established by the Legislature in 1974
(MGL c.6, §116) to provide systematic training for all
Massachusetts Criminal Justice personnel. Council jursidiction
includes the training of law enforcement, corrections,
rehabilitation, probation, parole and court employees, and the
establishment and operation of schools for that training. The
Council also enforces rules and regulations of training
programs run by municipal, county or state agencies which have
police, corrections, probation, parole or court employees.
The Council has authority to approve training schools and
programs; to make rules and regulations relating to courses of
study; and to determine the qualifications of instructors.
The Council determines training needs and develops courses
to fulfill those needs. The Council may conduct its own
training programs or provide funds to other agencies for this
purpose .
Massachusetts General Laws c.41, §96B states that every
appointed full-time permanent police officer shall, prior to
exercising any police powers, attend and complete a Council
approved academy.
The 23 members of the Council include officials or
representatives of state and local criminal justice agencies,
including the Attorney General, representatives of the
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X
judiciary, law enforcement, prosecution, defense, probation,
parole, corrections, the Department of Personnel Administration
and the Governor's Committee on Criminal Justice. Representa-
tives of the FBI, the State Department of Education and the
Massachusetts Bar Association serve as advisory members.
The present chairman of the Council is Chief John P. McHugh
of the Winchester Police Department.
There are 11 Municipal/Regional Basic Police Recruit
Training Academies certified by the Council. They are located
in Barnstable, Boston, Cambridge, Foxboro, Plymouth, Topsfield,
Needham, New Bedford, Waltham and Agawam. The Registry of
Motor Vehicles conducts its academy in Needham. The
Massachusetts State Police has its own academy for troopers in
Framingham.
Local police academies must be certified every two years.
The Council is required to re-examine the certification before
expiration to determine that it meets all requirements. Those
requirements include the availability of at least one classroom
equipped with desks, projectors, a movie screen and other
equipment; access to a range and gymnasium; and an Academy
Director .
Trainees at the local academies are initially selected by
the Chief of Police, or other appointing authority in the city
or town. They must be full-time employees of the municipality
at the time of entrance to a Council academy. Any officer
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hired before completing an academy program must be granted a
temporary exemption to perform police work, and must be
qualified in CPR, firearms, first aid and passed a written
examination on criminal law. Exemptions, which last for 90
days or until the start of the next class, can only be granted
by the Council chairman or his designee, the Deputy Director.
Should any cadet drop out of a class, fail, or otherwise
not complete an academy program, his/her police chief must
request an exemption from the Council in writing. The Deputy
Director reviews each request, and then makes a recommendation
to the Council Chairman. The first 90-day exemption may be
granted simply with the signoff of the Chairman. Any
subsequent exemptions require a review and vote by the
Council's Law Enforcement Committee which meets quarterly prior
to the full council meeting.
o o o
The Edward W. Connelly Criminal Justice Training Center at
Agawam is located at 702 South Westfield Street. The Director
of the academy is Earl D. Harrington, who also serves as a
Council Zone Manager. The Director of Recruit Training at the
time Class 12 began was Trooper Charles Blake Gilmore and his
assistant, Trooper John M. Richardson. Gilmore and Richardson
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also held the titles Commandant and Assistant Commandant and
their duties included supervision of physical training for the
trainees .
Prior Directors of Recruit Training at Agawam were State
Police Lieutenant (now Captain) Charles Appleton (January, 1984
to June, 1987); and Trooper John Spellacy (November 1987 to
August, 1988). Trooper Spellacy had been the Assistant
Commandant under Lieutenant Appleton from January, 1984 to
November, 1987.
Administratively, troopers at the academy report to Captain
Thomas White, Commandant of the State Police Academy, concern-
ing such matters as vacation, pay, their own training, etc.
They report to the Council and Harrington, about such matters
as cadet training, class schedules, instructors, etc.
The Council meets quarterly. No quorum is required.
Members are sent an agenda in advance of scheduled meetings, as
well as the minutes from the previous meeting. Typical agenda
items include such issues as budgetary matters, in-service
training, conditions of local academies, evaluation reports on
training conducted by other agencies, etc. The Council
operates on an annual budget of about $3 million. Troopers are
paid by the State Police. The Council does not have the
funding necessary to hire its own Class Instructors for those
subjects currently handled by the troopers, including physical
training .
o o o
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The Council and the Massachusetts State Police fall under
the Secretary of Public Safety, Charles Barry. The Council
relationship is unique, however, because the Executive Director
is appointed by a vote of the 23-member Council, without the
necessity of approval by the Governor or the Secretary.
PRINCIPALS
What follows is a brief introduction of significant Council
officials and the Troopers associated with the Agawam Academy.
GARY F. EGAN
Egan has been Executive Director of the Council since
1976. He holds a bachelor's degree in Criminal Justice from
Northeastern University and a Master's degree in Education from
Boston University. In 1985, he was a senior executive fellow
at the JFK School of Government, Harvard. He was a
Massachusetts State Trooper for nine years. As Executive
director, he oversees the operation of local police academies
where county and municipal police officers are trained,
including the Academy at Agawam.
JAMES M. CANTY
James M. Canty was appointed Deputy Director of the Council
in 1980. He was a Special Agent of the FBI from 1947 to 1978.
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He joined the Council in 1978 as a coordinator of police
training .
JUDITH PANORA CROSSEN
Crossen is Director of Training for the Council, a position
she has held since 1981 except for three months this year when
she was removed from those duties. She says from June 13 -
September 18 she was demoted and subsequently reinstated
following an affirmative action grievance process. She holds a
B.A. degree in Psychology from Southeastern Massachusetts
University. She is also also a third-year law student at New
England School of Law. She began working at the Council in
1976 as an intern. She is responsible for the administration
of training in 14 training academies, including Agawam. She
reports to Canty and to Egan. Reporting to her is Agawam
Director Harrington. Academy directors normally report to the
Zone Manager, who in turn reports to the Director of Training.
MARTIN K. MICHELMAN
Michelman has been a training Coordinator for the Council
since 1983. He works in the Council's Needham headquarters.
He is presently a candidate for a Bachelor's degree in sports
and fitness. He holds certification in physical fitness,
aerobics exercise, firearms, and related subjects. He is
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responsible for conducting a screening of applicants to the
Council academies. On August 26th, he conducted the screening
for the cadets of Agawam Class 12.
EARL D. HARRINGTON
Harrington has been the Director of the Agawam Training
Center since it opened in January 1984. He holds a Bachelor's
degree in recreation and community development from Springfield
College. He has worked in youth services and in criminal
justice planning. As Director, Harrington is responsible for
the physical plant; staffing; and all training, including
physical training. He is also a Zone Manager for the Council
and as such is responsible for in-service and other specialized
police training throughout the four western counties.
JOHN M. SPELLACY
Trooper Spellacy was the Assistant Commandant at Agawam
from 1984 to 1987, under Lieutenant Charles Appleton who was
the Academy's first Commandant. Spellacy was Commandant of
Classes 10 and 11, serving from November of 1987 to May of
1988. In August, he was reassigned to the State Police Academy
at Framingham.
CHARLES BLAKE GILMORE
Gilmore has been a Massachusetts State Trooper since 1982.
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On September 6, he was assigned "Director of Recruit
Training/Commandant" at the Agawam Academy. (He is presently-
assigned to the State Police Academy, Framingham, having
requested a transfer from Agawam on September 30.) Gilmore
holds an Associate's Degree from Springfield Technical
Community College in biomedical electronics. He has taken
courses in paramedics and legal studies. He has taught courses
at the State Police Academy since 1986. Gilmore has been an
instructor at 11 other "first days" of training classes, four
at Agawam. Class 12 was the first under his command.
TROOPER JOHN M. RICHARDSON
Richardson became a Massachusetts State Trooper in 1982
after seven years on a municipal police department. He was
assigned to the State Police Academy in Framingham in 1986.
In October, 1987 he was assigned to the Agawam Academy as
Assistant Commandant. In this capacity he participated in
Agawam Training Classes 10 and 11, continuing as Trooper
Gilmore's assistant for Class 12. He also requested and
received a reassignment back to Framingham.
FRANCIS S. KOZACZKA
Kozaczka holds a Bachelor's degree in Criminal Justice from
Western New England College. He became a Massachusetts State
Trooper in 1977. In 1987 he was promoted to Corporal. Trooper
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Kozaczka has assisted in the training of all but one of the 12
classes that have been held at the Agawam Academy. He
participated in 10 other "first days" at Agawam before Day One
for Class 12 on September 19.
JAMES TMELIO
Imelio joined the Massachusetts State Police in 1987. He
holds a Bachelor of Science degree from the University of
Massachusetts with a major in plant and soil science. He is
studying for a Master's degree in Criminal Justice. He
participated in the first day of training for Class 12 at
Agawam. He had performed similar instruction for Class 11.
CARY M. MARONI
Maroni has been a Massachusetts State Trooper since 1981.
He holds an Associate Degree. He has regularly taught at the
Agawam Academy. Trooper Maroni was an instructor on the "first
day" of Class 11, and again on September 19 for Class 12.
RICHARD C. CADRAN
Cadran graduated from the State Police Academy in 1988. He
holds a B.A. degree in physical education and Associate's
degree in Criminal Justice. He is now studying for a
Bachelor's degree in Criminal Justice. He had never been
involved in cadet training before September 19 when he
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participated in Day One of Class 12.
TROOPER FRANCIS P. HUGHES
Hughes became a state trooper in 1986. He has studied
criminal justice at Middlesex Community College and is one
course short of an Associates Degree. Trooper Hughes has
participated in two previous "first days" for police academy
classes, including Class 11 at Agawam. On September 19, he was
a participant in Class 12.
TROOPER THOMAS NARTOWICZ
Nartowicz graduated from the State Police Academy in
December 1986. Before joining the State Police he was a
Deerfield police officer for two years. He has been an
Emergency Medical Technician since 1978. Nartowicz has an
Associate's Degree in Criminal Jutice. He is assigned to the
Northampton barracks. This was Nartowicz's first class. He
was expressly requested by Gilmore to serve as medical officer
for Class 12.
THOMAS R. WHITE
Captain White graduated from the State Police Academy in
October 1967. He has worked in the Narcotics Unit and has been
assigned in the Worcester County and Suffolk County District
Attorneys' offices. When promoted to Captain, he served as a
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staff inspector, assuming command of the Framingham Academy in
August 1987. He has an Associate's Degree in Criminal
Justice. Troopers on assignment to local training academies,
including Gilmore and Richardson, report to White in the State
Police chain of command, while reporting to the Academy
Director in matters pertaining to recruit instruction.
CHIEF STANLEY J. CHMIELEWSKI
Chief Chmielewski is the President of the Western
Massachusetts Chiefs of Police Association. He has been Chief
of the Agawam Police Department since September 1978, and an
officer with that department since June of 1958.
His daughter Dorie Anne Chmielewski is an employee of the
Council and works at the Agawam Academy
ooo
TRAINING: PHYSICAL TRAINING AND
MODIFIED STRESS TRAINING
There is a significant lack of guidelines or regulations
from the Council which address physical training. Egan sent a
memo on February 6, 1985 to all Academy Directors, Staff
Officers and Instructors on basic rules and regulations. One
section dealt with physical training. The memorandum was sent
after the council received several complaints from the
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Massachusetts Commission Against Discrimination and the ACLU on
the treatment of cadets. Eaan said the attached regulations
would become the Council's "first line of defense in any future
actions . "
The Council bases much of its curriculum for the training
of police officers from a 1979 report produced under a federal
grant by Arthur D. Little. The report does not address
physical training, according to Canty.
It is in Egan's memo that the concept of modified stress
training is found. This approach "utilizes a surrogate stress
environment by maintaining a highly structured system of
training to induce similar stress levels on the recruits to
approximate the field environment." This, writes Egan, teaches
recruits self control and self discipline.
During his interview, Egan defended the so-called "modified
stress" aspect of recruit training. He feels that police work
is in reality very stressful and that the Academy must prepare
officers for the street where they will encounter domestic
violence, barroom brawls, angry citizens, and be subjected to
verbal abuse.
The objective of the Academy's stress training, he said,
is to ascertain whether or not a trainee will be able to
withstand the stress he's likely to encounter as a police
officer. In addition, Egan said, Academy instructors must
immediately compel the trainees to act in unison as a group. In
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other words, to approximate a police unit. He described the
program at local academies as a modified version of the one
used at the State Police Academy but not as strenuous.
There is no physical punishment at the academies, he
insists, only "reinforcement" to correct errors by cadets. Such
reinforcement can consist of push-ups and other physical
exercises. It is common for a group to be made to exercise as
a result of a mistake of one cadet.
Egan said this inducement of stress is particularly
important on opening day of a new class so that cadets who may
not be able to handle stress can be identified. He said it
also reinforces the concept that mistakes must be held to a
minimum. He said the stress induced from the start of classes
increases bonding. Initially, cadets bond together against the
instructors he said. Later, as stress is reduced, the cadets
realize that their instructors are there to help and a bond
develops between instructors and cadets.
Harrington said that when he first became Director
four-and-a-half years ago, he thought the stress-inducing
drills were excessive. He now believes in them. Harrington
says the drills foster an ability among police to work
together. This, he says, increases the likelihood of their
safety on the job. Harrington said he never saw Egan's 1985
memorandum on modified stress training, but added he thinks the
Troopers/Instructors have .
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Another section of Egan's 1985 memo dealt with correct
interactions with the cadets. It advised Troopers/Instructors
to address recruits only by his/her last name, or "'TRAINEE.'"
Additionally, no remarks should be made regarding a trainee's
fitness to serve as a police officer. There should be no
personal remarks about cadets. And, "the use of vulgar,
obscene, profane, humiliating, racially, ethnically, or
sexually degrading language" is prohibited.
Hazing is prohibited. Egan's memo says hazing includes
anything that imposes on a recruit or group of recruits a
punishment or action that would cause them to suffer cruelty,
injury, humiliation, or the deprivation of any right.
The only regulations regarding Physical Exercise are found
under that heading, and follow in their entirety.
"Academy Staff /Instructors are prohibited from causing
recruits to perform authorized exercises or activities to the
degree where life or health is endangered and illness or injury
may be reasonably foreseen as a result. When conducting
exercises or physical activities Academy Staff /Instructors will
utilize the following consideration in determining duration and
number of repetitions: 1. Individual phsysiology; 2. State of
completion of the organized physical training program of the
Academy; 3 . Exercises and physical activities will be conducted
in moderation . " (Emphasis added).
Neit her Troopers Gilmore nor Richardson, nor any of the .
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other six troopers who par hicipated in Class 12 had seen or
knew of Eqan's memo.
By contrast, the Massachusetts State Police program for
recruits has a small informational booklet on physical fitness
which is given to each applicant. It addresses pre-academy
conditioning, and suggests the purchase, for example, of good
running shoes .
The State Police booklet says exercise is "not fun." Pain
should be a warning that "something is wrong . " " No pain, no
gain is a myth . " If there is an injury, training should stop .
"If you are injured, you should rest that particular body
part." (Emphasis added).
State Police cadets are also told to "drink plenty of
water, especially in the warm weather. You must drink all day
long, not just while you are exercising." (Emphasis added).
The troopers in charge of training on September 19 based
their Day One activity on their own experience at the State
Police Academy in Framingham. Trooper Cadran would later
remark that compared to their own first day under the state
police program, Day One at Agawam was a "beach party".
INSTRUCTOR TRAINING
It appears the only Council guidelines relating to the
training required by instructors are contained in a May 4, 1988
memorandum from Council Training Director Crossen to all Zone
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Managers and Academy Directors. Those standards became
effective July 1, 1988.
Crossen wrote that all instructors must have "training
council certification or an equivalent." There are nine areas
of instruction requiring such certification. One is physical
training .
The standards require each instructor to have "presentation
skills and subject matter knowledge." The first can be
obtained by completing either a Trainer Level II program
offered in Southboro, or by completing a particular, even
unrelated, council program where presentation skills are taught.
As for subject matter, instructors must complete a specific
program, and teach three classes in those programs within two
years; get re-certified every two years; and serve as an
assistant instructor for three programs. Instructors may
depart from the requirements with permission from the Executive
Director "prior to instruction."
SCREENING RECRUITS FOR CLASS 12
There are no physical exercise standards necessary to be
met by a candidate prior to admission to the Agawam Academy.
And, but for running a mile in eight-and-one-half minutes at
the end of the 14 weeks, there is no physical exercise standard
necessary for graduation. Michelman said it was his
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understanding that some form of physical exercise standards
would be adopted by the Council in July of 1989. In
anticipation of this, the Council deleted some of the
traditional exercise tests in the screening process and added
others. The Council added an agility run, a weight lifting
bench press, and a so-called skin-fold test designed to measure
body fat .
The Council made the changes to begin collecting a data
base which could prove useful when new standards were adopted.
The exercise eliminated from the traditional screening was the
measurement of a candidate's ability to do push ups. Michelman
said that it was his understanding that information on the new
standards would be distributed to police departments in January
of 1989, giving candidates six months to prepare themselves.
Michelman stressed that until those standards are in place.
there are no specific standards of physical accomplishment
reguired of candidates for the local academies.
Michelman noted that he was impressed with the size of the
class he tested at Agawam on August 26. Including three
candidates who didn't show up at Agawam and who were tested on
another day in Needham, the original class size was 52, instead
of the usual size of 30 or more.
Michelman said that he assembled the candidates at Agawam
in one classroom. He then went over the various tests that the
cadets had completed, and told individual candidates how they
- 27 -
might improve. Michelman noticed that some candidates were in
good or fair shape, and others in poor condition. During the
interview, which was conducted in the presence of the Council's
attorney, Michelman initially said his personal evaluation of
the group was that they were in "poor condition." He later
qualified his comments by saying that it was his personal
opinion that the group was pretty much an average one. He
expressed concern for the general physical condition of
contemporary candidates for the police forces. He said he
instructed the candidates that in the three weeks remaining
before Class 12 began they should exercise. Michelman said he
offered some advice on how to best prepare.
Several cadets interviewed recalled that on August 26
Michelman had announced that as a group, their test results
were "about the worst I've ever seen." Some candidates were
told by Michelman initially that because their body fat levels
were too high, they would not be admitted.
According to several cadets, Michelman told Shepard and at
least three others that their body fat measurement was too
high. Michelman recalls pulling several cadets aside,
informing them that their measurements were too high, but he
doesn't remember their names. The cadets in question, he said,
had height-to-weight ratios within acceptable limits under
current standards. If the new standards, effective July 1,
1989 were in place last August, Michelman says those cadets
- 28 -
would never had been admitted.
Actually, according to the weight-f or-height table used by
the Council, Shepard was two pounds over the limit even under
current guidelines.
Michelman emphasized during his interview that he had
advised the cadets on August 26 that the minimum amount of
water the average person should consume each day is 64 ounces.
Gilmore said he wanted to be present at the screening of
cadets, but had duties at the State Police Academy. He arrived
in Agawam two hours too late.
Michelman said that he has no role in the training of
cadets. He said he is unaware of the qualifications of the
Agawam Academy's instructors and that he never discussed
training methods with Gilmore, Richardson or Spellacy.
Michelman mailed the results of August 26 to the Agawam
Academy the week before Class 12 was to arrive. Gilmore savs
that he first saw the results on the Friday before the Monday
start of class. There was no cover letter. The envelope
simply contained the raw scores of each test for each recruit.
There was not one word of explanation. Gilmore says that he
did not understand certain notations on the test sheets. For
example, he thought that the column marked "BP" meant blood
pressure, not bench press. Gilmore says he sought help in
interpreting the data from both Richardson and Harrington but
that neither could offer clarification. He placed two calls to
- 29 -
Michelman that day, he said, neither of which was returned.
Michelman does recall two telephone conversations with
Ric_har_dso_n on September 8 during which Richardson asked about
results of the bench press and agility run. Michelman says he
provided that information but when he was not questioned
further about test results, he assumed that Richardson
understood them. He also says that aside from the new addition
of the bench press and agility run, all the data was identical
to tests used in previous classes.
Michelman says that Richardson, referring to the class,
asked, "How did they look?"
"Not too good, John," Michelman replied.
Michelman conceded that he did not discuss with the
troopers how the cadets should be handled. He said he believed
that the individuals at the Agawam Academy were experienced
instructors and that it was not Michelman' s job to offer any
suggestions. He said that he would not have offered
suggestions even if the instructors had been civilian, and not
state police. He said that he does not know whether or not
Gilmore and Richardson have sufficient expertise to evaluate
the results of the screening.
When specifically asked if he tested anyone on August 26
that he felt to be in danger while undergoing training in
Agawam, Michelman said no. He then qualified this answer by
observing that because of the number of individuals and tests
- 30 -
he conducts for all the academies/ Michelman sees the recruits
"as a bunch of names and faces."
Gilmore savs he still does not know what the Council's
standards are for recruits. It should be noted that Gilmore
has participated in "First Day" for recruits approximately
eleven times, including four times at Agawam.
Gilmore said that he thought the Council would provide a
set of target goals for individuals and instructors. He
received none, he said, and developed none.
o o o
RELATIONSHIPS OF CONFLICT
The relationship between Council Staff and the
Trooper/Instructors at Agawam was marked by a history of
mistrust and lack of communication. For example, Spellacy, in
a memo to Capt. White says, "It has been my experience during
the more than four years assigned here, that the cooperation
with the council has been questionable at best." He went on to
say there was absolutely no cooperation and communication with
the Council's Director of Training. Spellacy says he coped
with the Council's lack of understanding of training at Agawam
by maintaining the "standards and attitudes" of the
Masschusetts State Police.
- 31 -
The State Police use military-type training. This training
stresses military commands, formations and discipline. Its
purpose is to instill an attention to detail, teamwork and
espirit de corps in trainees. When used as part of stress
training, it involves superior-inferior relationships between
instructors and trainees, loud and harsh verbal abuse, and
group and individual public discipline. It includes required
performances designed to either exceed the trainee's capacity
or the time allowed for completion. Several people
interviewed, including high-level Council staff, say that
police are more receptive to instructions received from those
with direct police experience than from civilians.
Gilmore, Spellacy's successor, was transferred to Agawam on
September 6, iust 13 days before Class 12 was to begin. He
says he received no written or verbal instructions from anyone
regarding training in Agawam. On his own, he obtained a
syllabus regarding physical training from Corporal Greeley of
the State Police Academy.
Sometime in August 1988, a meeting in Agawam occurred
attended by Gilmore, Egan, Harrington, Richardson, and Capt .
White. The main point of the meeting was to make it clear to
Gilmore that Harrington was in charge of the Agawam Academy.
It was explained during the meeting that Lt . Appleton, the
Academy's first training supervisor arrived in Agawam prior to
Harrington. As a result, Egan explained, Appleton had assumed
- 32 -
duties that would have normally been performed by Harrington.
This approach, continued throughout Appleton's tenure, was
adopted by Spellacy. In other words, in f our-and-one-half
years, Harrington had never sufficiently asserted himself to
regain control of the Academy.
All present agreed that the training program under Gilmore
would essentially remain unchanged. Harrington agreed with
Gilmore's decision to use the staff and instructors Spellacy
had used.
Gilmore felt pressed for time. The transfer would not come
until after Labor Day. Consequently, he spent some of his own
time, he says, lining up instructors for Class 12.
Harrington wanted things to change at the Aqawam Academy
with the arrival of the new trooper. He said the main purpose
of the August meeting was to reinforce to the troopers that
Harrington was the boss. He had, in the past, been largely
ignored by the troopers. For example, Trooper Spellacy would
send dismissal notices for trainees directly to Council
Headquarters without consulting or notifying him in advance.
As a result, Harrington's first knowledge of a trainee's
dismissal would be a copy of Spellacy's memorandum cc'd. to
Harrington after it was approved by the Council. Harrington's
name and position were not even mentioned by Spellacy until
just prior to graduation when Harrington would generally first
appear .
- 33 -
In fact, it was Harrington's practice to have very little
contact with the trainees. He never gave a single welcoming
address to any new class. He said that he only knew the
trainees names at graduation when he would preside as master of
ceremonies and present them with certificates. When he was
interviewed by investigators on September 29, Harrington said
he still did not know any of the trainee's names other than
Shepard from Class 12.
When Harrington was asked by investigators on October 4 to
provide a roster of class names, addresses, and screening test
results, Harrington said he had no such information. The
troopers, he said, handled everything regarding training.
Harrington also told investigators that day that he had
planned to address Class 12 sometime during the first week,
even though he had never done this in the past. He said his
talk would have included an explanation of his position at the
academy and how he is in charge of the troopers. Because of
the medical problems experienced by Class 12, he said, he still
has not spoken to the cadets.
Relationships were apparently not much better at Council
headquarters. And if Harrington was having difficulties
asserting his authority at the Agawam Academy, Judith Crossen,
the Council's Director of Training, was having very little
success asserting her own.
Crossen described her atmosphere of employment as one of
- 34 -
back-biting and constant frustration. Her superior provided
her with no support, she said. Those under her direction
disregared her authority and frequently ignored her orders.
Crossen said that her complaints to Egan concerning staff
problems were met by Egan's assertion that Crossen had a
"people skills problem." During the three months of her
removal as Training Director, Crossen says Egan assigned her to
explore solar heating possibilities for the Council.
Crossen said that she has five zone managers, including
Harrington in Agawam, who supposedly work for her. She
concedes that she has very little day-to-day supervisory
contact with them. Instead, she says she schedules manager
meetings every six weeks.
Crossen detailed a history of extensive confrontations with
the Troopers beginning with problems with Appleton in 1984 when
the Academy opened, and later with Spellacy. When she told
Egan about the problems with one zone manager, Crossen says
that Egan's solution was to direct her not to speak with that
particular manager or anyone on his staff. Appleton, she says,
refused to meet with her to discuss training. Crossen says
when she told Egan she wished to confront Appleton, Egan
discouraged such a session. She believes Egan was afraid to
confront the State Police.
In October, 1984, Appleton wrote the commander of the
Massachusetts State Police Academy requesting that he, Captain
- 35 -
Frederick G. Bohnenberger , provide the Council with curricula
for physical training. Crossen had asked Appleton to do this.
Crossen says she received those materials as well as an
invitation from Bohnenberger to visit the Academy and view the
training first-hand. In addition, she said she received a
follow-up note to Egan forwarded to her by Deputy Director
Canty. It read: "Lt. Appleton called re: Judy's memo re:
documentation of PT, etc. He says what he teaches is the same
as the State Police Academy -- Has no indepth lesson plans,
etc. Al Thompson has book on 'School of Soldier." (Sergeant
Thompson runs the physical training at Topsfield .)..." IF THEY
DON'T WANT PARA-MILITARY TRAINING, HE FEELS COMMISSIONER WILL
PULL THEM ALL OUT." (emphasis added).
Crossen noted that the Agawam Academy has a dismissal rate
much higher than any other academy. She said the rate for
other academies was in the vicinity of five percent, while
Agawam' s rate is between 20-25 percent.
Among physical exercise professionals, the enforced
consumption of water after physical exertion is known as the
"philosophy of hydration. " When asked if she was familiar with
this, Crossen indicated that she was not until after the Agawam
problems .
Crossen confirmed that there are no specific levels of
physical training accomplishment required of candidates for the
local academies and no such requirement is necessary for
- 36 -
graduation except the eight-and-a-half -minute mile.
Crossen added that Harrington "had been treated like dirt"
in the past by the Agawam troopers. She said she believed
Harrington was afraid of Spellacy. Crossen said when she
raised this possibility to Egan, Egan replied that Harrington
"is not their kind of guy."
Crossen said that when Egan told her about Shepard's
illness, she called Harrington to get the facts. Harrington's
advice to her was to speak directly to Gilmore.
Crossen said that she chastised Harrington for not keeping
her informed. He said, "You mean you want to know when the
trainees are in the hospital? OK, two others are. We think
they have a gall bladder and appendix problem."
o o o
It appears that one source of conflict between Trooper
Spellacy and the Council had to do with the physical condition
of the Academy and its grounds. It would be Spellacy' s
recommendation, in fact, that Class 12, which the Chiefs wanted
to begin in June, be postponed until construction was completed
on the building's basement. This conflict with the Chiefs over
the scheduling of the class -- Spellacy said it was the first
time there was a disagreement about scheduling -- would lead to
his transfer out of Agawam.
- 37 -
Writing to Capt . White on April 19, Spellacy makes his case
for a suspension of classes, while noting a deteriorating
relationship with the Council. Spellacy says the Academy
facilities are a disgrace. He cites, among other things: the
lack of showers; no indoor facilities for physical training and
exercise; the disgraceful condition of the locker room and mess
hall which were, at that time, in the basement; and an outside
track which is nothing more than a widely mowed strip of grass
encircling a patch of wild grass. He says cadets have been
injured because of these conditions. These matters have been
"brought up
time
and time
again.
" he writes
•i ,
yet
no ac
:tion has
been
taken . "
As
to the Council,
SDellacv a
dds
it seems to me
that
a varie
;ty of
stories
and excuses come
out
of
that
agency
to fit the occassion. "
Spellacy cited his own need of a vacation, adding that it's
possible he could lose accumulated vacation time if he did not
take time off that summer. And, he says, it would be difficult
to find instructors willing to work the summer weeks, if Class
12 were to begin in June.
When Spellacy sends a much shorter memorandum to Chief
Stanley Chmielewski outlining the same position -- that a June
start-up would be impossible -- the chief goes around the
trooper . On April 7, following a meeting of the Association of
Western Massachusetts Police Chiefs, Chmielewski writes Egan to
say there was "a great deal of concern" about the lack of a
- 38 -
summer class. Saying there were enough cadets to fill two
classes -- one in the summer and another in the fall --
Chmielewski asks Egan for both classes.
Harrington said that there were never complaints from
either cadets or police chiefs about Spellacy or his training
methods. He believes Spellacy ran a good program and was a
great trainer.
He said Spellacy seemed to know each cadet's limits. He
could be tough, he could joke around and he knew when to push
an individual and when to ease off. Spellacy' s problem,
according to Harrington, was that he could not give ground in
the administrative details of the program. It was this which
caused his removal.
(It should be noted that Spellacy; Sgt. Robert Scofield,
zone manager for METRO/Boston; and Cpl. William Coulter,
primary physical training specialist at the State Police
Academy; declined, upon the advice of counsel, to be
interviewed . )
Spellacy's refusal to start Class 12 in June was the "final
straw", according to Harrington. Harrington said that Spellacy
emphasized that the hot weather, the poor conditions of the
building, and a lack of available instructors militated against
starting a class in June.
Spellacy was removed from the Agawam Academy and trans-
ferred in August 1988. There was no class in June. The fall
- 39 -
class was scheduled even though the renovation of the basement
didn't even begin until just before the cadets arrived. That
class would be Class 12.
After Gilmore arrived on September 6, he looked for a
satellite location where he could run the physical education
training classes. He agreed with Spellacy's assessment that
the physicial plant, especially its lack of showers, was
inappropriate for physical training. On his own, Gilmore
obtained from Coulter's Office a syllabus for physical
training. The outside locations sought by Gilmore, including a
YMCA Camp in the Agawam area, didn't pan out.
When it became apparent that he had to use Agawam for
physical training, Gilmore got Harrington's approval to move
the mess hall and locker room upstairs away from basement
construction.
- 40 -
V. CHRONOLOGY OF SIGNIFICANT EVENTS
Monday, September 19, 1988
About 7 AM Trooper Richardson alerts Agawam Fire Department
to arrival of Class 12; asks that ambulance be on
call .
7:30 AM Cadets arrive. Troopers Gilmore and Nartowitz
greet them.
8:00 AM Physical and psychological stress exercises begin
including: push-ups, running, inventory of
equipment, boot pile.
11:30 AM Lunch.
11:50 AM Formation drills.
1:30-2:00 PM Classroom.
3:30-4:30 PM Physical Training
4:05 PM Cadet Shepard collapses. Attended by Gilmore and
Nartowicz .
4:15 PM Ambulance arrives, transports cadet to Baystate
Medical Center, arriving at 4:44 PM.
5:30-5:45 PM Class 12 dismissed.
Evening The three Pittsfield cadets go to Baystate to see
Shepard who is listed in critical condition.
Tuesday, September 20. 1988
7:30 AM Cadets arrive. At roll call, five cadets are out
due to illness or injury.
8:15-11:30 AM Class in first responder. Instructor distributes
cold packs to cadets and, on questioning about
dark urine, says it is caused by dehydration and
advises class to drink plenty of liquids.
Morning One cadet admitted to Ludlow Hospital.
- 41 -
11:30 AM - Lunch followed by punishment laps around the
12:30 PM track. Cadets crawl on their stomachs from the
lunchroom to the locker room.
12:30-3:00 PM First responder class continues.
3:00-4:30 PM Physical Training.
5:00 PM Class 12 dismissed.
Evening One cadet sees doctor for pulled tendon; another
goes to Holyoke Hospital where he will be
admitted the next morning.
Wednesday, September 21, 1988
7:30 AM Roll call. Four cadets are now in the hospital.
8 :00-ll:30 AM Class.
11:30-12:00 Lunch
12 :00-2 :00 PM Class.
4:30 PM Trooper Gilmore calls Agawam Health Department
requesting water testing at the Academy.
4:00-4:30 PM Academy staff posts signs "Don't drink the tap
water" in men's and women's lavatories.
Afternoon Massachusetts Department of Public Health (DPH)
receives request to investigate illnesses about
the cadets.
4:30 PM Class 12 dismissed.
6:20 AM Technicians from Tighe & Bond, the environmental
consulting firm, called by the town arrive at the
Academy. Water samples are taken for a bacteria
examination, and a scan for organics, lead and
other trace metals.
Evening Richardson and the Academy secretary, on the
advice of Captain White, call local police
departments with sponsored cadets to report
illnesses among the class.
- 42 -
Evening Local police departments call their cadets. Some
continued order cadets to get tested; others advised to see
a physician if experiencing any problems.
23 cadets go to various hospitals for testing.
Four are admitted.
Pittsfield Mayor orders her cadets not to return
to the Academy.
Thursday. September 22, 1988
7:30-10:00 AM Academy is closed. Training is moved to the
Agawarn Police Department. State officials arrive
by helicopter.
Roll call. Eight cadets now in hospital; three
cadets call in absent for the day; five are out
for half the day.
7:40 AM DEQE Oil and Hazardous Material Soil/Release
Division is notified. Brief description of
incident is noted and case is referred to DPH.
No site visit is made.
10:40 AM Academy building posted by the town health
department .
Morning Cadets advised to drink lots of water.
Afternoon Cadets, staff and construction workers, doing
renovation of the Academy basement, are tested by
DPH.
DPH team begins on-site investigation. This
continues until September 25, 1988.
Tighe & Bond collects samples.
DEQE representative interviews assistant health
director of the town health department.
Class dismissed.
Evening Three more cadets admitted to hospitals. There
are now 11 cadets from Class 12 in the hospital.
- 43 -
Fr iriay, September 23, 198ft
7:30 AM Cadets report to Academy, then to Agawam Police
Department .
Morning DEQE ' s William Pendergast of the Water Supply
Division meets with local public works officials,
Academy Director, and a representative from
DCPO . Also makes cross connection survey of
water supply system(s) at the Academy.
2:30 PM 34 cadets taken by bus to Baystate Medical Center
for testing and for medical histories.
30 cadets released by 11:00 PM. Four stayed for
further testing, but were released.
Saturday, September 24, 1988
Springfield Water Department collects sample from
Karakla home at 703 South Westfield, directly
across the street from the Academy.
Thursday, September 29, 1988
Agawam Health Department lifts closure of Academy
Tighe & Bond gives town Public Works Department
its preliminary lab report. Both advise Academy
staff to run water until cold before drinking to
clean the pipes of any lead possibly dissolving
from the soldered joints in the copper pipes.
Friday, September 30, 1988
Troopers Gilmore and Richardson request
transfers. State Police Commissioner grants
requests .
Monday, October 3. 1988
Lt. William J. Shea and Trooper James M. Ryan are
appointed Commandant and Assistant at Agawam by
the Commissioner.
- 44 -
VI . NARRATIVE
FIRST DAY
At 4:30 a.m. on September 19, Cadet Jeffery Kemp of the
Pittsfield Police Department, awoke, showered and shaved. He
had two bowls of Rice Chex with milk, put on his uniform and
heaved his duffel bag into his car. The bag contained the
items that Kemp and 49 other cadets had been instructed to
bring to their first day of 14 weeks of training at the Edward
w. Connelly Training Academy. Kemp drove to pick up Dwane J.
Foisy of the Pittsfield Department at home. Foisy was running
late, so Kemp went inside to help him straighten his uniform
and tie. They left Foisy's at approximately 5:35 a.m. and
arrived at the Pittsfield Police Department to find fellow
Cadet Tim Shepard already there. Cadet Glenn Civello showed up
a minute or two later. Kemp, Shepard and Foisy put their bags
inside Civello' s car and headed for Agawam. Civello drove,
Shepard rode shotgun. "All the trainees were in good spirits,
talking about what it was going to be like," Kemp recalled.
"Timmy Shepard was especially funny."
About an hour later, the four stopped at McDonald's in
Westfield to use the restroom and make final adjustments of
their new creased Khaki uniforms. They then drove the last
short leg to the Academy. Cadets milled about in the parking
lot behind the center. The group was a little nervous, not
- 45 -
quite knowing what to expect.
Three weeks earlier, Tim Shepard had been one of the cadet
candidates pulled aside from the rest of the group during the
screening of candidates. Martin Michelman, Training
Coordinator of the Massachusetts Criminal Justice Training
Center, journeyed from his Needham headquarters to the Agawam
site on August 26 to supervise the testing of each candidate's
basic physical exercise skills: running, pull-ups, sit ups, sit
and reach, bench presses and more. Candidates were also
measured for height, weight, blood pressure and body fat.
Michelman originally told Shepard and at least three others
that their body fat was too high and they wouldn't be
admitted. But near the close of the session Michelman
announced that each candidate had qualified for the Academy.
He added that the test results for the group as a whole were
"about the worst scores I've ever seen."
Dominic Serino of Easthampton was one of the cadets
Michelman told had high body fat. Serino says he was told to
be in shape prior to reporting to the academy, which was set to
begin in 24 days.
Trooper Gilmore had wanted to attend the screening of his
first prospective class. But duties at Framingham delayed him
and he arrived in Agawam two hours after the candidates had
gone home.
On August 26, Tim Shepard, 25, stood 5'7" and weighed 171
- 46 -
lbs. He was recorded as able to perform 22 sit-ups, 15
sit-and-reach, and two pull ups . It took him 15 minutes and
five seconds to run the mile-and-a-half .
John F. Pronovost, 28, newly appointed to the Chicopee
P.D., was another candidate who had been pulled aside during
the screening. Pronovost recalls that he, Shepard and
Morrissette were among those initially advised by Michelman
that their body fat was too high and that they would not be
allowed into Class 12. In any case, each candidate was
admitted.
Pronovost recalls Michelman saying on August 26 that, if
the decision were his, three-quarters of the class tested would
be denied admission.
Pronovost, 24, stands 5 '7" and on August 26 weighed 166
lbs. He performed 22 sit-ups, 19 sit-and-reach, one pull up,
and he ran the mile-and-a-half in 10 minutes and 44 seconds.
After the screening, Pronovost began to watch what he ate and
to exercise. He said he was down to 160 lbs. on the day he
came back to Agawam.
In describing the screening process to investigators,
Director Harrington said that the purpose of the physical
skills testing is to determine where an applicant is now and
where he should be. He stated that it was Michelman' s practice
to rate each applicant's ability as good, fair, or poor.
Despite his posturing to the candidates about their poor
- 47 -
physical condition, there is no evidence that Michelman
conveyed any substantive warning or recommendation about the
candidates to anyone in a position to act. In fact, he later
told investigators that the class looked about average.
Richardson asked Michelman over the telephone on September
8 how the group looked.
"Not too good, John," was all Michelman said.
Michelman told investigators that he felt that the troopers
were experienced instructors and that it was not his job to
offer suggestions as to how this group should be trained.
Other than supplying the Council with a statistical data
base for future undefined purposes, the individual test scores
at Agawam are put to no meaningful use.
Ann M. Charest, 23, of the Ludlow Police Department, says
she did daily push-ups and sit-ups as well as a mile run to
prepare for the Academy after screening day. She had been
three lbs. over her height/weight limit on August 26.
Gilmore, Richardson and the troopers selected for First Day
held a brief meeting shortly after 7:00 a.m. During this
session they agreed that the day would be run pretty much like
previous ones. Gilmore said that Nartowicz would be the
medical officer. Gilmore emphasized that he wanted no
derogatory names thrown at the cadets by troopers and he wanted
no derogatory statements as to the jurisdictions of the cadets
and no comments rooted in race or sex.
- 48 -
Since coming to Agawam, Gilmore had learned that the
Academy employees did not drink the tap water because it was
frequently discolored, although the town said it was safe.
At the September 19 morning meeting, he told the troopers
that the cadets would drink only from the bottled bubbler.
It is unknown whether the subject of running a garden hose
out back to supply water to thirsty recruits arose at the
meeting. Such a hose had been used in the past on warm weather
"First Days." Richardson knew this. Cpl. Kozaczka, who had
participated in all of the warm weather "First Days" at Agawam
also would have known it. Gilmore was later quoted in a
newspaper interview as saying that he did not use a hose
because of concerns about the tap water and the condition of
the janitor's slop sink from which the hose was run.
Gilmore says that he and the troopers discussed getting the
trainees to drink the water and that they actively encouraged
the trainees to drink. He said he personally told the cadets,
"Drink plenty of water." There is, however, strong indication
that this remark was not made until after Cadet Shepard
collapsed.
During his interview, Gilmore said that it was not his
specific job to force water upon trainees. He noted that he
has never been trained as to how much water is required to
sustain an individual participating in physical activity.
On September 29, Captain Thomas R. White, Commandant of the
- 49 -
Massachusetts State Police, told investigators that part of
Gilmore's previous job as instructor at the State Police
Academy was to force liquids upon trainees who looked as if
they needed it. Part of his job and the job of any state
police instructor is to override the "intimidation factor" that
might prevent a trainee from drinking when thirsty, said White.
At 7:30 a.m., Monday, September 19, it was a cool 60
degrees. By mid-afternoon, the temperature would rise to 81
degrees with humidity of 54 percent.
Class 12 was comprised of 50 cadets from communities
throughout western Massachusetts. Fifty-two had been
admitted. Two never showed. It was still the largest class in
Agawam's history. The youngest was 20, the oldest 32. At 7:30
a.m. sharp, two troopers came out the back door of the building
to the so-called rear company street. The cadets were called to
order. Shepard, Kemp, Pronovost, Civello and all the rest
lined up. The roll was called. The cadets were ordered to
change their boots for running shoes quickly. Each had brought
the required duffel bag containing personal necessities, a rain
coat, towel, gun cleaning kit, extra uniforms, jacket, gym
clothes, etc. Immediately after changing into sneakers, they
were led up to classroom 110 carrying their duffel bags above
their heads.
Once inside the room, Gilmore had instructed the class on
the rules and regulations of the Academy with an emphasis on
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the required deference to drill instructors. The first and
last word out of a trainee's mouth was to be "Sir!" The
presence of a trooper entering the classroom would be
announced sharply by the cadet nearest to the door. All inside
were to snap to attention to the phrase "Trooper on deck!" A
cadet must never look directly at a trooper. A cadet must
request permission even to walk past a trooper: "Sir, by your
leave, sir!" A cadet must answer a trooper properly: "Sir, yes
sir!" or "Sir, no sir!"
Each cadet was given a list of regulations to read and to
initial. Gilmore then left the classroom. The cadets were
alone, sitting at the desks, for a few silent minutes. The
windows on the doors of the classroom had been taped over with
paper by Richardson on Friday to preserve the element of
surprise for what was about to happen.
At 8:15 a.m., the doors to Classroom 110 burst open. Six
state troopers, each with a swagger stick, rushed inside
yelling and screaming . The cadets leaped to their feet beside
tightly grouped desks. There was no room in the aisles.
Troopers jumped onto the desks and stomped across them. Others
stormed about the room kicking waste baskets, banging swagger
sticks against tables and walls, knocking over flags and
chairs, yelling for cadets to stare stone straight ahead; and
shouting in an apparent fury. No cadet was touched by a
trooper. Two cadets were struck by flying pieces of swagger
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stick. Pronovost bruised his side against the knob of a
slammed door. The stress training had begun.
The fury abated after five to ten minutes. The troopers
shouted for the cadets to fall out on the company street. The
group moved "too slowly" and, upon lining up outside, was
ordered to drop for push-ups. The cadets were told to hold
their boots over their heads with one hand and to raise their
duffel bags with the other. In this manner, they were led in a
run around the academy building out to South Westfield Street,
a distance of .28 miles. If the boots or duffel bag were held
in the wrong hand, the cadet dropped for push-ups.
The shouting troopers intended the group to function as
one. If a cadet "messed up" the group suffered extra push-ups,
running, "mountain climbers" (arms in push-up position, legs
alternately moved forward and backward) or "dying cockroach"
(back on ground, arms and legs raised skyward) . Those who
could not continue to perform push-ups were ordered to "rest"
in the stationery push-up position until they could resume
exercising. At alternating blasts of the whistle, cadets were
required to drop to a front leaning rest or leap back to
attention.
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"Down! "
"Up! "
"On the deck!"
"Straighten those legs!"
"Knees off the ground!"
"Faster! "
"You ' re too slow! "
echoed through the company street for the next two hours.
Cpl. Kozaczka confirmed that the first lap of the day
around the Agawam building was done with the trainees holding
their equipment bags up over their heads.
During that time, cadets ran the perimeter of the building
an estimated five to eight times, twice with full equipment
carried above their heads. Cadet Jose Cedeno of the Holyoke
Police Department nearly fainted and a trooper took him inside
the building where he could sit on a bench.
Earlier, at approximately 7:00 a.m., Tpr. John Richardson
had telephoned the Agawam Fire Department and advised that this
was the first day of a new cadet class, and to have an
ambulance on standby.
Records of the Agawam Fire Department indicate that
ambulances from Agawam or the West Springfield Police
Department have responded 12 times within five years to
requests for medical assistance at the Academy. Once in 1984,
two times in 1985, four times in 1986, two times in 1987, and
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three times this year. Each time the person in need of help
was a cadet .
Eleven of these calls have required transporting a Cadet to
the hospital. Once, emergency medical technicials treated a
hyperventilating cadet on the grounds; a transfer was
unnecessary.
Symptoms of cadets requiring assistance are most often
described as chest pain, shortness of breath or faintness. One
report of back injury and one of leg pain also are recorded.
Sometime after the exercise began on company street, the
troopers discovered that the academy's oxygen tank was empty.
James Currier, Academy custodian, was dispatched to fill it.
Cadet recollections of the first morning vary but their
thrust is centered upon a day of seemingly ceaseless physical
exertion or mental stress. Cadet Michael Bullett, 32, of
Williamstown, the oldest, remembers that, "two men passed out
while running." Cadet Ann Charest of Ludlow states, "if you
slowed down, they yelled at you. A few people had cramps but
nobody fainted while running." Cadet Ellen Kummerle of Amherst
remembers seeing one man faint and the trooper who helped him.
She nearly fainted herself. ("It was hot and I had not had
breakfast.") When she began to falter, a trooper pulled her
aside and told her to rest.
Pronovost recalls the troopers being, at times,
compassionate. He says that when cadets fell to the ground,
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the troopers would not push them harder, as long as they tried
to perform. Those who did not make an attempt, he says, were
pushed harder. A trooper took Pronovost out of formation,
saying, "Come on, do one for me. Do you want to resign?" "Sir,
no sir!" "Get back in line!"
Cadet Neil Leveille of Greenfield, at 32, second oldest in
the class, remembers Gilmore asking the cadets in formation if
any had physical impediments or had hurt themselves in
preparation for the academy. No one stepped forward. Leveille
had known Gilmore for years and was acquainted with Richardson.
A gear drill was begun shortly after the cadets had the
morning run around the building. Push-ups and other exercises
were coupled with cadets retrieving items from duffel bags and
holding them with raised arms and for minutes at a time. If a
cadet failed to find an item in the bag swiftly, the class was
ordered to do push-ups, ups-and-downs , cockroaches, "mountain
climbers", or to run around the academy. The cadets were
required to find things so quickly it often could not be done
successfully. Cadet William Baker, 26, of North Adams,
remembers that the inventory went on and on "to the point where
it was stupid", saying they were required to do 15 sets of 10
push-ups each. The cadets performed so many incentive
exercises during this drill that Baker was unable to hold his
blousing rubbers over his head when that item was called. (A
blousing rubber is used to ensure that the pants leg billows
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properly from the boot. It is similar to a large elastic band.)
Cadet Nelson Vasquez of Holyoke and Edward Connor of Agawam
were singled out for special treatment by the troopers. Each
had completed nine weeks of training in class 11 -- the last
class run by Spellacy and Richardson. Each left at the start
of week 10 for failure to qualify with firearms.
"What are you doing back here? Do you like it here?"
Richardson asked of Connor.
The entire group was made to drop down and do push-ups
because of supposed infractions committed by the "repeaters".
Connor and Vasquez were sent to the grass track behind the
parking lot to run while their classmates continued the gear
drill. Connor recalls that he ran, off and on, for an
hour-and-a-half that morning. He faltered once and says that
troopers made him do push-ups, jumping jacks, and mountain
climbers. Group punishment, in the form of exercise, was
credited to Connor and Vasquez.
Vasquez says that during that first morning he had to drop
for push-ups nearly every time a trooper walked past him. He
believed he did about 50 by 9:30 a.m. When he went inside for
a haircut, Tpr. Kozaczka made him do more push-ups and, Vasquez
said, commented: "I'm going to get rid of you."
Once during the morning, Agawam Police Chief Stanley
Chmielewski, watching the cadets from a second-floor window,
heard a trooper call out that "Spellacy may be gone, but his
- 56 -
spirit lives on! "
For close to two hours, the troopers put the cadets through
the gear drill. Troopers frequently dumped the contents of
duffel bags onto the pavement if a cadet did not move quickly
enough. By the end of the drill, rear company street was
littered with towels, raincoats and personal items.
Cadet Rich stated that the cadets did push-up after
push-up. He was able to do 50 to 60 good push-ups, he says,
before his arms wore out by 10:00 a.m.
At one point the troopers discovered that Rich had
graduated from college and said to him, "Just what we need,
another goddamn liberal cop." He says they also told him,
"Rich, you won't be here tomorrow."
The other troopers continued to walk around hollering.
Leveille remembers that one of the three women cadets "screwed
up." She was made to stand at attention while all the others
did push-ups, and the cadets were required to thank her out
loud as they did their push-ups.
As Leveille was performing an "incentive" exercise during
the gear drill, he pulled a muscle in his lower back. The
injury made breathing difficult. A trooper pulled him out of
the line and told him to sit until he felt better. There were
other instances of trooper concern.
During one morning run, Jose Cedeno of Holyoke Police
Department nearly passed out. A trooper took him inside the
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building so that he could sit down and rest on the bench.
Runs were conducted in line formation. Scattered gear was
frequently stepped upon by cadets. Several lunches were
squashed.
From shortly after 9:00 a.m. when the barbers arrived,
until about 11:00 a.m./ groups of cadets were broken out of
ranks and sent inside to get their five-dollar, closely cropped
haircuts. Ann Charest remembers that the troopers outside had
asked the entire group if anyone wished to resign before
getting the haircut.
Following their haircuts, each cadet was sent into the
bathroom for a "head call", and to wash the hair clippings from
his face.
Tpr. Kozaczka was in the corridor where the cadets' hair
was being cut, between the barber chairs and the bubbler. Some
of the cadets were required to do push-ups in the hall.
Following the haircut, most, not all, cadets took the
opportunity to make a quick trip to the bubbler. One cadet
remembers that no one took more than one cupful. He says that
a trooper specifically told his group they were limited to one
cup each. However, it is more likely that no direct
restriction was made. The water line stood at attention
toe-to-heel .
Cadet George Moriarty, West Springfield, doesn't recall a
one-cup restriction, but he said he didn't want to call
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attention to himself and risk having to do more push-ups by
taking more.
Tpr. Maroni said that he and other troopers actively-
encouraged the cadets to drink. "We are not unreasonable.
"Drink the water," he recalls saying.
Gilmore, according to Kozaczka, then told him, "Give the
trainees a break after their haircuts."
"A head call?" responded Kozaczka.
"Yes, then have them go into the classroom and give them
the rules and regulations they left there, and bring them out
to the rear company street."
During this time, Kozaczka said that he would address the
cadets in a low voice, telling them to pay the barbers, get a
haircut, use the bathroom and "do what you have to do, clean
up, then get the rules and regulations from the desk and then
go back to the rear company street."
Kozaczka concedes that he did not specifically tell the
cadets to drink — or not to drink — water.
Kozaczka said that haircuts were completed at about 10:45
a.m. and that at this time the whole class was given a morning
water break. A few didn't get the word.
Cadet Chris Patnode from East Hampton said that on the
morning of September 19 cadets were given a water and toilet
break and were told to get a cup of water. He said he took
this to mean that the cadets were only allowed one cup from the
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dispenser. No one wanted to risk taking more, Patnode noted,
or getting singled out or spoken to by the troopers who were
around the dispenser.
Ann Charest said she did not have a drink of water until
just before lunch. When the cadets were finally given a water
break, she says, "the troopers told us we could have one
cupful." Lawrence Rich from Monson was handing out three-ounce
paper cups. He drank only one. A trooper stood next to the
bubbler and another near the cadets who were lined up
toe-to-heel at attention.
Vasquez said he had his first water break after lunch
during which he drank a single paper cupful. "Nobody dared to
drink any more", he said.
Asked to describe the difference between the first day of
Class 11 and the first day of Class 12, Vasquez said that the
difference was that Class 12 did more exercise and got less
water .
After the bubbler visit, most cadets gulped more from the
lavatory taps — by the handful. Harrington told investigators
that the janitor had complained to him about the cadets
spilling water onto the men's room floor when they were
slurping from the taps.
Harrington told investigators that he was unaware of the
application of any hydration standards at Agawam, but he said
on October 4th that he still believes sufficient water had been
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made available to the cadets, saying that spilled water on the
men's room floor was evidence that the cadets had been drinkiny
from the taps.
Sometime before 11:00 a.m., one of the barbers recognized
Tim Shepard as a former customer. The barber said Shepard
looked fine.
After the haircuts and the gear drill, the cadets were told
to drop their boots into a big pile on the rear company street
and to report inside. The cadets were then instructed to carry
tall metal lockers from the basement to the third floor. One
described this as a welcome break. The first few lockers were
carried one locker to one man. A locker was dropped in this
manner, striking a cadet on the shoulder. The troopers then
changed the drill to two cadets per locker. Tables and chairs
had to be moved upstairs as well. The three women cadets were
told to put down the lockers and carry something lighter.
Theodore Klaus, Chicopee, cut his hand while carrying a
locker. Richardson referred him to Trooper Narcowitz who
washed his hand, disinfected and bandaged it.
Cadets saw construction workers in the basement. There
were holes in the floor and the air was dusty.
For the next few minutes, cadets stored their equipment
from the duffel bags in the lockers, assembled in rooms on the
third floor.
Trooper Hughes later said in his interview that he
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estimated the morning drills had provided sufficient time for
possibly 130-140 push-ups. But he doesn't believe that any
cadet actually performed that many.
A copy of a videotape documenting some training at the
Agawam Academy on the opening day of Class 11, February 22,
1988, was obtained by the Attorney General. "First Day" Class
11, according to Vasquez and Connor, began at 8:00 a.m.. The
video records the initial assembly of cadets. The video, after
several interruptions, ends with the medical assist provided to
Cadet Rachel Rondeau, for whom an ambulance was called at 11:30
a.m., the second ambulance call required that morning.
The video runs two hours and 27 minutes, not recording
approximately one hour of elapsed time during the first three
and one half hours of training.
During the two hours and 27 minutes recorded, the main
group of cadets is required to perform approximately 188
push-ups. Smaller groups are made to do more. Additionally,
the group as a whole spends a total of approximately 13 minutes
in the stationary push-up position (front leaning rest). The
video also records that the group made four runs around the
building. Additional exercises such as ups-and-downs and
"mountain climbers' were performed but not counted.
At about 11:30 a.m., Class 12 was marched into the
lunchroom to eat.
Tables and chairs were stacked off to the sides of the
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lunchroom. Cadets Vasquez and Connor, the two repeaters from
Class 11/ were made to stand back-to-back in the center of the
room. The other cadets were ordered to form a tight circle
around Connor and Vasquez. The troopers then made the cadets
press up against Vasquez and Connor and themselves as closely
as possible and to sit down on the floor. The troopers wanted
no daylight between bodies.
"Push tighter, I want you to smell the sweat of the guy in
front of you!", shouted a trooper.
The cadets were urged by the troopers to share their
lunches and drinks with the cadets who had none.
The cadets nibbled pieces of sandwiches and drank their
drinks sitting sprawled upon each other on the floor. Some
felt nauseous. The air stank. The troopers circled above them
continually throughout the lunch, which lasted about 20 minutes
Lawrence Rich gave away his iced tea and forced down two
grape drinks before lining up "nuts to butts" to leave the
room. The troopers, Rich recalled, said they wanted "to see
noses in the back of somebody else's head."
At 11:55 a.m. the temperature was 73 degrees and the
humidity 71 percent, according to the weather station at
Westover Air Force Base in Chicopee. Michael Purcell of
Northampton wanted out.
Purcell went to Richardson in the trooper's office and
announced he wished to resign for "personal* reasons.
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Richardson was concerned and he brought Gilmore into the room.
Purcell assured the troopers that his decision had nothing to
do with his first day experience. He had a wife and baby, he
explained. Being a police officer would keep him away from
home too much. Richardson asked if he had another job lined
up. Purcell said no. Gilmore asked Purcell to reconsider, to
sleep on it, at least.
The cadets were then told to clean up the lunchroom and to
fall out onto the company street. It was not quite noon.
The cadets were lined up by height and told to count off in
the following manner:
"Sir, One, Sir!"
"Sir, Two, Sir!"
"Sir, Three, Sir!"
"Sir, Four, Sir!"
The cadets couldn't quite get it. They made many mistakes
in counting. Each time a cadet made a mistake every cadet
dropped for push-ups.
When they weren't doing push-ups, they did dying
cockroaches, mountain climbers or "rested" in the stationary
push-up position.
Leveille had his legs in the air in the dying cockroach
position. His back started to hurt again and he lowered his
legs. Trooper Hughes ran over to him, he says, called him a
Communist, and began to berate him. The trooper who had
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assisted Leveille that morning, probably Nartowitz, came out
again and told Hughes to back off and again took Leveille aside
to rest .
David Sacco of North Adams felt light-headed and a trooper
told him to sit on the curb to catch his breath, instructing
him on how to breathe. Sacco rested for while, then rejoined
the group.
Director Harrington acknowledges that punishment push-ups
are regularly performed by all because of one cadet's failure
to accomplish a task. Harrington says that he does not believe
that such punishment is appropriate on the first day, but he
has never discussed his position with any instructors.
When squads finally were formed, Hughes ran the close order
drill and marching instructions. This lasted about half-an-
hour. The troopers were favorably impressed by cadets'
performance .
The troopers soon blew a whistle and told the cadets they
had 30 seconds to retrieve their boots from the pile made
earlier that morning. Five times the cadets tried to run to
the pile, find their boots and get back in line within 30
seconds. Each time they failed they dropped for push-ups or
the so-called front leaning rest. Occasionally they were told
to run around the building.
Around this time, Cadet Garner felt sick. Hughes and
Nartowicz took him inside, sat him down, and gave him water.
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Finally, a few cadets overheard a tropper suggest that if
the cadets had any brains it would speed the process to grab
any two boots from the pile. The cadets caught on.
Trooper Gilmore took Leveille into his office and asked him
how he was feeling. Leveille, who knew Gilmore, described the
pain he experienced. Gilmore lifted Leveille's shirt, probed
the painful area. He told Leveille not to participate in
physical training.
The boots exercise apparently lasted until sometime between
1:00 p.m. and 1:30 p.m. Richardson's administrative log
indicates that close order drill continued from 12:30 p.m. to
2:45 p.m. when the cadets went inside for Officer Thrasher's
first aid class. It appears, however, that the cadets went to
see Thrasher much earlier. Thrasher says that he held class
from 1:00 p.m. to 1:30 p.m. and drove to work at Amherst, some
30 minutes from Agawam. Thrasher says he reported to work in
Amherst at about 2:45 p.m. Thrasher's lieutenant at Amherst
says that office records confirm Thrasher showed up at about
2:50 p.m. on September 19 and worked the 3:00-11:00 p.m. shift.
The significance of this discrepancy between Thrasher and
the state police is its effect upon determining when the
afternoon physical training began and how long the cadets ran
before Shepard collapsed.
The second water break of the day, not counting lunch,
occurred right before or right after the next event: a visit to
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Classroom 110. Trooper Kozcazka puts the first afternoon water
break at about 2:30 p.m. Once again, most cadets consumed a
single three-ounce cup of water and then slurped from the
lavatory faucet. By now some cadets had begun to put their
mouths directly on the faucets. Handfulls were no longer
sufficient .
The cadets reported to Classman 110 to see U-Mass/Amhers t
Officer Robert A. Thrasher for instruction in the first Aid/CPR
course. Thrasher introduced himself, handed out texts and the
cadet's homework assignment for Monday night. Thrasher also
told the cadets that the troopers couldn't bother them so long
as they were in his class. He urged them to "stick it out"
because things would improve after first day. Between 3:00 and
3:30 p.m., the cadets changed into gym clothes for the start of
P.T. The temperature had risen to 80 degrees. Humidity was 52
percent .
Troopers Hughes, Cadran, and Maroni left for the day.
The cadets were assembled on a grassy area adjoining the
parking lot for stretching and "warm-up" exercises prior to a
run. These lasted about 20 minutes.
Harrington noted that when past classes had been conducted
in warm weather, a garden hose was left, for the use of cadets,
in the rear of the building near the training area. He stated
that this hose was only made available during the first day of
a new class. On September 19, 1988, there was no hose.
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At about 2:00 p.m. the cadets left the Classroom and were
given a break to visit the bathroom and bubbler. The cadets
were lined up in the front of the bubbler, toes-to-heels .
Nearly every cadet drank just one cup of water, approximately
three ounces. Most then visited the lavatory, where they
gulped tap water by the handful.
According to Cpl. Kozaczka, the entire class had another
supervised water break after the close order drill in the
afternoon at about 2:30 p.m.
Following the stretching exercises, Gilmore led the run.
Kozaczka said that the troopers "didn't make one lap before
people started dropping out." Ten to 15 stopped and walked.
He said that different instructors would take different groups
of stragglers. Kozaczka suggested to Gilmore that the
stragglers do push-ups. Gilmore disagreed saying that he
wanted the trainees to keep their heads above their hearts to
continue an aerobic exercise. Cpl. Kozaczka suggested duck
walks. Gilmore said ok, and that is what Kozaczka did.
After 20 minutes of "warm-ups" the troopers marched the
class by squads onto the track. The mown grass track is
approximately one-fifth of a mile long. Gilmore led the run
starting at about 3:45 p.m. Richardson and other troopers
followed. The formation began breaking down almost
immediately. Runners began to falter after less than two
laps. Slower runners were pulled off the track by the trooper
- 68 -
and made to do duck walks in the opposite direction or to lie
on their backs in the dying cockroach position. A group of
runners who could not keep up with Gilmore moved off to the
side 3nd made the run down a slope leading to the golf course.
Those who finished first assumed the stationary push-up
position to wait for the rest. Gilmore later said the track
run was conducted at about the pace of a 10-11 minute mile. He
said he had decided to reduce the planned running time from 35
minutes to only 20 "to bring them along gradually."
Brian Duffy of the West Springfield Police Department said
that the cadets were sweating profusely, out of breath and
vomitting. He said that the trooper who ran with the cadet's
said "things don't get easier." Duffy said that nothing was
said about the importance of drinking water.
Ann Charest ran a half-mile run and developed pains in her
side and chest. She began to walk and was pulled aside by a
trooper. She was required to do more push-ups and jumping
jacks, and then told to run with the group again.
Several times she said Gilmore stopped to allow slower
runners to catch up. The other troopers supervised the ordered
exercises of those too tired to run. She says she felt dizzy
and she remembers hearing a cadet ask for water. A trooper,
she said, replied that no one had done enough yet to deserve
any water.
Cadet Rich stated he was so tired he could hardly run. He
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had cramps in the lower back and chest and a pain in his
testicles. The pain finally made him stop after five laps, at
which point a trooper made him do a duck walk and then to lie
on his back with his feet and arms in the air.
The trooper then wanted him to run again. Rich ran another
two-to-three laps, got cramps again, and stopped. He tried to
run a couple of more times. He recalls that he was very
thirsty and that he got to the point where he wasn't sweating
anymore .
By now some trainees were just sitting, Kozaczka said.
"They could not do any of the routines, could not do any more
at all." So Kozaczka said he got them up and walked them
around. To those who said they were going to throw up,
Kozaczka told them to do so off the track. Kozaczka says he
did not actually see anyone vomit.
Kozaczka and Richardson took some stragglers on the run off
the track and down a hill leading to the golf course. After
reaching the tree near the bottom, a couple of hundred yards
away, they reversed their direction and led the group back up
again. About half way up, Kozaczka said, he stopped because
some did not appear to be making it.
He and Richardson got their group running again on the
track with Gilmore. At this point, says Kozaczka, they saw
Shepard fall and Gilmore told Richardson to call an ambulance.
Cpl. Kozaczka remembers the weather of September 19 as
- 70 -
being in the upper 70* s to low 80' s -- "It was a nice day, mild
humidity. "
Moriarty had the dry heaves. He saw others in the same
condition. Of the original group starting the run, it seemed
that only two trainees finished -- Provost and Jeff Gawron.
Milledge finished right behind them, but the troopers
didn't realize it. Milledge kept his mouth shut and had to do
the run over. He finished first the second time.
Cadet Klaus was taken off the track by a trooper. He and
eight others did cockroaches or "rested" in a stationary
push-up position. After a while they were told to start
running again. Klaus ran one lap and slowed down. He was
pulled from the track and made to do cockroaches again. He saw
other cadets crawling around perimeters of the track; others
were holding their sides. During another attempt at running
Klaus fainted. When he came to, Trooper Gilmore was standing
over him saying:
"Are you alright?"
"I'm okay. "
"What happened?"
Cadet Klaus said he didn't know. Gilmore then told him to
"get up and walk." It was about this time, he said, that
Shepard collapsed.
Jeff Gawron and Jon Provost were allowed to cool down and
go inside after finishing the run. Gawron said he noticed
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troopers gathering around someone on the track as he walked
inside. It was just past 4:00 p.m.
Tim Shepard was rounding the turn in the grass track when
he stumbled straight ahead and collapsed. Two cadets say that
Shepard fell once, got up, ran a bit more and collapsed.
Kevin Garner cried: "Man down!" Trooper Nartowicz rushed
to Shepard's aid. Gilmore arrived behind him. Gilmore says
Nartowicz called for oxygen. Gilmore ran to get the tank from
his office. On his way back he told Richardson to call an
ambulance .
Shepard was pale and sweating, he said, and he and
Nartowicz gave him a little oxygen. Shepard came to a bit and
tried to get up. The troopers and two cadets carried him
inside and placed him lying on a bench. Shepard's breathing
became rapid, Gilmore recalled, and they gave him another shot
of oxygen. They put an ice pack on the back of his neck.
He was on the bench, limp, when EMT Michael Mercadante
arrived at 4:15 p.m. in the ambulance.
Mercadante said that Shepard felt warm but not 106
degrees. He also said that Shepard was hyperventilating at a
rapid rate. He said he counted a respiration rate of 60+ per
minute. Mercadante said that he tried to get Shepard to
respond to a pinch and ammonia without results. He said that
Shepard's pupils were mid-point and slow reacting. Mercadante
noted that Shepard was wet from perspiration but he is unsure
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if Shepard was sweating at that time. Mercadante said that
Shepard did not show the typical signs of heat stroke. He said
that in the first 30 seconds he saw Shepard change from flush
to pale. He said that Shepard had an unsteady but strong pulse
counted at 160/minute.
Mercadante said that he tried to slow down Shepard's
breathing by putting a mask on his face for the purpose of
building up carbon dioxide in Shepard's system. After 30
seconds of mask use, Shepard was still pale. He then tried to
insert an airway but Shepard gagged so he "went to a bag
valve." By use of this device, Mercadante said he was able to
slow Shepard's breathing rate to 40/minute. Shepard continued
to have a strong pulse. Mercadante said Shepard had some
frothing around the corners of his mouth.
After having been at Shepard's side for less than a minute,
the other cadets entered the area to get water. According to
Mercadante, they were told by the three or four troopers
present not to look, to keep their "eyes ahead."
Mercadante said that the troopers didn't know Shepard's
name and that there was no medical profile for the cadets
available at the academy. Mercadante said a cadet volunteered
that he had known Shepard for two years and that Shepard had no
history of medical problems.
Mercadante said that the troopers told the cadets to "make
a hole, let the EMT through" when his partner entered with the
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stretcher. He said that the cadets hurried through the water
1 ine .
Meradante said that Shepard was then put on the stretcher
and brought out to the ambulance. Shepard's blood pressure
dropped quickly to the point that he could not get a diastolic
reading. The blood pressure readings that Mercadante said he
could get were 100/40 and then 76 by palpitation. He said he
tried to find the diastolic by sound but could not.
When Harrington saw the ambulance arrive, he walked outside
and asked Gilmore what happened. He told him a cadet had
collapsed apparently from heat stroke.
Cadet Rich was one of the two wrro helped carry Shepard into
the Academy. He recalls lifting one of Shepard's legs and
feeling it "spasm" in his hands. He said that Shepard was more
unconscious than conscious during the time he was carried
inside. Rich then went back out to move the orange cones from
the driveway so the ambulance could get by.
Gilmore now urged the cadets, apparently for the first
time, to drink plenty of water.
The cadets were told to go up to the locker room and change
back into their duty uniforms and boots. At 5:00 p.m. they
reported to Classroom 110 for instruction about the proper
wearing of the duty uniforms. Sixteen minutes earlier Tim
Shepard's ambulance pulled into Bay State Medical. Between
5:30-6:00 p.m. the cadets fell out onto the rear company street
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with their duffel bags for dismissal.
Tpr. Gilmore called out the names he had recorded for those
cadets who had been injured or felt ill during the day. He
suggested they see their doctors and bring excused notes to the
Academy in the morning if necessary.
Afterward, the cadets were given 30 seconds to race to
their cars with their gear:
"Group dismissed!"
"Sir , yes , sir ! "
"Get! '
Someone flinched before the trooper said "Get!" Everyone
dropped for push-ups. A second time they raced for their
cars. The trooper's whistle blew: "Too slow!" The group
returned to formation for more push-ups. Again, the race.
Again, the whistle. On the third try, the troopers let them
leave .
"First Day" officially was over.
Gilmore called Civello back and took him upstairs. He
asked Civello to be certain to check on Shepard's condition at
the hospital and to report back tomorrow.
A few cadets showed up at Agawam High School to sort out
their gear, most did not. Ann Charest went back to Ludlow.
She was experiencing a pain in her chest and had trouble
breathing. Her parents took her to the doctor who, she says,
told her she had muscle strain. Afterwards, she reported to
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Ludlow Police Department and was taken to the emergency room.
She reports that her urine was "almost dark brown."
One Tuesday, Ann could not move her right arm. She went to
her chief and he telephoned the Academy. Charest told Gilmore
over the phone that she had to see a doctor. Gilmore told her
go ahead. She was admitted to Ludlow Hospital in the
afternoon. She recalls that her arm was so swollen below her
elbow that she could not distinguish her wrist. On Wednesday,
Gilmore telephoned Charest at the hospital, speaking to her and
to her doctor.
Leveille stopped at a convenience store and drank a large
bottle of Gatorade between Agawam and Greenfield. When he
arrived home he showered, drank some soda and coffee, and drove
to the doctor. Gilmore had advised him to seek treatment for
his back pain. He had noticed that his urine was brown and
Leveille knew from the army that it was a symptom of
dehydration. When he got back home from the doctor's, he had
some chicken and potatoes, drank some more, and went to bed at
10:00 p.m. He tossed and turned most of the night. At 3:45
a.m., feeling like he had a "toothache in his shoulder", he
went back to the Franklin Medical Center, where a doctor told
him not to report back to the Academy before Wednesday at noon.
When Cadet Rich got home to East Longmeadow, he drank a few
small grape drinks. Shortly afterward, he started to vomit.
His mother cooked supper but he was not hungry. He took two
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tylenol and went to bed at 8:00 p.m. By morning, he had
decided to quit the Academy. He went to see his chief and told
him he was leaving for "personal problems", but after spending
some time at the station, Rich changed his mind again and asked
the chief if he could return to Agawam. The chief said he
would see what he could do.
Brian Duffy's arms were so limp that night that he couldn't
pull the string switch to turn on the light. He was afraid to
lift his eight-month-old son for fear of dropping him.
Cadet Michael Purcell had had enough. Tomorrow, he would
qui t .
DAY TWO "
7:30 a.m., September 20, Gilmore and Richardson were the
only two Troopers present. The cadets were sore. When roll
was called Ann Charest, Jeffrey Gawron, Levielle, Rich and Tim
Shepard were among the missing. Gawron had called at 7:15 to
say that he was seeing a doctor about his shoulder. Within an
hour-and-one-half of formation, two more cadets had received
permission from Gilmore to go to Bay State Medical Center for
treatment of injuries incurred the day before.
Prior to the roll call, Richardson had shouted from the
window of the building, instructing the cadets to hit the deck
in a stationary push-up position. Following inspection, the
cadets were put through a ritual of push-ups, ups-and-downs ,
mountain climbers and occasionally held their duffel bags over
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their heads.
At 8:00 a.m. Class 12 filed inside the building for a water
break and "head call." That morning David Sacco's arms were so
sore that he couldn't knot his tie.
During morning head call Sacco noticed that his urine was
"as brown as Hershey's Syrup."
The cadets stored their gear and reported to Officer
Thrasher in Room 110 for instruction until 11:15 a.m. Thrasher
asked the cadets if they had any injuries and passed out ice
packs .
At 9:45 a.m. Cadet Purcell officially resigned. Gilmore
told Purcell he wanted a letter. Purcell gave him one which
stated "the main reason is family time involved which will
lessen in this field of work and will interfere at this moment
in time with the new born child." He specifically stated that
his decision "has nothing to do with the Police Academy staff
or any part of (sic)."
The cadets broke for lunch between 11:15 and 11:30. They
set up tables and chairs in the upstairs room where yesterday
they had eaten while crushed together on the floor. They were
given 30 minutes to eat. After lunch Trooper Richardson burst
in to say that he had heard that Connors and Vasquez had been
putting out the word that this class was easier than the last.
The cadets were told to clean the lunch room, put on their
sneakers, and report to the company street.
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Richardson then called them back into the mess hall saying
"I thought I told you to clean up this lunch room." Richardson
apparently had dumped the trash back on the floor and the
cadets cleaned the room a second time.
When they got outside they did several laps on the grass
track and then had to roll around in the grass. Several cadets
were feeling sick. Sacco remembers Richardson saying "You'd
better not puke on my deck."
They were taken back upstairs and made to crawl on their
stomachs along the floor from the lunch room into the locker
room, pulling themselves along by their elbows. These events
since lunch are not recorded in Trocper Richardson's
Administrative Log.
The cadets got another water break and returned to
Thrasher's classroom where they remained until about 3:00. At
2:30 p.m., the cadets who had gone to Baystate, Liquori and
Otero, reported back. They were put on light duty, including
no push-ups for one week.
Duffy said on Tuesday Trooper Richardson told the cadets
"You will drink water, take as much as you want."
At 3:00 p.m., the cadets were out back again in gym clothes
for 20 minutes of stretching and warm-ups. Gilmore then lead
the afternoon run, which lasted for about 25 minutes.
Tpr. Gilmore had called six cadets aside and told them that
they shouldn't make the run. One insisted on being permitted
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to do so.
Several cadets said it was at a slower pace than the first
day's run. About one third of the class stayed with Gilmore
throughout the run. Again, slower cadets were pulled off the
track and made to run up and down the slope to the golf course.
Those who could not keep up with Gilmore on the second
attempt at the run were instructed by him to write a "to/from"
letter to Gilmore explaining why they could not complete the
exercise. Another water break followed the run and the cadets
changed and went back to the classroom. Academy patches were
distributed .
Gilmore went off duty about 4:30.
Richardson announced to the cadets on the company street
that Gilmore had gone home and that he, Richardson, didn't care
how long he had to stay with the cadets because he was living
right there at the academy. The cadets did more "incentive"
exercises because there was unauthorized movement within the
formation. According to several cadets, they were made to run
around the track with duffel bags carried overhead. Quite a
few cadets could only walk. They were dismissed at 5:00 p.m.
with a 30-second dash to their cars.
At 7:35 a.m. Gilmore and Richardson came out on to the
company street. The cadets stood at attention during an
inspection of each. Connor was made to do push-ups. Vasquez
was sent to the track t- do laps in his boots. He said he ran
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laps for close to an hour before going to Thrasher's class on
CPR. At the first break Vasquez went to the bathroom and
gulped 10-15 mouthsful of water from the tap. During the break
he said several cadets in the bathroom talked about the
discolored urine. That never happened in Class 11 Vasquez said
Back in class Thrasher asked if anyone was hurting and
threw out ice packs for sore backs.
DAY THREE
There appears to have been little or no physical activity
on the morning of Wednesday, September 21. The most
significant event occurred during Officer Thrasher's course
when several cadets told him that they were experiencing
discolored urine. The cadets say that Thrasher told them the
condition was a sign of dehydration and that they ought to
drink more fluids.
The third day's Administrative Log kept by the troopers
notes that Cadet Rich was unreachable; Shepard was in the
hospital in critical condition, Morrisette was home with health
problems, and Charest was in Baystate Medical. Leveille showed
up at noon after being treated at Franklin Medical Center.
At 2:45 p.m., Gilmore and Richardson took the class for
another run. The pace was slower now, three quarters of the
class finished it.
At 3:20 p.m., Cadet Morrisette called to say that he was
being admitted to Mercy Hospital with kidney problems.
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At 4:00 p.m., after a water break, Gilmore assembled the
cadets in Room 110 to ask how many were experiencing discolored
urine. He then asked how many had drunk from the lavatory
faucets. About 20 said they did.
Gilmore told the class not to drink the tap water. No
reason was given.
At about 4:45 p.m., Gilmore called the Agawam Board of
Health reporting that the trainees had contacted some type of
illness and inquiring about the possibility of foul water.
After the cadets were dismissed, Gilmore reported the
developments to Captain White at the State Police Academy and
to Gary Egan at the Criminal Justice "Training Council. On the
advice of White, Richardson and the Academy secretary
telephoned the police chiefs to advise their cadets to seek
medical attention for any symptoms they had.
That night, water samples were taken from the academy.
Gilmore and Richardson stayed on duty until 8:00 p.m.
By Day Four, the cadets training had relocated to the
Agawam Police Station.
EPILOGUE
It should be noted that many of the trainees, including
some of those who are quoted in the narrative, felt that the
training regimen of Day 1 was not excessive. They were
supportive of the Troopers/Instructors, and they expressed
regret that Troopers Gilmore and Richardson were transferred
from their class. All of those who remain in Class 12 want to
get on with their training, and become police officers.
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VII . ENVIRONMENTAL REPORT
Introduction:
By Wednesday, September 21, 1988, the last day classes were
held for cadets enrolled in Class 12 of the Agawam Training
Center, the staff had focused its attention on the environment
as the source of problems for the cadets who had become ill.
By now, Cadet Timothy Shepard was hospitalized in critical
condition .
Before the State Troopers went home that evening, the town
health department would be called, as would each local police
department sponsoring a cadet. The police were advised that
some cadets had gotten sick and that there might be some
problem, probably with the water, at the academy. Trooper
Gilmore requested water testing at 4:30 p.m. in a telephone
call to Cass Treba of the Agawam Dept. of Health. It was the
town's Department of Public Works which asked the environmental
consulting firm of Tighe and Bond of Easthampton to begin
testing immediately. A company technician was there by 9:30
p.m. collecting tbe first water samples. More would be taken
over the next two days.
That night, following the calls of concern by the troopers,
the local police departments called each cadet. Some ordered
their cadets, irrespective of any medical problem or symptom,
to see a physician; others cautioned the cadets to report to a
doctor if they experienced any problems. By now, many cadets
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would have noticed their urine discolored.
By Thursday morning, the State Department of Public Health
(DPH) began an onsite investigation designed, among other
objectives, "to determine whether there was any hazardous agent
in the vicinity or the surroundings." A three-member team,
headed by State Epidemiologist, Dr. George Grady, began
interviewing, reviewing medical records, and collecting water
samples. A large share of the team's efforts was a search for
any toxic substance which may have contributed or caused the
cadets' sudden illnesses.
The Department of Environmental Quality Engineering (DEQE)
dispatched William Prendergast on September 23, to do a cross
connection survey. Other than this, DEQE staff did not visit
the Academy because they had been told DPH would handle the
case .
Dr. Grady issued his preliminary report to the Commissioner
on September 26th. His conclusion: the ill cadets suffered
from rhabdomyolsis , a breakdown of the muscle of the skeletal
type. He also concluded that the rhabdomyo lysis was caused by
an insufficient water intake by the cadets.
Nonetheless, questions about the environment persisted.
Some concerned the use of pesticides either at the Academy, or
the adjacent golf course or strawberry and sod farms nearby;
others continued to look to the water supply as the source of
the problem; there were lingering concerns about asbestos and
- 84 -
lead in the paint in the second-floor locker room where some
cadets had crawled on their bellies on troopers' orders to the
lunchroom across the hall on day two; and any sources of common
air, food or clothing.
To fully examine these and other questions, the Attorney
General recruited an environmental consultant to assist in the
investigation. After a thorough search, Floyd B. Taylor,
B.S.S.E., M.P.H., Professional Engineer (Environmental)
Massachusetts, was retained. (Curriculum Vitae attached in
Appendix). Mr. Taylor began his onsite, independent,
environmental assessment on October 5. What follows is his
report .
The Aqawam Training Center
The Center is a large brick and stone structure. There is
no central air duct system and heating is provided by a steam
boiler to radiators in the several rooms. Water supply comes
from the Agawam Town system through a two-inch copper service
line installed in 1982.
Building water Supply and waste Disposal
Just after the service line enters the front basement wall,
there is a two-inch meter. Below that is a short pipe with a
threaded end that does not include a vacuum breaker. At the
end of that pipe, a hose is attached. The two-inch line
services the building, but before continuing, a 3/4-inch pipe
branches off to the steam boiler. In this line, not far from
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the boiler and above it, is a 3/4-inch gate valve connected to
a Watts #777 3/4-inch bronze strainer, followed by a 3/4-inch
Watts 9D Back Flow Preventer. Then, the line leads to the
boiler through a McDonnell #51 Boiler Water Control. The
boiler is also equipped with a Honeywell Pressure Control and
sight gauge. There is no chemical feeder and it was reported
that no chemicals are or have been used to condition the boiler
water .
The building water system branches out to the first floor
plumbing fixtures in the men's and women's lavatories, the
kitchen, the instructor's lavatory, and a shower-slop sink in
the custodian's room. In the basement there is an electric
water heater fed by a two-inch C.W. branch. All potable water
piping is copper with soldered joints. There is no connection
to the old shower system.
Drinking water is also provided by a Great Bear Spring
Company water "bubbler" with hot and cold taps in room 107 on
the first floor. The "bubbler" uses five gallon carboys. It
was installed in August 1988.
Waste water is drained from the various plumbing fixtures
to a six-inch cast iron (soil) pipe in good condition beneath
the basement floor. That pipe leads to a septic tank behind
the Academy building.
The Aqawam Water Supply
The Town of Agawam gets its water supply from the Greater
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Springfield system. The source is 25-billion gallon Cobble
Mountain reservoir which feeds the West Parish filter plant.
This consists of slow sand filters, capacity 10 mgd, and a
25-30 mgd rapid sand plant. Treatment of slow sand effluent is
with chlorine and caustic. Raw water to the rapid sand filter
is coagulated with polyimmine, Magnafloc 572C; the effluent
receives chlorination and corrosion control. This source
serves the town of Agawam by gravity. There are no auxilliary
supplies or pumping stations except for a small pneumatic
booster serving a high elevation. Another feature of the
Springfield system is the Provin Mountain, a 60-million gallon,
covered reservoir which both helps tz maintain pressure and
provide some storage.
According to Roland J. Dupuis, Deputy Regional
Environmental Engineer, DEOE Western Region, there have been no
violations of DEOE (and U.S. EPA) primary, drinking water,
maximum contaminant levels. When any violation occurs, the
public must be notified. This is true both for Agawam and the
greater Springfield systems.
Agawam Street Mains
The service line to the Academy comes from a six-inch,
cast-iron line which was installed in 1912. That line runs
from the intersection of Pine Street, down South Westfield
Street to the state line. In 1978 this dead end was eliminated
by constructing an eight-inch ductile iron line
- 87 -
beginning at the end of the six-inch pipe and running
westerly to Pine Street, thus completing a loop. There have
been periodic episodes of cloudy water in this system which
have been relieved by flushing fire hydrants, most recently
on October 14, 1988. Cloudy water has also been reported in
another section of Agawam and, as is frequently the case, at
dead ends .
Water Quality Tests
As noted, the first water sample was collected at the
Academy on the evening of September 21st. This was to check
for the presence of total bacteria, organics, lead, trace
metals and coliform organisms, the indicator of water
contamination. The result was 0 per 1QQ mL. On September 22
and 23, Tighe & Bond took samples to find any back flow or
back siphonage of boiler water into the potable water
system. Two substances commonly used for boiler water
corrosion control were tested, namely chromium and
orthophosphate. The results follow:
Date Point Sampled Hexavolent Orthophosphate
Chromium
9/22 Boiler Water <0.005mg/L. 1.40mg/L
9/22 Men's Room <0.005mg/L O.OlOmg/L
9/23 Intake Strainer Not Tested O.llmg/L
Results of the more extensive tests made by Tighe & Bond
on samples from a tap in the men's lavatory are shown in
Table 1. Next, samples of both hot and cold water from the
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"bubbler" were collected September 26th and those test
results are in Table 2. Finally, a water sample was
collected by Robert Hoyt of Springfield's water department on
September 24 from the Karakla residence at 703 S. Westfield
Street. The Karakla home is directly across the street from
the Academy. The sample was taken at her request because of
cloudy water and her own health concerns. Table 3 contains
the results.
Cross Connections
A cross connection is a point at which potable water in a
closed pipe system may be contaminated through a connection
to another piping system containing -impure water or fluid.
Another type of cross connection is a point on a potable
water system, such as a hose bib, from which a hose or pipe
may be connected to a container of impure water or toxic
liquid. Several instances of these were investigated.
At the Academy:
As noted there is a hose bib on a small pipe from the
two-inch copper line at the meter. It does not have a vacuum
breaker and a hose is connected to it. While there is no
apparent source of contamination, the surroundings are untidy
In the janitor's closet, there is a hose bib over a floor
drain in the shower stall. Both hot and cold water serve
this outlet and there is a vacuum breaker, (SPEAKMAN-S (or 5)
5811 SVB-80) on the fixture. This may not be state approved.
- 89 -
A third cross connection is near the boiler where the
3/4-inch copper feed line connects to a bronze strainer and
back flow preventer. DEQE ' s Prendergast has said this point
should be protected by an approved Reduced Pressure Back Flow
Device.
When new plumbing was installed in renovating the first
floor, water closets and urinals in the men's lavatory and
water closets in the women's lavatory were equipped with
flushometer valves, each of which was protected by an
approved vacuum breaker (Sloan Valve Company, model
V-500-AA) . Hot and cold water taps over sinks in both rooms
were at safe distances above the rims. Also, a hose bib in
each lavatory was provided with an anti-siphon device. The
water closet and sink in the instructors' lavatory were
similarly protected. The water line to the kitchen garbage
disposal is protected by an air gap (Eastman Co., Model
No. CD-3) at rear of the countertop. Faucets discharge
safely above sink rims.
There had been reports that on September 19th, two empty
pesticide containers were found near an outside hose which
ran to an inside hose bib. However, Tighe & Bond, which is
said to have reported the incident denies having seen such a
condition. Furthermore. Mr. Treba of the town health
department said the State Police told Tighe & Bond that no
pesticides had been used for a long time and that "cadets
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drinking from hoses is a thing of the past. "
Overview
The episode of illness on September 19-21 among 50 cadets
at the Criminal Justice Training Center in Agawam has the
characteristics of a common cause, acute outbreak or epidemic
of disease. This is based on the medical data contained in
the September 26 report of Dr. Grady to Dr. Prothrow-Stith .
Dr. Grady described this still further in a meeting October
14 with Attorney General Shannon. Specifically, all 50
cadets had abnormal laboratory tests. In some there were
significant physical symptoms that began that first day of
training, Monday September 19, and continued through
Wednesday, September 21, 1988. A total of 12 trainees were
hospitalized, one in such serious condition that an emergency
transfer to a Pittsburgh, PA hospital was required for a
liver transplant. The medical diagnosis was rhabdomyo lysis .
It is significant that the Academy employees and the
construction crew working on the basement, with one
exception, did not have any of the symptoms exhibited by the
cadets. A construction worker was later found to be
suffering from an unrelated condition. One state trooper who
had participated in physical exercise exhibited mild
rhabdomyloysis .
The possible common causes of the cadets' illness
included:
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Water supply from both the Agawam Town supply and
the "bubbler" in the lounge.
Food;
Air ;
Clothing ;
Pesticides; and
Housing .
Housing was quickly eliminated because all cadets, except
those hospitalized, returned to their respective homes each
night .
Pesticides are ruled out because, according to Academy
officials and State Police, no pesticides had been used for
years, and the only significant pesticide container found was
an empty, rusty, five-gallon can containing the herbicide
Alachlor. This was found in the brush near the large trailer
behind the Academy, and doesn't appear to have contained any
product as of September 19. Technicians from Tighe & Bond
visiting the Academy over three days (September 21-23) saw no
evidence of any pesticide use except for a single,
pressurized aersol spray can used to kill flying insects.
Clothing was not a common factor because each cadet
purchased his or her own uniform prior to training, and
although several had purchased from the same store some had
washed their uniforms. Others had not.
Air transport of a toxic substance or bacterial agent was
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considered. However, the cadets were mainly outdoors, there
was no pesticide use that day, or the preceding days on the
Academy grounds, the neighboring Oak Ridge Country Club, the
sod form, or the strawberry farm. Also, because the cadets
went home every night (except for those hospitalized) , there
was no common exposure to niaht air.
As each cadet brought their own lunches, there was no
common source of food preparation.
Lead
The possibility of lead ingestion was raised because
cadets had crawled on their elbows across the second-floor
locker room floor in wet clothing. Paint hung from the
ceiling and there were pieces of it on the floor, but the
floor was not covered with it when examined October 12th, and
the custodian said he had swept the room before the cadets
used it. Dr. Prothrow-Stith, DPH Commissioner, said while
several substances could be associated with rhabdomyolysis ,
lead was not one.
Asbestos
The asbestos insulation had been removed from the water
pipes in the basement a year before the incident.
Water supply was studied from two viewpoints: (1) the
quality of the drinking water from the two sources; and (2)
the possibility of contamination of the two supplies through
cross connections. As the "bubbler" was supplied from an
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inverted, five-gallon bottle, there was no cross connection.
In summary, all sinks and toilets are properly-
protected. The hose bib near the point of entry on the
service line does not have a Hose Bib Vacuum Breaker, but
there was no apparent source of contamination in the vicinity
of the attached hose. It also appeared and was reported,
that the hose had not been recently used for drinking or any
other purposes. Although the back flow preventer on the 3/4
inch-line to the steam boiler was not of an approved type,
there was evidence that it was working. The orthophosphate
content of water in the boiler September 22 was 1.40 mg/L;
and water from the intake strainer on September 23 showed
0.11 mg/L orthophosphate and at a sink top in the men's
lavatory on September 22 the content was 0.010 mg/L.
The chief chemist at the Springfield West Parish Filter
Plant measured the orthophosphate content of raw water on
October 13 and October 19. It was 0.10 mg/L, and on October
19th the finished water content was 0.05 mg/L. These values
are not significantly different from the values on the
upstream side of the vacuum breaker. Although one report had
it that the faucet in the janitor's closet was not protected,
it was discovered that, in fact, there was a vacuum breaker
between the valves and the hose bib. This has added
significance in that previous classes had been served water
outside from a hose connected to this hose bib.
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Tests of water quality were made by Tighe & Bond on
September 21 and 26 for substances shown on Tables 1 and 2.
A comparison of concentrations with EPA maximum contaminant
1 e v el s__s hows that on September 21 and 23 the water quality of
the public supply at the Academy met or exceeded nearly all
the EPA standard.
The values for iron, color and turbidity were higher than
the standard but the bacteria content was excellent, as shown
by a coliform count of 0 per lOOmL, and a standard plate
count of 11 per mL. EPA does not have a limit for
heterotrophic bacteria as measured by the standard plate
count, but values which have been considered range from 50 to
100 organisms per mL. The iron, color and turbidity came
from the old street main.
"Bubbler" water quality was also good. Methylene
chloride is a substance for which EPA has yet to publish a
maximum contaminant level. EPA does, however, have a health
advisory: a 10-day limit of 1.5 mgL for toxicity.
Table 3 shows results from tests made at Springfield
water laboratory on a sample collected at Mrs. Karaklas's
residence on September 24. The test results in all cases
were lower than EPA maximum contaminant levels.
Finally the experience of those who have used the two
supplies is important. Over the years, staff at the Academy
have drunk town water, even when it was cloudy, and bottled
- 95 -
water. There have been no reported illnesses. There have
been no reported communicable disease cases from residents on
S. Westfield Street. On the day of the episode, three cadets
reported drinking only bottled water. Jon K. Provost said he
drank only from the "bubbler" and he was hospitalized and had
dialysis. Glen Scott Civello said he drank water only from
the cooler and he did not get sick. Jeff Gawron did not
drink water from the sink tap, only from the "bubbler," and
did not experience discolored urine.
DPH REPORTS
The Department of Public Health began its onsite
investigation on Thursday morning, September 22. Its focus
was to "1) uncover information of potential medical value to
the treatment of the trainees, and 2) to determine whether
there was any hazardous agent in the facility or the
surroundings . "
The investigation was conducted by a three-member team
led by Dr. George Grady, State Epidemiologist.
The DPH team initially:
Interviewed the hospitalized trainees and their
attending physicians, as well as those who were seen
as outpatients; training and supervisory staff and
construction personnel, including the DCPO project
engineer, all of whom were working on the basement
reconstruction.
Interviewed the staff of the private environmental
consulting firm, Tighe and Bond, who were already
collecting samples when the DPH team arrived.
- 96 -
Reviewed clinical and laboratory records from the
hospital charts, attending physicians, and
pre-enrollment physicals and laboratory tests.
Reviewed pre-enrollment physical condition scores
resulting from tests of enrollees between August 26-29
Collected biological and environmental specimens for
laboratory testing.
The test results confirmed a medical diagnosis of
rhabdomyolysis , a "breakdown of muscle of the skeletal type."
Dr. Grady wrote that kidneys may become damaged, "if the amount
of muscle breakdown is too large or if the volume of blood flow
through the kidneys is reduced by dehydration."
Dr. Grady concludes that Cadet Shepard, first showed signs
of heat stroke that "initially overshadowed the rhabdomyolysis
problem and has contributed to additional complications that
the seven others do not have."
The causes of rhabdomyolysis, Dr. Grady reported, are
"toxins, including chemicals and alcohol, certain immune
diseases and rare infections, crash injuries and an imbalance
between fluid intake and exercise." Because the cadets did not
share common food, and those who shared common air did not fall
ill, DPH turned its attention to the water. DPH determined in
its examination that "there was no similar illness among others
at the facility or Agawam residents who also used the town
water supply. "
DPH took water samples from the Academy boiler, the bubbler
and the potable water system. No toxic substances were found
- 97 -
in the samples and no toxins or toxin byproducts in the urine
of the cadets.
DPH concluded "an insufficiency of water intake relative to
the exercise performed" appeared to have been the cause for the
rhabdomyolvsis . The DPH team concluded that the average total
water intake for each cadet was less than 1 1/2 quarts
includina a
12-ounce drink
DPH allowed at lunchtime. At the
meetina October
14th Dr
. Grady stated that each cadet should
have had 7
1/2 quarts.
The cadets consumed one aallon or more
of water in
the i
*ay of
"make-up" fluid on the way home. DPH
further rep<
Drted
. "Our
preliminary analysis suaaests that the
disease mav
have
been 1
ess
severe in those who happened to take
in sliahtly
more
water.
or
whose water needs may have been less
because of 1
bette:
r physical
conditioning before the program
began. "
While DPH had not issued its final report on the Agawam
incident at the time of this report's publication, Dr. Grady,
said in an interview that all data will support his preliminary
report ,
Dr. Grady said his report will confirm that there was
nothing in the water at the bubbler or in the Academy system
that contributed to the diagnosis. He said the report would go
into some detail on this point.
Dr. Grady also said that DPH examined the pre-screening
shape of recruits from Class 12 and the two previous classes.
- 98 -
He said they examined the scores on standard tests and found
some differences between Class 12 and the two preceeding it,
but nothing that was significant.
The final report will also confirm that all 50 cadets, and
one State Trooper were diagnosed with rhabdomyolysis . The
difference, Dr. Grady will report, is in physiologial degrees,
with ten cadets and the one trooper at the lower end of the
scale showing muscle enzymes in the bloodstream approximately
10-times the standard resting level. By contrast, those cadets
who experienced the worst symptoms, had levels around 400-times
the resting level.
CONCLUSION
A full analysis and investigation of all possible
environmenal factors in and around the Agawam Training Center
shows that none caused the sudden illness and abnormalities
experienced by the cadets between September 19 and 21, 1988.
Water, initially the leading suspect for the problems, is
not to blame. Water samples were collected from the center
Wednesday evening, September 21. Those samples and the ones
to follow over the next two days, give a picture of
conditions during the period the cadets were training. In
short, despite reports of the water's cloudiness from time to
time, the quality of the drinking water at the center except
for iron, color and turbidity met DEQE drinking water
- 99 -
standards. Furthermore, according to Agawam's public health
and public works departments, no illnesses or irregularities
have been reported by residents living in homes served by the
same water lines. They report "the town complies with all
testing required under the safe drinking water act," which
includes bacterial tests of 30 water samples each month.
Also the Deputy Regional Environmental Engineer reported that
there have been no violations of the Commonwealth's drinking
water standards in Agawam and the Greater Springfield area.
Finally, three cadets drank only from the water cooler.
The other cadets reported augmenting their intake with
occasional drinks from the lavoratory faucets. Only one of
the three fell ill and the others tested positive for muscle
enzymes. Again, the cooler water quality met EPA standards
under testing.
While some town residents, and particularly neighbors of
the Academy, express concern about the relationship of the
water quality and the incidence of certain cancers, there is
an important and distinct difference between the sudden
illness of the cadets, and a long-term illness such as
cancer. The relationship between drinking water quality and
cancer is complex and difficult to establish.
Rhabdomyo lysis does not fit the spectrum of water-borne
disease. According to the glossary of terms published by the
American Public Health Association, a water-borne disease is
- 100 -
a disease caused by organisms or toxic substances carried by
water. The most common water-borne diseases are typhoid
fever, Asiatic cholera, hepatitis, giardiasis, dysentery,
tetanus, polio, and other intestinal disturbances.
EPA water epidemiologists have advised that the symptoms
of dissolving muscle tissue associated with rhabdomyolvsis
may occur in alcoholics, crash victims, or those engaged in
violent exercise. In the Baltic area, this disease is called
Haff 's disease and one outbreak was thought to be associated
with toxins in fish. There has been no known association of
rhabdomyolysis with drinking water.
Finally, it seems appropriate to re-emphasize the finding
that pesticides did not contribute to the problems of the
cadets. In observation, interviews and reports, it is clear
that pesticides simply had not been used in or around the
Academy in the days or weeks preceeding Class 12. The
adjacent golf course, and the nearby sod farm and strawberry
farm reported no use of pesticide. One empty five-gallon
container of herbicide was found, as was a spray can of
insect spray. That was the only evidence of any pesticide at
the Academy.
In summary, a full review of all the environmenal factors
discussed in this report does not support a conclusion that
they were the cause of the illnesses or abonomalities
experienced by the 50 cadets in Class 12 at the Aqawam Police
Training Center.
- 101 -
Table 1
Record of Water Tests
At Agawam Police Training Academy
From Tap In Men's Room - Tests by Tighe & Bond
(Samples Collected September 21, 1988)
Constituent
Concentration
EPA MCL
Colif orm
0/100 ml
1
Standard Plate Count
11 /ml
None
Turbidity
3.2
1
Arsenic
<0.005
0.05
Cadmium
<0.005
0.10
Cobalt
<0.05
None
Chromium
<0.05
0.05
Copper
0.111
1.00
Iron
0.91
0.3
Manganese
<0.01
0.05
Lead
0.096
0.05
H
<0.010
(1
minute)
0.05
•i
<0.010
(10
minutes)
0.05
Mercury
<0.005
0.002
Thallium
<0.005
None
Alkalinity
14
None
Chloride
13
250
Color
25
15
Odor
2
3
PH
7.0
6.5-8
S. Conductance
73
None
Sodium
10.5
None
Ammonia
<0.01
None
Nitrite-Nitrate
0.09
10
Oraanics
Bromodichlorome -
0.004
0.100
Thome
Chloroform
0.062
0.100
Notes :
Except for PH, color and turbidity, EPA Maximum Contaminant
Levels and test results are in mg/L.
Turbidity is in NTU.
Color is in Color Units.
PH is in PH Units.
Odor is in Threshold Odor Units.
MCL - maximum contaminant level.
* The limit for combined trichloromethanes .
- 102 -
J I
Table 2
Records of Water Test
At Agawam Police Training Academy
From Water Cooler
Taken October 26, 1988
Tests by Tighe & Bond
Constitutent
Cold Water
Hot Water
EPA MCL
Colif orm
Alkalinity
Chloride
Color
Hardness
N02-N03
H
0/100ml
3
1
5
42
<0.05
5.9
0/100ml
2
<1
5
2
<0.05
6.0
1
None
250
15
None
10
6.5-8.5
Turbidity
Lead
Arsenic
Copper
Chromium
Sodium
0.05
<0.01
<0.005
0.05
<0.05
Orqanics
0.1
0.01
0.005
0.18
1.0
1
0.05
0.05
1.0
0.05
None
Chloroform
Methylene Chloride
Toluene
Trichlorethane
BQL*
0.0038
BQL*
BQL*
ND
0.014
BQL*
ND
0. 100
Nonea
2.000b
None
Notes :
Except for PH, color and turbidity, EPA maximum contaminant
levels and results are in mg/L.
Turbidity is in NTU.
Color is in Color Units.
PH is in PH Units.
*BQL: Detected but below quantitation Units
a: An EPA Health Advisory recommends a 10 day limit of 1.5
mg/L.
b: This toluene limit is being proposed.
MCL: Maximum Contaminant Level.
- 103 -
Table 3
Record of Water Tests At
Mrs. Karakla's Residence, 703 S. Westfield
Street, Agawam, MA - Sampled 9/24/88
Tests Done At West Parish Filter Plant
By Springfield Water Works Chemist
Constituent
Test
Results
Colif orm
0
Color
10
Odor - Hot
0
Odor - Cold
0
Turbidity-
0.56
Free CO2
1
PH
7.5
Alkalinity-
14
Chlorides
12
Hardness
13
Iron
0.18
Manganese
0.00
Nitrites
0.00
Nitrates
0.03
Sulfates
8
Aluminum
0.01
S. Conductance
78
Copper
0.00
Calcium
3.2
Notes :
EPA MCL
1
15
3
3
1
None
6.5-8.5
None
250
None
0.3
0.05
Note
10
250
None
None
1.0
None
Except for PH, Color and turbidity EPA maximum
contaminant levels and test results are in mg/L.
Turbidity is in NTU.
Color is in Color Units.
PH is in PH Units
Odor is in threshold odor units.
MCL: Maximum Contaminant Level
Note: The EPA limit for total nitrite and nitrite is
10 mg/L.
- 104 -
CONCLUSION
A consumption of fluids by cadets of Class 12 wholly-
inadequate to compensate for the levels of physical exertion
demanded of their bodies caused the conditions suffered at
Agawam.
While in any distribution of responsibility some measure
must be borne by those charged with the custody and supervision
of the cadets, it is clear that the Agawam experience directly
resulted from a massive failure in the method of training
police cadets by the Criminal Justice Training Council. My
investigation shows that individuals involved in the training
of Class 12, from top to bottom, failed woefully in their
duties. This failure began with a bureaucracy that paid little
or no attention to the end product of its paper shuffling: the
care and training of human beings. Instead, like the three
monkeys of the legend, and despite the existence of cause for
alarm, the training bureaucracy saw no evil, heard no evil, and
spoke no evil.
The guidance provided to Troopers Gilmore and Richardson by
the Massachusetts Criminal Justice Training Council ranged from
the inadequate to the nonexistent.
The Academy Director, Earl Harrington, assumed so little
responsibility for the well-being of the class that he did not
even possess a class roster. Despite his expressed concern for
his own authority, he exercised no meaningful role in the
Academy's primary mission.
- 105 -
There are next to no physical standards necessary for a
cadet to be admitted to Agawam. While the Council assumed
responsibility for testing the cadets' physical skills, it
showed so little concern for their well-being that test results
were conveyed to the trainers in a raw and partially
indecipherable form.
The Council acquiesced to the demand of Western
Massachusetts police chief for Class 12, despite its knowledge
of the inadequacy of the facility.
The Council depended upon the state police to provide
physical training at Agawam. The fear that disputes with the
state police would lead to their withdrawal resulted in an
abdication by the Council of its responsibility to supervise
physical training at Agawam.
Council Director Egan failed to ensure that the Agawam
facility was adequate, that the staff was fully competent in
physical training or that even the Council's minimal physical
training standards were observed. The Council itself, of which
I am a member, is structured so that it effectively diffuses
lines of authority, fails to isolate cores of responsibility
and diminishes accountability.
Finally, the troopers into whose custody the cadets were
entrusted were either ignorant of the medical harm which could
result from a full day of exertion with little water, or failed
to adequately monitor how little the cadets actually drank.
- 106 -
I have concluded, based upon the facts now known to me and
upon the circumstances as they now stand, that no criminal
prosecution is appropriate in this case. There are three
primary reasons for this decision. First, there is no criminal
statute of the Commonwealth which fairly fits, or naturally
applies to, the facts and conduct here at issue. Second, it is
my belief that none of the instructors acted with the intent
that any cadet be seriously injured or harmed. And third,
there was in this case a diffusion of responsibility for the
injuries and illnesses suffered by the cadets which renders
criminal prosecution innappropriate.
My conclusion that there be no prosecution at the present
time should not be construed as a complete exoneration of any
individual, institution, or entity. In retrospect, it is clear
that there were indefensible deficiencies in communication and
coordination, not only among individuals, but among groups and
institutions as well. It seems equally clear that supervision,
to the extent that it existed, was thoroughly inadequate at
every level. Among the effects of these systemic shortcomings
was the ignorance of instructors at the Academy of the very
regulations which ostensibly governed their own conduct, and
the failure of the Council even to provide these regulations to
the troopers. They also were apparently ignorant of the
potential gravity of the physiological effects of dehydration.
No one individual is solely responsible for the events at
Agawam. Any one of a number of individuals, as detailed in my
- 107 -
report, might have prevented those events from occurring.
This investigation has produced nothing to inspire
confidence in the current management of the Council and its
Agawam Academy at virtually every level.
I expressly reject the contention that exercising cadets on
the first day of a program until they drop can meaningfully be
termed "training". Speculative belief in "character building"
or the utility of confronting one's limits cannot justify
endangering the health of trainees. Cadets are peculiarly
susceptible to being pushed to the point of collapse or injury:
they are under orders to obey all commands (reinforced by a
plainly conscious element of intimidation); and their
professional futures depend upon successful completion of the
program.
To serve a useful function, rules and regulations must be
communicated to those whom they govern. Compliance must be
monitored. If regulations exist (such as those of the Council
governing physical training) but are not implemented, they are
worse than meaningless. The fact of their promulgation only
gives the illusion of control, of order, and of some regulatory
oversight. They must be implemented properly to have any
worthwhile purpose.
It should not be forgotten that what happened at Agawam
will stay with some for the rest of their lives. It now rests
with others to ensure that it will never happen again.
- 108 -