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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 


-  2  - 


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 


-  3  - 


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 


-  4  - 


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 


-  5  - 


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. 


-  6  - 


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 


-  7  - 


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 


-  8  - 


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 


-  9  - 


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.) 


-  10  - 


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 

-  11  - 


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 

-  12  - 


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 

-  13  - 


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 
-  14  - 


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. 

-  15  - 


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 

-  16  - 


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. 

-  17  - 


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 

-  18  - 


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 

-  19  - 


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 

-  20  - 


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 

-  21  - 


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 

-  22  - 


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 . 

-  23  - 


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 . 

-  24  - 


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 

-  25  - 


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 

-  26  - 


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 

-  50  - 


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 

-  51  - 


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. 


-  52  - 


"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 

-  53  - 


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, 

-  54  - 


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 

-  55  - 


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 

-  57  - 


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 

-  58  - 


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 


-  62  - 


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 

-  64  - 


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. 


-  65  - 


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. 

-  67  - 


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 

-  69  - 


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 

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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 

-  71  - 


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 

-  76  - 


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. 

-  78  - 


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. 

-  81  - 


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 


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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 


-  85  - 


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 


-  86  - 


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 


-  88  - 


"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 


-  90  - 


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: 


-  91  - 


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 


-  92  - 


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 


-  93  - 


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. 


-  94  - 


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  -