OFFICE OF THE SPECIAL INSPECTOR GENERAL FOR IRAQ RECONSTRUCTION

OPPORTUNITIES TO IMPROVE

PROCESSES FOR REPORTING,

INVESTIGATING, AND REMEDIATING

SERIOUS INCIDENTS INVOLVING

PRIVATE SECURITY CONTRACTORS

IN IRAQ

SIGIR 09--019

AAPPRRIILL3300,,22000099
Special Inspector General for Iraq 

SIGIR

Reconstruction

For more information, contact SIGIR Public Affairs 

at (703) 428-1100 or PublicAffairs@sigir.mil Special Inspector General for Iraq Reconstruction

Summary of Report: SIGIR-09-019

Why SIGIR Did This Audit

This report responds to a congressional mandate 

that audits be conducted of the incidents 

involving private security contractors (PSCs). It 

focuses on the Department of Defense’s 

(DoD’s) oversight of serious incidents (such as 

attacks, death, injury, and property damage) 

involving PSCs in Iraq. The report examines 

DoD’s (1) policies, procedures, and practices for 

reporting, investigating, and remediating those 

incidents and (2) efforts to identify trends and 

lessons learned. Because some Department of 

State (DoS) PSCs report their serious incidents 

through DoD channels as well as DoS channels, 

SIGIR reviewed pertinent DoS policies and 

procedures related to that reporting.

Congressional concerns about the adequacy of 

the U.S. government’s oversight of PSCs in Iraq 

increased after a serious incident involving a 

DoS contractor, Blackwater, that resulted in the 

death of 17 Iraqi civilians. As a result of the 

incident, DoD and DoS agreed on core 

standards, policies, and procedures for 

accountability and oversight of PSCs. DoD 

delegated its implementation of the agreement 

to Multi-National Force-Iraq (MNF-I), which 

established Contractor Operations Cells 

(CONOC) and an Armed Contractor Oversight 

Division (ACOD) to manage serious incidents 

involving PSCs. DoS delegated its 

implementation to the U.S. Embassy’s Regional 

Security Office (RSO).

What SIGIR Recommends

SIGIR makes a number of recommendations to 

the Commanding General, Multi-National 

Force-Iraq, and the U.S. Ambassador to Iraq to 

improve the serious incident reporting, 

investigating, and remediating processes. 

Based on management comments and additional 

information provided by MNF-I and the U.S. 

Embassy, SIGIR deleted two draft 

recommendations from the final report. MNF-I 

and the Embassy generally agreed with the 

remaining recommendations.

April 30, 2009

OPPORTUNITIES TO IMPROVE PROCESSES FOR REPORTING,

INVESTIGATING, AND REMEDIATING SERIOUS INCIDENTS 

INVOLVING PRIVATE SECURITY CONTRACTORS IN IRAQ

What SIGIR Found

The U.S. military and the U.S. Embassy have improved their 

information sharing concerning PSC operations and serious incident 

reporting. They have established policies for reporting serious 

incidents and have assigned responsibility to specific organizations for 

overseeing that serious incidents are reported and investigated. 

Although these improvements are significant, SIGIR identified a 

number of opportunities to improve the accuracy and consistency of 

the serious incident information, the analysis of that information, and 

the consistency of policies and procedures pertaining to investigating 

and remediating incidents. These specific improvements in these areas 

should help DoD and DoS achieve their overall program goals and 

objectives:

The CONOC and RSO databases do not capture all reported serious 

incidents and do not present a complete picture of the serious incidents 

they are tasked to track. This could be caused by database management 

problems or the failure of PSCs to follow reporting requirements.

ACOD judgmentally decides which incidents to track even though it is 

responsible for ensuring that all serious incidents received by the 

CONOC are reported, tracked, and investigated. ACOD is applying a 

more limited definition of a serious incident than the definition 

contained in MNF-I guidance.

MNF-I guidance has a more expansive definition of a serious incident 

than in Embassy guidance.

ACOD and CONOC have established their own databases even though 

they are supposed to be tracking the same incidents, although for 

different purposes. As a result, information for the same incidents is 

inconsistent, which raises questions about information accuracy.

ACOD has performed analyses but has not developed formal lessons 

learned even though it is responsible for lessons learned. The limited 

incidents that ACOD tracks do not represent a complete picture of what 

PSCs are reporting, and its limited analyses may be impacting its ability 

to develop lessons learned.

No organization appears to have visibility of subcontractor PSCs, which 

is a potential gap in PSC incident reporting processes.

DoD and DoS have different approaches and policies for condolence 

payments to Iraqis for the same types of incidents. Consequently, the 

United States is not presenting a uniform approach to the Iraqi people 

and government.
April 30, 2009

MEMORANDUM FOR U.S. AMBASSADOR TO IRAQ

COMMANDING GENERAL, CENTRAL COMMAND

COMMANDING GENERAL, MULTI-NATIONAL FORCEIRAQ

COMMANDING GENERAL, MULTI-NATIONAL CORPSIRAQ

COMMANDER, JOINT CONTRACTING COMMANDIRAQ/AFGHANISTAN 

DIRECTOR, DEFENSE CONTRACT MANAGEMENT 

AGENCY

SUBJECT: Opportunities To Improve Processes for Reporting, Investigating, and 

Remediating Serious Incidents Involving Private Security Contractors in Iraq 

(SIGIR 09-019)

We are providing this report for your information and use. It primarily pertains to the 

Department of Defense’s oversight of serious incidents involving private security contractors 

in Iraq. Because some Department of State private security contractors report their serious 

incidents through both Department of Defense and Department of State channels, we 

examined pertinent Department of State policies and procedures related to that reporting. 

The audit was conducted by the Special Inspector General for Iraq Reconstruction (SIGIR) as 

project 9008 under the authority of Public Law 108-106, as amended, which also 

incorporates the duties and responsibilities of inspectors general under the Inspector General 

Act of 1978. It is also in response to a requirement in the National Defense Authorization 

Act for 2008 (Public Law 110-181) that requires audits of the reporting, documenting, 

investigating, and prosecution (where appropriate) processes for incidents involving private 

security contractors in Iraq. 

We considered written comments on a draft of this report from the Multi-National ForceIraq, the U.S. Embassy’s Regional Security Office, and the Department of State’s Bureau of 

Diplomatic Security when finalizing this report. The comments on the recommendations are 

included in Appendix E. Technical comments were also provided and are addressed in the 

report where appropriate.

We appreciate the courtesies extended to the SIGIR staff. For additional information on the 

report, please contact Glenn Furbish, Principal Deputy Assistant Inspector General for 

Audits, (703) 428-1058/ glenn.furbish@sigir.mil, or Nancee Needham, Deputy Assistant 

Inspector General for Audits (240-553-0581/ nancee.needham@iraq.centcom.mil).

Stuart W. Bowen, Jr.

Inspector General

Special Inspector General for Iraq Reconstruction
Table of Contents

Executive Summary i

Introduction 1

Background 1

Contract and Legal Provisions Governing Contractors' Conduct 3

Objectives 5

Database, Reporting, and Analysis Weaknesses 6

Serious Incident Reporting Process and Requirements 6

Problems with Incidents Reported and Recorded 8

Serious Incident Frequency and Trends 14

Potential Gaps in Subcontractor Reporting 19

Some Serious Incidents Involving Department of Defense Private 

Security Contractors Are Not Being Investigated 21

Multi-National Force-Iraq Serious Incident Investigation Process 

Not Working As Required 21

Differing Use of Security Cameras 22

The Department of Defense Incident Remediation Process and the 

Different Approaches to Payments for Serious Incidents 24

Conclusions, Recommendations, and Lessons Learned 27

Conclusions 27

Recommendations 27

Lessons Learned 28

Management Comments and Audit Response 28

Appendices

A. Scope and Methodology 31

B. Acronyms 34

C. Serious Incidents Reported by Contractors 35

D. Audit Team Members 36

E. Management Comments 37
i

Opportunities To Improve Processes for 

Reporting, Investigating, and Remediating 

Serious Incidents Involving Private Security 

Contractors in Iraq

SIGIR 09-019 April 30, 2009

Executive Summary

Introduction

This report primarily focuses on the Department of Defense (DoD) oversight of serious incidents 

(such as attacks, deaths, injuries, and property damage) involving private security contractors 

(PSCs) in Iraq. It examines DoD’s (1) policies, procedures, and practices for reporting, 

investigating, and remediating those incidents and (2) efforts to identify trends and lessons 

learned. Because some Department of State (DoS) PSCs report their serious incidents through 

DoD channels as well as DoS channels, SIGIR reviewed pertinent DoS policies and procedures 

related to that reporting.

The report responds to a mandate in the National Defense Authorization Act for 2008 (Public 

Law 110-181), which requires audits of the processes used to report, document, investigate, and 

prosecute (where appropriate) incidents involving private security contractors in Iraq.

The U.S. government has relied extensively on PSCs in Iraq to protect personnel, supplies, and 

facilities. Although issues have surfaced over the years concerning the oversight, control, cost,

and legal status of PSCs, the Blackwater incident in September 2007, during which 17 Iraqi

civilians were killed, brought to the forefront concerns about the U.S. government’s oversight 

and control of the PSCs. In December 2007, DoD and DoS signed a memorandum agreeing that 

they would jointly develop, implement, and follow core standards, policies, and procedures for 

the accountability, oversight, and discipline of PSCs in Iraq. Their objective was to reduce the 

number and impact of serious incidents. DoS assigned responsibility for implementing its part of 

the agreement to the U.S. Embassy, which in turn delegated responsibility to its Regional 

Security Office (RSO). DoD assigned its responsibility to the Multi-National Force-Iraq (MNFI). MNF-I established Contractor Operations Cells (CONOC)1

to coordinate PSC missions and 

to gather, assemble, and distribute information on serious incidents involving PSCs. MNF-I also 

established the Armed Contractor Oversight Division (ACOD) to ensure that all serious incidents 

are reported, tracked, and investigated.

RSO is responsible for coordinating DoS Tier 1 missions, which are defined as missions that 

directly support the Chief of Mission. For example, Tier 1 missions involve transporting DoS 

personnel, ambassadors, other diplomats, and congressional delegations. Missions that do not 

 

1 The CONOC was established by Multi-National Corps-Iraq, a subordinate command to MNF-I.
ii

directly support the Chief of Mission, such as transporting contractor personnel supporting DoS 

contracts, are categorized as Tier 2 missions.2 PSCs on Tier 1 and Tier 2 missions are to report 

serious incidents to the RSO. In addition, DoS PSCs on Tier 2 missions and DoD PSCs are to 

report serious incidents through the CONOC to ACOD.

Results

The U.S. military and the U.S. Embassy have improved their information sharing on PSC 

operations and serious incident reporting. They have established policies for reporting serious 

incidents and have assigned responsibility to specific organizations for ensuring that serious 

incidents are reported and investigated. These improvements are significant; nevertheless, 

SIGIR identified a number of opportunities to improve the accuracy and consistency of the 

serious incident information, the analysis of that information, and the consistency of policies and 

procedures pertaining to investigating and remediating incidents. These specific improvements 

should help DoD and DoS achieve their overall program goals and objectives:

The CONOC and RSO databases do not capture all reported serious incidents and do not 

present a complete picture of the serious incidents they are tasked to track. This could be 

caused by database management problems or the failure of PSCs to follow reporting 

requirements.

ACOD judgmentally decides which incidents to track even though it is responsible for 

ensuring that all serious incidents received by the CONOC are reported, tracked, and 

investigated. ACOD is applying a more limited definition of a serious incident than that 

contained in MNF-I guidance. 

MNF-I guidance has a more expansive definition of a serious incident than Embassy 

guidance.

ACOD and CONOC have established their own databases even though they are supposed 

to be tracking the same incidents, although for different purposes. As a result, 

information for the same incidents is inconsistent, which raises questions about 

information accuracy. 

ACOD has performed analyses but has not developed formal lessons learned even though 

it is responsible for lessons learned. The limited incidents that ACOD tracks do not 

 

2 The Department of State’s Bureau of Diplomatic Security objected to SIGIR’s use of Tier 1 and Tier 2 missions. 

The Bureau states that DoS considers contractors providing services to DoS under the Worldwide Personal 

Protective Services contract to be Tier 1 contractors regardless of the nature of the missions these contractors are 

performing and all other DoS affiliated PSCs to be Tier 2 regardless of the missions being conducted. SIGIR could 

find no formal definition of Tier 1 and Tier 2. It chose to describe Tier 1 and Tier 2 in terms of missions in the 

report because a CONOC document shows that PSCs under the Worldwide Personal Protective Services 

contract─Blackwater, Triple Canopy, and DynCorp─can perform both Tier 1 and Tier 2 missions with the 

distinction being that Tier 1 PSCs perform mission that directly support the Chief of Mission whereas Tier 2 PSCs 

perform missions that indirectly support the Chief of Mission. Moreover, an RSO representative provided the 

following distinction: All U.S. government direct hire employees and certain others that fall under the Chief of 

Mission authority and are not under the security responsibility of MNF-I are transported as Tier 1. U.S. Agency for 

International Development, Department of State, and other DoS contractors, grantees, and other employees that do 

not fall under the Chief of Mission authority are transported under Tier 2. Consequently, we made no change to the 

final report on this issue and noted Diplomatic Security’s position here and in the management comments section.
iii

represent a complete picture of what PSCs are reporting, and its limited analyses may be 

impacting its ability to develop lessons learned.

No organization appears to have visibility of subcontractor PSCs, which is a potential gap 

in PSC incident reporting processes.

DoD and DoS have different approaches and policies for condolence payments to Iraqis 

for the same types of incidents. Consequently, the United States is not presenting a 

uniform approach to the Iraqi people and government.

Recommendations

To improve the accuracy and consistency of the serious incident information, the analysis of that 

information, and the consistency of policies and procedures pertaining to investigating and 

remediating incidents, SIGIR recommends that the Commanding General, MNF-I, and the U.S. 

Ambassador to Iraq take the following actions as they relate to their respective responsibilities:

1. Require CONOC and RSO to institute a process to periodically compare serious incident 

data on Tier 2 missions to identify PSCs that may be unaware of, confused about, or not 

complying with the dual reporting requirements.

2. Require ACOD and RSO to jointly establish a standard definition of serious incidents and 

incorporate that definition in guidance for their PSCs.

3. Require ACOD and RSO to jointly establish or use an existing contractor working group 

to share information with PSCs and to solicit their views and concerns.

4. Require CONOC and ACOD to establish a joint database for serious incidents that both 

can use to capture the information they need to fulfill their responsibilities.

5. Require ACOD to track all serious incidents, include data on all incidents in its analyses, 

perform more extensive analyses of serious incidents, and develop lessons learned from 

those analyses.

6. Task supporting organizations, such as the Defense Contract Management Agency, to 

identify all PSC subcontractors that support DoD and DoS contracts.

7. Task contract audit organizations to periodically review the prime contractors’ oversight 

of subcontractor PSCs’ compliance with incident reporting requirements.

Lessons Learned

Over time, DoD and DoS have learned important lessons in Iraq pertaining to PSCs. Those 

lessons have been applied incrementally to improve oversight of PSCs and coordination between 

MNF-I and the U.S. Mission. In other contingency operations, where extensive use is made of 

private security contractors, such as Afghanistan, the overarching lesson learned is that DoD and 

DoS need to establish core standards, policies, and procedures early in the contingency. Specific 

lessons related to that action include the need to develop:

a memorandum of agreement to jointly develop, implement, and follow core standards, 

policies, and procedures regarding PSCs
iv

a common definition and common reporting requirements for serious incidents

mechanisms to share information on incidents between the U.S. Embassy and the military 

command

a common approach to condolence payments

audit mechanisms to ensure that PSCs at all levels understand and comply with incident

reporting requirements

Management Comments and Audit Response

SIGIR received management comments from MNF-I, the U.S. Embassy’s Regional Security 

Office, and the Department of State’s Bureau of Diplomatic Security. MNF-I concurred with 

seven recommendations, partially concurred with recommendation 5 and non-concurred with 

recommendation 9. With regards to recommendation 5, MNF-I stated that the Armed 

Contractor Oversight Branch3reviews all serious incidents it receives from the CONOC and 

forwards serious incident reports needing further attention to requiring activity commanders. It 

further stated that ACOD developed fragmentary orders throughout its tenure in response to 

lessons learned. Moreover, the Branch, in partnership with the U.S. Embassy RSO, will 

endeavor to develop joint ―lessons learned‖ of general applicability to all PSCs operating in Iraq. 

MNF-I did not concur with recommendation 9. It stated that DoD is legally prohibited from 

making condolence payments on behalf of contractors and that is the reason for the perceived 

lack of a common policy for condolence payments in Iraq. Moreover, it states that PSCs are 

generally required to possess liability insurance by the terms of their contracts and that the 

insurance premiums on ―cost type‖ contracts are reimbursed as long as the charge is reasonable, 

allocable, and allowable.

With regard to MNF-I’s comments on recommendation 5, the report recognizes ACOD’s 

position that it used lessons learned to produce fragmentary orders. SIGIR continues to believe 

that ACOD needs to track all serious incidents, include data on all incidents in its analyses, 

perform more extensive analyses of serious incidents, and develop lessons learned from those 

analyses. Concerning recommendation 9, MNF-I said that although it is prohibited from making 

condolence payments directly, it is indirectly paying for those costs by reimbursing contractors 

for liability insurance. Based on MNF-I’s position, we did not include the draft recommendation 

in the final report. We continue to believe that DoD and DoS should have a common approach 

to condolence payments as noted in SIGIR’s lessons learned. 

The Embassy RSO concurred with recommendation 1, concurred in principal with 

recommendation 2, and did not concur with recommendations 3, 8, and 9. With regards to 

recommendation 2, the RSO stated that establishing a standard definition of a serious incident 

should be accomplished at the Washington, D.C. level by appropriate DoS and DoD legal and 

contracting experts, with input from the Embassy and MNF-I. Although it non-concurred with 

recommendation 3, the RSO stated the recommendation could be best accomplished through the 

Embassy/DoD Contractor Working Group which could ensure that cross cutting information and 

actions are properly shared and coordinated within the context of ongoing U.S. government and 

 

3

In April 2009, ACOD became the Armed Contractor Oversight Branch under the MNF-I Protection Division.
v

Government of Iraq bilateral efforts to resolve issues and problems with U.S. government 

affiliated contractors in Iraq. With regards to recommendation 8, the RSO stated that a joint 

group to study the installation of video recording equipment in PSC vehicles is unnecessary. 

Instead, confirmation that video recording equipment is a Government of Iraq requirement is 

sufficient for incorporating this requirement into contracts and grants and other agreements. 

Concerning recommendation 9, the RSO stated that the recommendation is not feasible due to 

funding requirements and foreign policy concerns. It stated that the Embassy’s condolence 

program is funded by DoS funds for ex gratia payments determined to be necessary to further 

foreign policy objectives and that a common inter-agency policy for condolence payments in 

Iraq may not always comport with the Embassy’s foreign policy concerns. Moreover, DoS and 

DoD private security contractors do not always perform similar functions, and a common interagency policy is untenable for this reason as well.

With regards to recommendation 3, SIGIR recognizes that an existing working group of U.S. 

government officials and contractor representatives could accomplish the objectives of the 

recommendation. Our final recommendation reflects this change. Concerning recommendation 

8, SIGIR received confirmation on April 23, 2009, that the Government of Iraq, Ministry of 

Interior, will require that cameras be placed on all vehicles of a PSC convoy. As a result of this 

requirement, SIGIR deleted the draft recommendation from the final report. Concerning 

recommendation 9, SIGIR believes the foreign policy implications of serious incidents involving 

death, serious injury, or property damage by DoD PSCs can be as significant as those involving 

DoS PSCs. Also, some DoD PSCs do perform the same types of missions as those performed by 

DoS PSCs. However, SIGIR recognizes that funding may be an issue since MNF-I states that it 

is legally prohibited from making condolence payments whereas DoS has funds for such 

payments. As stated above, SIGIR’s draft recommendation is not included in the final report. 

However, the report does include a lesson learned related to this issue.

The Bureau of Diplomatic Security provided a number of technical and clarifying comments. 

Concerning recommendation 6, the Bureau stated that it is already discussing with the 

Department’s Office of Acquisition Management the need to identify all PSC subcontractors that 

support DoS contracts and grants. According to the Bureau, this effort is to ensure the Bureau 

identifies 100% of the Tier 2 PSCs and is a follow-on effort to several data calls conducted by 

the U.S. Embassy Baghdad over the last 6 months, which are also designed to identify these 

firms. Most of the other comments relate to the definition and use of the terms Tier 1 and Tier 2. 

The Bureau states that the term Tier applies to PSCs as opposed to missions. Specifically, the 

Bureau states that DoS considers contractors providing services to DoS under the Worldwide 

Personal Protective Services contract to be Tier 1 contractors regardless of the nature of the 

missions these contractors are performing. All other DoS affiliated PSCs, including 

subcontractor PSCs, are considered by DoS to be Tier 2 contractors regardless of the missions 

being conducted. SIGIR could find no formal definition of Tier 1 and Tier 2. It describes Tier 1 

and Tier 2 in terms of missions in the report because a CONOC document shows that the three 

PSCs under the Worldwide Personal Protective Services contract─Blackwater, Triple Canopy, 

and DynCorp—can perform both Tier 1 and Tier 2 missions and that Tier 1 PSCs perform

missions that directly support the Chief of Mission whereas Tier 2 PSCs perform missions that 

indirectly support the Chief of Mission. Moreover, in commenting on SIGIR’s description of 

Tier 1 and Tier 2, an RSO representative provided the following distinction: All U.S. 

government direct hire employees and certain others that fall under the Chief of Mission 
vi

authority and are not under the security responsibility of MNF-I are transported as Tier 1. U.S. 

Agency for International Development, Department of State, and other DoS contractors, 

grantees, and other employees that do not fall under the Chief of Mission authority are 

transported under Tier 2. Therefore, we continue to believe describing Tier 1 and Tier 2 in terms 

of missions of the contractors is appropriate. 
1

Introduction

The U.S. government has relied extensively on private security contractors (PSCs)

4

to perform a 

number of functions in Iraq to include protecting personnel movements, supply convoys, and 

facilities. Although issues have surfaced over the years concerning the oversight, control, costs, 

and legal status of PSCs,

5

a watershed event that occurred in September 2007 brought to the 

forefront concerns about the U.S. government’s oversight and control of the PSCs’ actions. That 

event involved Blackwater, a PSC under contract with the Department of State (DoS), and the 

death of 17 Iraqi civilians. Subsequently, the Department of Defense (DoD) and DoS took 

actions to improve their coordination and oversight of PSCs involved in serious incidents (such 

as attacks, death, injury, and property damage).

This is a follow-on report to the Special Inspector General for Iraq Reconstruction (SIGIR) 

report in which we discuss Aegis’s reporting of serious incidents while under DoD contracts.6 

This report pertains to the DoD process for recording, investigating, and remediating serious 

incidents involving its PSCs. It also includes information and analyses pertaining to serious 

incidents involving DoS contractors to the extent those contractors are required to report their 

incidents through the military process. The report responds to a mandate in the National Defense 

Authorization Act for 2008, Public Law 110-181, which requires audits of the reporting, 

documenting, investigating, and prosecution (where appropriate) processes for incidents 

involving private security contractors in Iraq.

7

Background

In December 2007, DoD and DoS signed a memorandum agreeing that they would jointly 

develop, implement, and follow core standards, policies, and procedures for the accountability, 

oversight, and discipline of PSCs in Iraq. Their objective was to ―reduce the number and 

strategic impact of serious incidents involving PSCs by thorough and impartial investigations of 

these incidents, transparent information and intelligence sharing, close coordination of PSD 

[personal security detail] operations, and joint engagement with the Government of Iraq (GOI).‖

Responsibility for implementing the agreement was assigned by DoS to the U.S. Embassy 

Baghdad and by DoD to the Multi-National Force-Iraq (MNF-I).8 Within the Embassy, 

responsibility for coordinating PSC missions with coalition and Iraqi forces and tracking and 

investigating serious incidents was delegated to the Regional Security Office (RSO).

9

 MNF-I 

 

4

PSC refers to companies, rather than individuals, performing under contracts with those companies.

5

Issues have been raised in reports by the U.S. Government Accountability Office; the U.S. Department of State, 

Office of Inspector General; the Congressional Research Service; and the Congressional Budget Office. A list of 

reports is included in Appendix A in the prior coverage section of the scope and methodology. 

6 Oversight of Aegis’s Performance on Security Services Contracts in Iraq with the Department of Defense (SIGIR09-010, 1/14/2009).

7

Section 842, Private Security Contractor Audit Plan as of October 17, 2008.

8 MNF-I is a subordinate command to the U.S. Central Command.

9

Included are PSCs under contract with DoS, the U.S. Agency for International Development, and any federal 

agency under Chief of Mission authority.
2

established Contractor Operations Cells (CONOC)10 to coordinate PSC missions and gather, 

assemble, and distribute information on serious incidents involving PSCs.11 It also established 

the Armed Contractor Oversight Division (ACOD) to receive serious incident reports from the 

CONOC and ensure that all of them are reported, tracked, and investigated.

12

 The RSO is 

responsible for coordinating DoS Tier 1 missions, which are defined as missions that directly 

support the Chief of Mission.13 For example, Tier 1 missions involve transporting DoS 

personnel, ambassadors, other diplomats, congressional delegations, and other government 

employees. Missions performed by DoS PSCs that do not directly support the Chief of Mission, 

such as transporting DoS contractor and grantee personnel, are categorized as Tier 2 missions.

14

All Tier 2 and DoD PSC missions are to be coordinated through the CONOC. DoS Tier 1 and 2 

PSCs involved in serious incidents are to report on them to the RSO. In addition, DoS PSCs 

involved in serious incidents while conducting Tier 2 missions and all DoD PSCs on missions 

are to report serious incidents to the CONOC, which is to forward them to ACOD. Figure 1

presents an overview of the serious incident reporting process described in DoS and MNF-I 

guidance.

 

10 The CONOC was established by the Multi-National Corps-Iraq, a subordinate command to MNF-I.

11 Cells were established at Headquarters, Multi-National Corps-Iraq, and five major subordinate commands’ 

operations centers located throughout Iraq. The CONOC achieved full functional capability in February 2008.

12 According to an ACOD official, although ACOD became operational in May 2008, it took awhile for the new 

organization to learn the PSC industry and fragmentary order system, get personnel trained on their new 

responsibilities, and develop the tools and processes to track serious incidents. 

13 The Department of State’s Bureau of Diplomatic Security objected to SIGIR’s use of Tier 1 and Tier 2 missions. 

The Bureau states that DoS considers contractors providing services to DoS under the Worldwide Personal 

Protective Services contract to be Tier 1 contractors regardless of the nature of the missions these contractors are 

performing and all other DoS affiliated PSCs to be Tier 2 regardless of the missions being conducted. SIGIR could 

find no formal definition of Tier 1 and Tier 2. It chose to describe Tier 1 and Tier 2 in terms of missions in the 

report because a CONOC document shows that PSCs under the Worldwide Personal Protective Services 

contract─Blackwater, Triple Canopy, and DynCorp─can perform both Tier 1 and Tier 2 missions with the 

distinction being that Tier 1 PSCs perform mission that directly support the Chief of Mission whereas Tier 2 PSCs 

perform missions that indirectly support the Chief of Mission. Moreover, an RSO representative provided the 

following distinction: All U.S. government direct hire employees and certain others that fall under the Chief of 

Mission authority and are not under the security responsibility of MNF-I are transported as Tier 1. U.S. Agency for 

International Development, Department of State, and other DoS contractors, grantees, and other employees that do 

not fall under the Chief of Mission authority are transported under Tier 2. Consequently, we made no change to the 

final report on this issue and noted Diplomatic Security’s position here and in the management comments section.

14 Three DoS PSCs—Blackwater, Triple Canopy, and DynCorp−can perform both Tier 1 and Tier 2 missions.
3

Figure 1−Reporting Chain for Serious Incidents

Source: SIGIR developed from DoS and MNF-I guidance (3/2009).

Contract and Legal Provisions Governing Contractors’ Conduct

The Joint Contracting Command-Iraq/Afghanistan (JCC-I/A) requires that all DoD PSC 

contracts include standard provisions pertaining to the conduct of contractors and their 

personnel.15 For example, all contracts are to include a provision requiring contractors, their 

subcontractors, and their personnel to comply with all existing and future U.S. and host nation 

laws, federal and DoD regulations, and U.S. Central Command orders and directives, including 

rules on the use of force, which is applicable to personnel in Iraq. Contractor and subcontractor 

employees are to provide written acknowledgement that they understand the penalties for 

noncompliance. Such penalties could include criminal and civil actions, revocation of weapons 

authorization, and contract termination.

JCC-I/A also requires that all contracts exceeding $25,000 with contractors operating in the U.S. 

Central Command’s area of responsibility but not authorized to accompany U.S. armed forces 

deployed outside the United States16 include provisions requiring the contractors and their 

employees to comply with (1) U.S. and host country laws; (2) treaties and international 

agreements; (3) U.S. regulations, directives, instructions, policies, and procedures; and (4) force 

protection, security, health, or safety orders, directives, and instructions issued by the Combatant 

Commander.

 

15 Requirements are specified in the Contracting Officer’s Guide to Special Contract Requirements for 

Iraq/Afghanistan Theater Business Clearance (11/12/2007).

16 Contractors that are not subject to the Defense Federal Acquisition Regulation Supplement 252.225-7040.
4

In addition to the administrative penalties available under the contracts, contractors may be 

subject to criminal actions for serious offenses under both Iraqi and U.S. law. Under Coalition 

Provisional Authority Order 17, PSCs were generally immune from the Iraqi legal process for 

acts performed under the terms and conditions of their contracts. As of January 1, 2009, Order 

17 was suspended by resolution of the Iraqi Council of Representatives, Iraq’s main legislative 

body.17 Consequently, U.S. contractors and their personnel became subject to Iraqi laws and, as 

a result, lost civil, criminal, and administrative immunities previously granted by the Order.18

Additionally, U.S. contractor personnel who committed criminal acts in Iraq were potentially 

subject to prosecution under U.S. laws before CPA Order 17 was suspended, and that remains 

the case. Examples of such laws, including some recent legislative changes, are discussed in the 

following paragraphs.

Jurisdiction of certain federal statutes extends to U.S. nationals at U.S. overseas facilities that 

qualify as part of the special maritime and territorial jurisdiction of the United States. This 

jurisdiction includes ―premises of the United States diplomatic, consular, military, or other 

United States government missions or entities in foreign States‖ as well as ―residences in foreign 

States ..., irrespective of ownership, used for purposes of those missions or entities or used by 

United States personnel assigned to those missions or entities.‖19 Criminal statutes that apply 

within this jurisdiction include maiming,20 assault,21 kidnapping,22 murder,

23 and manslaughter.24

Military personnel who commit crimes in the United States or abroad are subject to the Uniform

Code of Military Justice. Traditionally, contractor personnel have been subject to the Code if 

serving with or accompanying an armed force in the field during wartime, or if they are retired 

members of a regular component of the armed forces who are entitled to pay. In 2006, Congress 

extended the Code’s jurisdiction to persons serving with or accompanying an armed force in the 

field during ―contingency operations‖ as well as during a declared war.25 Thus, U.S. personnel 

performing under DoD contracts in support of U.S. military operations in Iraq may be subject to 

prosecution in a court-martial, and at least one such prosecution occurred (resulting in a guilty 

plea).26 However, as a matter of policy, DoD has stated that it will give the Department of 

 

17 Resolution of 21 December 2008, Iraq Council of Representatives (37th Sess. 2008). See also the U.S.-Iraq 

Security Agreement, Agreement Between the United States of America and the Republic of Iraq on the Withdrawal 

of United States Forces from Iraq and the Organization of Their Activities during Their Temporary Presence in Iraq

(entry into force 1/1/ 2009); Article XII affirms Iraq’s primary jurisdiction over U.S. contractors to DoD even 

though it gives the United States primary jurisdiction over U.S. armed forces and their civilian components in 

specified situations.

18 Order 17, as revised June 27, 2004, Section 4.

19 18 U.S.C. § 7(9).

20 18 U.S.C. § 114.

21 18 U.S.C. § 113.

22 18 U.S.C. § 1201.

23 18 U.S.C. § 1111.

24 18 U.S.C. § 1112.

25 John Warner National Defense Authorization Act for Fiscal Year 2007, Public Law 109-364, § 552, codified at 10 

U.S.C. § 802(a)(10).

26 For a general discussion of that case and related matters, see Contractors’ Support of U.S. Operations in Iraq, 

Congressional Budget Office, U.S. Congress, Pub. No. 3053 (2008); Elsea, Jennifer K., and Nina M. Serafino, 

Private Security Contractors in Iraq: Background, Legal Status, and Other Issues, CRS Report for Congress 
5

Justice an opportunity to prosecute in federal district court any alleged federal criminal offenses 

by civilians and will not initiate court-martial charges if the Department of Justice elects to 

prosecute those offenses.27

DoD contractor personnel could also be subject to the Military Extraterritorial Jurisdiction Act of 

2000. The act extends the jurisdiction of U.S. courts to anyone who commits a felony outside 

U.S. territory while employed by or accompanying the Armed Forces outside the United States. 

The term ―employed by the Armed Forces outside the United States‖ means civilians and 

contractors (a) of DoD, or (b) of any other federal agency or any provisional authority to the 

extent their employment ―relates to supporting the mission of the Department of Defense 

overseas,‖ and (c) who in each case are present or residing outside the United States in 

connection with their employment and are not nationals of, or ordinarily resident in, the host 

country. If the host country has prosecuted or is prosecuting a person covered by the act, the 

person cannot be prosecuted under the act unless the Attorney General or Deputy Attorney 

General personally approves.28

Under the War Crimes Act,29 as amended by the Military Commissions Act of 2006,30 U.S. 

nationals may be fined, imprisoned, or put to death for war crimes prohibited by several 

international conventions. Such crimes include murdering or maiming an individual taking no 

part in hostilities, intentionally causing serious bodily injury, and rape, among others.

Objectives

SIGIR’s overall objective was to examine DoD’s oversight of serious incidents by PSCs in Iraq. 

Specifically, we examined DoD’s (1) policies, procedures, and practices for reporting, 

investigating, and remediating those incidents and (2) efforts to identify trends and lessons 

learned. Because DoS PSCs on Tier 2 missions are required to report serious incidents to both 

the RSO and CONOC, we reviewed pertinent DoS policies and procedures related to that 

reporting and made comparative analyses when we noted differences.

For a discussion of the audit scope and methodology and a summary of prior coverage, see 

Appendix A. For a list of acronyms used, see Appendix B. For a list of incidents reported by 

contractors, see Appendix C. For the audit team members, see Appendix D. For management 

comments, see Appendix E.

 

RL32419, Congressional Research Service (2007). Prosecutions of civilians under the Code, however, have been 

challenged on constitutional grounds. Ibid.

27 ―UCMJ Jurisdiction Over DoD Civilian Employees, DoD Contractors, and Other Persons Serving With or 

Accompanying the Armed Forces Overseas During Declared War and in Contingency Operations,‖ Memorandum 

from the Secretary of Defense to Secretaries of the Military Departments, et al. (3/10/2008).

28 18 U.S.C. §§ 3261-3267. Members of the Armed Forces subject to the Uniform Code of Military Justice may not 

be prosecuted under the act, except in narrow circumstances specified by the act. See 18 U.S.C. § 3261(d).

29 18 U.S.C. § 2441.

30 P.L. 109-366.
6

Database, Reporting, and Analysis Weaknesses

Both MNF-I and the U.S. Embassy have separately issued guidance pertaining to the reporting of 

serious incidents. The guidance pertaining to reporting timeframes and what should be reported 

are very similar, but the definitions of serious incidents are different. MNF-I’s definition is more 

expansive.

The CONOC, ACOD, and RSO maintain separate databases of serious incidents. Our review 

found that (1) the CONOC and RSO databases do not agree on incidents that should be reported

to both organizations, (2) the CONOC database does not, as required, include all incidents 

reported by PSCs, and (3) the ACOD database includes only the incidents that ACOD

judgmentally decides to track even though it is responsible for ensuring that all serious incidents 

are reported, tracked, and investigated. ACOD’s judgmental selection process has the effect of 

narrowing the types of incidents it tracks and applying a narrower definition of serious incidents 

than that contained in the MNF-I guidance.

ACOD has developed trend analyses using its data, but those analyses are limited in terms of the

incidents reported. ACOD officials stated that they have not done more analyses because they 

had been asked to do only one analysis. The limited analyses may be impacting its ability to 

develop lessons learned.

Although the serious incident database maintained by the CONOC is not complete, it is the most 

comprehensive information on serious incidents reported by PSCs and is useful in identifying 

frequency and trend data. For example, our analysis of the data shows that for the period 

February 24, 2008, through February 28, 2009, two contractors reported about 50% of the 

recorded serious incidents. In addition, graduated force responses31 and small arms fires 

generally decreased while road traffic accidents became the most frequent over time.

Serious incident reporting by PSC subcontractors that support DoD and DoS contractors and 

grantees appears to be a problem. A recent audit by the U.S. Agency for International 

Development’s Office of Inspector General found that PSCs supporting implementing partners 

(contractors and grantees) were confused about the requirements for providing serious incident 

reports. Officials of various organizations told us they have no visibility of reporting other than 

that of prime PSCs.

Serious Incident Reporting Process and Requirements

MNF-I guidance for DoD PSCs’ reporting of serious incidents has been provided in various 

fragmentary orders. The most current Fragmentary Order (09-109) was issued in March 2009

and replaces earlier orders.32 Although other requirements in the orders have changed, the

 

31 A graduated force response begins with nonlethal force measures (e.g., giving verbal warnings, showing weapons 

with intent to use them) and possibly escalates to lethal measures (e.g., using deadly force to remove the threat).

32 Fragmentary Order 07-428, Overarching Order for Requirements, Procedures, Responsibilities for Control, 

Coordination, Management, and Oversight of Armed Contractors/DoD Civilians and PSCs (first issued 12/2007). 

Fragmentary Order 08-575, DoD PSCs and Armed Contractors – Serious Incident Reporting Procedures (11/2008). 

Fragmentary Order 09-109, Overarching FRAGO for Requirements, Communications, Procedures, Responsibilities 
7

definition of a serious incident and the basic incident reporting requirements have remained the 

same. A serious incident is defined as any incident that includes, but is not limited to, ―any 

damage of equipment or injury to persons, attacks, any weapons discharge, criminal acts, traffic 

accidents, and any incident believed to have possible strategic or operational impact. Incidents 

where aggressive personal behavior and share the road policies are violated shall be reported.‖ 

PSCs are required to report to the CONOC all serious incidents that they observe, suspect, or in 

which they are participants. PSCs are to immediately alert the CONOC of a serious incident, 

submit an initial report within 4 hours, and conduct an internal investigation of the incident and 

submit a final incident report within 96 hours. PSCs are also to report serious incidents to the 

immediate commanders of the units to which they are assigned and the contracting officer 

representatives and contracting officers responsible for the contracts under which they are 

performing. The incident reports are to include such information as who, what, when, and where 

of each incident; the contract number; and contact information on the contracting officer 

representative.

Incident reports can also be submitted to the CONOC by other sources. Fragmentary Order 09-

109, as with previous orders, requires military units in the area that observe incidents involving 

PSCs to report those incidents through their military channels to the CONOC. ACOD has 

established contacts with the Iraqi Ministries of Interior and Defense to share information 

concerning incidents involving local nationals.

The U.S. Embassy’s guidance for its PSCs is specified in its Policy Directives for Armed Private 

Security Contractors in Iraq, dated May 2008. The directive defines as serious ―An incident 

involving the use of deadly force, the discharge of a weapon (other than in training or into a 

clearing barrel), and/or an incident that resulted in death, serious injury, significant property 

damage (even if a weapon is not involved), and other serious consequences.‖ According to the 

directive, PSCs must provide notification, either verbally or in writing via e-mail, of any serious 

incident to the RSO tactical operations center and to the CONOC (if the missions are coordinated 

by the CONOC) as soon as practical, but not later than 1 hour after the incident. A follow-up 

comprehensive written report of events surrounding the incident must be provided within 96 

hours unless otherwise directed by the RSO. Such reports must also be submitted to supervising 

contractors and to cognizant contracting/grant officer representatives. The incident reports are to 

include information on who was involved, what happened, where it happened, when it happened, 

impact on operations, and actions required.

In accordance with the December 2007 DoD/DoS agreement, the CONOC and the RSO have

assigned liaison officers to their respective operations centers. The liaisons are to facilitate the 

monitoring, recording, and timely dissemination of pertinent information related to DoD and 

DoS PSCs operating in Iraq. If an incident occurs involving a Tier 2 mission, the CONOC is to 

notify the RSO liaison officer, who in turn is to relay that information to the RSO operations 

center. Likewise, if a PSC on a Tier 1 mission has an incident that could affect DoD PSCs or 

any military operations, the RSO liaison is to notify the CONOC and the relevant military 

commander in the area.

 

for Control, Coordination, Management, and Oversight of Armed Contractors/DoD Civilians and Private Security 

Companies (3/2009).
8

Problems with Incidents Reported and Recorded

The CONOC, ACOD, and RSO maintain separate databases of serious incidents. Our review 

found that (1) the CONOC and RSO databases do not agree on incidents involving DoS PSCs on 

Tier 2 missions even though these PSCs are to report all incidents to both organizations, (2) the 

CONOC database does not include all incidents DoD PSCs and DoS PSCs on Tier 2 missions 

say they reported even though the CONOC is to track all such incidents, and (3) the ACOD 

database does not track all serious incidents received from the CONOC even though it is 

responsible for ensuring that all serious incidents are reported, tracked, and investigated.

CONOC and RSO Databases Do Not Agree on Tier 2 Incidents

The CONOC maintains a database of incidents reported to it, including incidents reported by 

DoS PSCs on Tier 2 missions. The RSO also maintains a database involving Tier 2 missions. 

To test the completeness of the CONOC and RSO databases for incidents involving DoS PSCs 

on Tier 2 missions, we obtained serious incident data from one PSC that performs Tier 2 

missions. We found the incidents provided by the contractor and the information provided to us 

by the RSO and CONOC for that contractor did not agree. There were differences for 5 of 13 

incidents. For example, the RSO data show that an incident occurred on March 8, but neither the 

contractor nor CONOC have it on record. Also, the contractor and RSO data show an incident 

on April 8 that the CONOC does not have recorded in its database. Table 1 compares the serious 

incidents reported by the contractor to the data for that contractor in the CONOC and RSO 

databases.
9

Table 1—Serious Incidents Reported by a Tier 2 Contractor and Incidents in the 

CONOC and RSO Databases (3/1/2008−2/3/2009)

Date of

Incident Contractor Data

CONOC

Database RSO Database

03/08/08 No record of incident No Graduated Force Responsea

03/16/08 Road traffic accident Yes Yes

03/17/08 Graduated force response Yes Yes

03/22/08 Graduated force response Yes Yes

04/08/08 Road traffic accident No Yes

04/10/08 Graduated force response No Yes

04/23/08 Road traffic accident No Yes

05/20/08 Graduated force response Yes Yes

06/10/08 Small arms fire Yes Yes

09/12/08 Negligent dischargeb No No

12/01/08 Road traffic accident Yes Yes

12/11/08 Negligent discharge Yes Yes

02/03/09 Improvised explosive device Yes Yes

Notes: 

a

 A graduated force response begins with nonlethal force measures (e.g., giving verbal warnings, showing weapons with intent to use them) and 

possibly escalates to lethal measures (e.g., using deadly force to remove the threat).

b Contractor stated it reported the incident to the RSO but not to CONOC.

Source: SIGIR developed from contractor, CONOC, and RSO data.

To further test the completeness of the CONOC and RSO databases for incidents involving Tier 

2 missions, we compared the incidents in both databases for seven PSCs performing Tier 2 

missions. As Table 2 shows, we found differences for five of the seven PSCs.
10

Table 2—CONOC and RSO Serious Incident Data for Selected Tier 2 Contractors 

(2/24/2008−2/28/2009)

PSC

CONOC

Database

RSO

Database Difference

A 1 1 0

B 5 8 3

C 1 0 1

D 1 1 0

E

a

28 17 11

F 6 7 1

G 9 14 5

Note:

a Contractor also has contracts with the Government of Iraq and DoD.

Source: SIGIR developed from CONOC and RSO data.

CONOC Database Does Not Agree With DoD PSC Incidents 

The CONOC database is to include all serious incidents reported by DoD PSCs. In addition, the 

fragmentary orders encourage PSCs supporting coalition forces, nongovernmental organizations, 

corporations, and others to report their serious incidents to the CONOC. To test the 

completeness of the CONOC database for incidents involving DoD PSCs, we obtained serious 

incident data from six DoD PSCs. We found differences between the incidents the PSCs told us 

they reported and the CONOC database. Table 3 compares the serious incidents reported by one 

of the DoD PSCs to the incidents for that contractor in the CONOC database. It shows that the 

contractor reported six more incidents than recorded in the CONOC database. We noted similar 

results for three other contractors. 
11

Table 3—Serious Incidents Reported by a DoD Contractor and Incidents in the 

CONOC Database (3/1/2008−2/18/2009)

Incident Type

Contractor 

Reported CONOC Database Difference

Improvised explosive devicea4 4 0

Negligent discharge 2 1 1

Road traffic accident 22 20 2

Small arms fire 7 4 3

Other 20 20 0

Total 55 49 6

Note:

a Explosive formed projectile incidents are included in this category.

Source: SIGIR developed from contractor and CONOC data.

A CONOC official was uncertain why the incidents in the CONOC database differed from the 

incidents reported by the PSC; however, he indicated that it is possible the PSC never reported 

the incidents to the CONOC.

ACOD Database Does Not Track All Serious Incidents

ACOD also maintains a database of serious incidents. Although it is to receive all incidents 

reported to the CONOC, we found considerable differences between the incidents in the 

CONOC’s and ACOD’s databases. We were told that some of the differences could be because 

ACOD became operational in May 2008, whereas the CONOC became fully operational in late 

February 2008. However, even adjusting for this timeframe difference by excluding incidents 

reported to the CONOC prior to May 2008, the ACOD incident data are far more limited than the 

CONOC incident data.

Specifically, ACOD’s database had only 264 of 618, or 43%, of the serious incidents recorded in

the CONOC database during the period May 1, 2008, through February 28, 2009. ACOD 

officials told us the reason for the difference is that ACOD has decided to track only incidents 

that could have strategic impact on the PSCs’ missions. To identify those, it reviews the 

incidents received from the CONOC in four principal categories and judgmentally decides which 

incidents to track. The four principal categories of incidents are: graduated force responses, 

negligent discharges of weapons, road traffic accidents, and small arms fires.

As a result of its judgmental selection process, ACOD did not track 354, or 57%, of the serious 

incidents reported to the CONOC from May 1, 2008, through February 28, 2009. Table 4 shows 

the difference in numbers of incidents in the CONOC and ACOD databases for the types of 

incidents.
12

Table 4—Serious Incidents in CONOC and ACOD Databases (5/1/2008−2/28/2009)

Incident Type

CONOC 

Database

ACOD 

Database Difference

Checkpoint incident 16 14 2

Graduated force responsea80 61 19

Indirect fire 21 2 19

Improvised explosive deviceb77 8 69

Negligent discharge 44 37 7

Other 177 38 139

Rocket propelled grenade 3 0 3

Road traffic accidents 149 82 67

Small arms fire 46 22 24

Complex attackc5 0 5

Total 618 264 354

Note: 

a A graduated force response begins with nonlethal force measures (e.g., giving verbal warnings, showing weapons with intent to use them) and 

possibly escalates to lethal measures (e.g., using deadly force to remove the threat).

b Includes suicide vest improvised explosive device and vehicle-borne improvised explosive device incidents.

c

Complex attacks include multiple forms of attacks, such as an improved explosive device, followed by small arms fire.

Sources: SIGIR analysis of CONOC and ACOD databases.

Since ACOD does not have written criteria for selecting the serious incidents it tracks, we 

reviewed the 354 serious incidents that were not in ACOD’s database to determine whether any

appeared to meet the selection factors (incidents that could have strategic impact on the PSCs’ 

missions and were in the four principal categories it focuses on) used by ACOD officials to track 

incidents. We found that 122 serious incidents appeared to meet those factors. Table 5 shows 

the 122 serious incidents by type.

Table 5—Serious Incidents That Appear to Meet ACOD Selection Factors but Are 

Not in Its Database (5/1/2008−2/28/2009)

Incident Type Number of Incidents

Road traffic accident 68

Small arms fire 23

Graduated force response 19

Negligent discharge 7

Complex attack 5

Total 122

Source: SIGIR analysis developed from CONOC and ACOD databases and reporting criteria.

We discussed the list of 122 incidents with ACOD officials, who provided the following 

explanations: 27 were included in their database but under a different date or contractor than 

shown in the CONOC database for the incident, 45 were not recorded and considered irrelevant, 
13

9 were received but not recorded for various reasons, and 41 were probably received but 

dismissed by ACOD. After further review of the 41 incidents, ACOD officials judged that 38 

were not significant enough to track but that 3 should have been tracked because of their 

significance. The fact that 122 incidents we identified could meet ACOD’s selection factors and 

it dismissed three significant incidents that meet those factors illustrates the subjectivity in 

ACOD’s incident screening process.

ACOD’s judgmental selection process has the effect of narrowing the types of incidents it tracks 

and applying a narrower definition of serious incidents than that contained in the fragmentary 

order.

In commenting on a draft of this report, MNF-I stated that ACOD reviews all serious incidents it 

receives from the CONOC; however, not all serious incidents are sufficiently ―serious‖ to merit 

the attention of the requiring activity or MNF-I. Also, MNF-I said that ACOD has maintained 

the following general criteria for elevating a serious incident to the requiring activities’ or MNFI’s attention: any interaction between a PSC and an Iraqi resulting in physical injury/property 

damage; any time a PSC fires shots downrange; and significant injury to PSC personnel as a 

result of PSC site security/convoy operations. Moreover, MNF-I stated that these criteria 

remained unwritten but they see the benefit of having written criteria. Lastly, MNF-I said it will 

work with the RSO to develop joint criteria for use in identifying ―serious‖ incidents. 

ACOD Developed Trend Analyses With Limited Data and No Formal Lessons Learned

From the limited incidents it tracks from the CONOC database, ACOD develops certain trend 

analyses for internal purposes only and others that are shared with members of the Joint Incident 

Review Board.33 We reviewed the analyses performed by ACOD that are shared with the 

Review Board and found that they do not present a complete picture of the incidents in its 

database. For example, ACOD’s analysis for the February 2009 meeting shows no mobile 

graduated force response incidents for the October through December 2008 period; however, the 

ACOD database shows two mobile graduated force responses and ten responses involving static 

guards for that period. The following example is drawn from incident reports of graduated force 

responses excluded from ACOD’s analyses.

In November 2008, a graduated force response incident occurred between a PSC convoy and a 

vehicle driven erratically behind the convoy. That particular vehicle overtook other vehicles 

which had been requested by the PSC convoy to slow down by the use of hand signs and flags. 

As the other vehicles slowed down to a safe distance from the convoy, the driver in the 

erratically driven vehicle continued to ignore the hand and flag signals made by the PSC. As a 

warning, the PSC fired a mini flare in front of the vehicle. As a result of this action, the vehicle 

immediately slowed and kept its distance. There were no injuries or casualties. Although the 

PSC determined that no further action was needed, ACOD requested that the requiring activity 

review the PCS’s internal report to determine if the PSC’s action was appropriate. After further 

review, the requiring activity and the Staff Judge Advocate concurred that no further 

investigation was required.

 

33 The Board was established by the DoD and DoS Memorandum of Agreement (December 2007) to share 

information and issues concerning serious incidents. It meets on a quarterly basis.
14

We asked ACOD why it has not shared more of its analyses and were told that only JCC-I/A had 

requested an analysis pertaining to graduated force responses. We were also told that ACOD had 

not developed formal lessons learned even though the fragmentary orders state that ACOD will 

use serious incident reports to develop lessons learned. An ACOD official stated that the seven 

fragmentary orders produced in the past ten months were a product of captured lessons learned.

The official also stated that ACOD’s ability to perform its missions was impacted by its limited 

staffing and the organization could have grown to three times its size, however, about the time 

efforts were made to expand the organization using contractors, the situation improved in Iraq. 

In commenting on a draft of this report, MNF-I stated that ACOD lessons learned were 

identified, analyzed, and incorporated through fragmentary orders. It cited trend analysis of road 

traffic accidents which resulted in the publication of Rules of the Road for PSCs operating in 

Iraq. The rules are part of Fragmentary Order 09-109 issued in March 2009. According to 

MNF-I, following the publication of this fragmentary order, a statistically measurable decrease in 

mobile graduated force responses and traffic accidents were noted.

Serious Incident Frequency and Trends

Although CONOC’s serious incident database is not complete, it contains the most 

comprehensive information on serious incidents reported by PSCs and is useful in identifying

frequency and trend data. Our analysis of the CONOC data from February 2008 through 

February 2009 shows that (1) the most frequent recorded incidents involved road traffic 

accidents, improvised explosive devices, and graduated force responses; (2) two contractors 

reported about 50% of the recorded serious incidents; (3) graduated force responses and small 

arms fires generally decreased while road traffic accidents became the most frequent over time;

(4) there was less than 1 incident per 117 missions; and (5) the Baghdad area accounted for over 

half of the recorded serious incidents.

The CONOC recorded 784 serious incidents during the period February 24, 2008, through

February 28, 2009. Table 6 shows these by type of incident. As the table shows, incidents 

involving road traffic accidents, improvised explosive devices, and graduated force responses 

were the most frequently recorded.
15

Table 6—CONOC Recorded Serious Incidents (2/24/2008−2/28/2009)

Type of Incident Recorded Incidents

Road traffic accident 171

Improvised explosive devicea105

Graduated force response 93

Negligent discharge 56

Small arms fire 53

Indirect fire 35

Complex attack 17

Checkpoint incident 13

Rocket-propelled grenades 3

Otherb238

Total 784

Note:

a Includes vehicle-borne and other improvised explosive devices.

b Includessuch incidents as personal injuries, deaths by natural cause or suicide, assaults, abductions, and security breaches.

Source: SIGIR developed from CONOC data.

Table 7 shows the serious incidents recorded by the CONOC for the 10 PSCs with the greatest 

number of serious incidents for the period February 24, 2008, through February 28, 2009. The 

table also shows the total obligations for the contractors under contracts or subcontracts with 

DoD, DoS, and the U.S. Agency for International Development since 2003. The top two PSCs 

with a combined total of 395 serious incidents accounted for about 50% of the 784 recorded 

serious incidents. Appendix C shows the recorded serious incidents for all PSCs in the CONOC 

database.
16

Table 7—Contractors with the Greatest Number of Serious Incidents

(2/24/2008−2/28/2009) ($ millions)

Contractor Recorded Incidents Obligationsa

Aegis Defence Services, Limited 224 $697.2b

EOD Technology, Inc. 171 $328.7

ArmorGroup 63 $137.6

Hart Group 58 $26.3

Special Operations ConsultingSecurity Management Group41 $271.9

Threat Management Group 40 $.5

Olive Group FZ LLC 37 $17.6

Sabre International Security 28 $284.5

Reed Incorporated 17 $9.2

Falcon Group 15 $29.3

Note:

a Unless otherwise noted, obligations are as reported in Agencies Need Improved Financial Data Reporting for Private Security 

Contractors (SIGIR-09-005, 10/30/2008).

b As reported in Oversight of Aegis’s Performance on Security Services Contracts in Iraq with the Department of Defense 

(SIGIR-09-109, 1/14/2009).

Source: SIGIR developed from CONOC data and SIGIR reports.

Figure 2 shows the primary types of incidents tracked by ACOD (graduated force response, 

negligent discharge, road traffic accidents, and small arms fires) recorded by the CONOC by 

month. As the figure shows, graduated force response and small arms fire incidents have 

generally decreased from February 2008 through February 2009. The figure also shows that 

road traffic accidents have become the most frequent incidents. An RSO official indicated that 

road traffic accidents may be increasing because more Iraqi drivers are on the road, PSCs are 

reporting more of their traffic accidents, PSCs are using warning signals less frequently since the 

issuance of share-the-road guidance, and a growing number of Iraqi nationals are working for 

PSCs.
17

Figure 2−Serious Incidents by Type and Month (2/2008 through 2/2009)

Source: SIGIR compiled from the CONOC database.

Figure 3 compares the total number of serious incidents reported to the PSC missions by month. 

Over the period February 2008 through February 2009, 784 serious incidents and 91,481

missions, or less than 1 incident per 117 missions, were recorded. The figure for incidents per 

mission includes incidents involving security guards at installations (static guards). Although the 

static guards do not participate in missions, we could not segregate these type incidents to

exclude them from our analysis.

0

5

10

15

20

25

30

Negligent 

Discharge

Road Traffic 

Accident

Graduated Force 

Response

Small Arms Fire
18

Figure 3−Serious Incidents During PSC Missions by Month (2/2008 through 

2/2009)

Source: SIGIR compiled from the CONOC database.

Figure 4 shows the serious incidents by multi-national division (MND) or multi-national force 

(MNF). As the figure shows, the MND-B region, which includes Baghdad, accounted for over 

half of the incidents during the period February 24, 2008, through February 28, 2009.
19

Figure 4−Serious Incidents by Multi-National Division Region 

(2/24/2008−2/28/2009)

Notes:

MND-Baghdad−Baghdad and past Falluja.

MND-Center−All provinces south of Baghdad except Basrah.

MND-North−All provinces north of Baghdad except about half of Ninewa.

MND-South East−Basrah Province.

MNF-West−Anbar and the other half of Ninewa.

Source: SIGIR compiled from CONOC database.

Potential Gaps in Subcontractor Reporting

There appears to be a problem in serious incidents reporting by PSC subcontractors that support

DoD and DoS contractors and grantees. The U.S. Agency for International Development

(USAID) Office of the Inspector General recently reported that in some instances PSCs working 

for contractors and grantees did not always understand the serious incident reporting 

requirements.

34 We were told of other instances where PSCs may be confused about reporting 

requirements. Officials with ACOD, RSO, JCC-I/A,

35 and the Defense Contract Management 

Agency36 told us they have no visibility of PSCs who may be performing as subcontractors to 

other PSCs, reconstruction contractors, grantees, and others.

In a March 2009 audit report, the USAID’s Office of Inspector General noted that USAID’s 

implementing partners (contractors and grantees that implement USAID programs) had not 

adequately overseen the reporting of serious incidents by their PSCs. The report also stated that 

PSC staff did not always understand the reporting requirements. As a result, the PSCs were not 

 

34 Audit of USAID/IRAQ’s Oversight of Private Security Contractors In Iraq, Office of Inspector General (Audit 

Report No. E-267-09-002-P, 3/4/2009).

35 According to Fragmentary Order 09-109, Annex A, if arming of contracted employees in Iraq is contemplated, the 

Command is responsible for including in all contracts a requirement for contractors to ensure that all subcontractors 

and their employees at any tier comply with the Fragmentary Order.

36 The Agency performs audits of the contractors’ compliance with the requirements of the Fragmentary Order.

52%

10%

21%

9% 8%

0%

10%

20%

30%

40%

50%

60%

MND-B MND-C MND-N MND-SE MNF-W

MND-B

MND-C

MND-N

MND-SE

MNF-W
20

reporting all serious incidents, were not reporting all serious incidents to appropriate authorities, 

or were not reporting all incidents within required timeframes. For example, the report showed 

that one PSC had 10 serious incidents during the period March 1, 2008, to September 30, 2008;

however, the key offices that are to receive reports of those incidents had only the following 

number on file: implementing partner−4, CONOC−5, ACOD−4, and RSO−3.

According to an ACOD official, some DoD PSCs had reported serious incidents to the Logistics

Movement Coordination Center rather than the CONOC. The Center falls under the U.S. Army 

Corps of Engineers, Gulf Region Division, and is responsible for managing logistics movements. 

One of its functions is to coordinate convoy movements with Coalition Forces, a function similar 

to that performed by the CONOC. The official identified three contractors that had reported their 

serious incidents in early 2009 to the Center. The incidents were later reported to the CONOC. 

Fragmentary Order 09-109, issued in March 2009, specifically states that PSCs are to report 

directly to the CONOC and not to the Logistics Center. The new Order should help address this 

specific reporting problem. However, as noted below, gaps in reporting could remain.

Because of the problems expressed in the Office of the Inspector General report cited above, we 

asked officials with ACOD, RSO, JCC-I/A, and the Defense Contract Management Agency if 

they had visibility of subcontractor PSCs who may be providing protective services to grantees,

reconstruction contractors, or other PSCs. These officials said that they have no visibility of the 

subcontractors in those arrangements.

The Defense Contract Management Agency audits contractors for which they have oversight 

responsibility. Agency officials said that they audit the contractors’ compliance with 

requirements in fragmentary orders but not whether the contractors are appropriately overseeing 

their subcontractors.
21

Some Serious Incidents Involving Department of 

Defense Private Security Contractors Are Not Being 

Investigated

MNF-I requirements specify a process military commanders are to use to review and investigate 

serious incidents. ACOD is to ensure that commanders are fulfilling their responsibilities. We 

found that requirements are not being followed for the most serious of incidents−those involving 

death, serious injury, and property damage over $10,000. According to an ACOD official, 

ACOD decides what incidents to investigate based on its interpretation of the intent of the 

fragmentary order rather than the stated requirements in the order.

The RSO is responsible for investigating serious incidents involving DoS PSCs. We did not 

review the RSO process but did learn that the RSO had conducted five investigations of serious 

incidents of Tier 2 contractors from January 1, 2008, through December 31, 2008.

Multi-National Force-Iraq Serious Incident Investigation Process 

Not Working As Required

PSCs involved in serious incidents are to conduct internal investigations and submit their reports 

to government entities. The government organization receiving the PSC’s services, hereafter 

referred to as the requiring activity, is to determine whether the PSC’s investigation sufficiently 

documents the relevant facts and whether further investigation is necessary. ACOD is 

responsible for ensuring that the requiring activity is fulfilling its responsibilities. From the 

CONOC database, we identified 47 serious incidents that required investigations because they 

involved deaths, serious injuries, or property damage over $10,000. We compared the 47 to the 

ACOD database and found only 21 in the database. Seven of the 21 indicated no action taken. 

An ACOD official indicated that ACOD determines what level of investigation is necessary 

based on the type of incident.

Multi-National Force-Iraq Serious Incident Investigation Process

MNF-I Fragmentary Order 09-109, Annex E, provides the requirements, procedures, and 

responsibilities that military commanders are to use to review and investigate serious incidents.37 

Under Annex E, the PSC involved in a serious incident is to conduct an internal investigation

and submit its final report within 96 hours to the CONOC and the contracting officer and the 

contracting officer representative for the contract. The contracting officer representative is to 

provide a copy of the PSC’s final report to the requiring activity. The requiring activity is to 

determine whether the PSC’s final report sufficiently documents the relevant facts and whether 

further investigation is necessary. If the final report is sufficient, the requiring activity must 

determine whether any disciplinary or corrective action is needed and report the results to 

ACOD. If the contractor’s final report is insufficient, the requiring activity must appoint an 

investigating officer or refer the matter to an investigative authority. The requiring activity must

 

37 The process is basically the same as that described in the prior Fragmentary Order 07-428.
22

request an Army Regulation 15-6

38 investigation if the incident involves death, serious injury, or 

property damage over $10,000. If the PSC’s final report, the inquiry by the requiring activity 

commander, or the 15-6 investigation suggests a felony, the requiring activity commander is to 

notify and consult the Multi-National Corps-Iraq Staff Judge Advocate. The investigative results 

and any corrective, disciplinary, or criminal actions are to be reported to ACOD. ACOD is 

responsible for ensuring that the requiring activity is fulfilling its responsibilities to promptly and 

thoroughly review and/or investigate all serious incidents and to initiate corrective actions, as 

appropriate.

Investigation Process Not Working As Required

Since ACOD tracks less than half of all serious incidents reported to the CONOC, we could not 

determine the full extent to which the process described in the fragmentary order is or is not 

working as intended. However, we were able to determine that the requirement that the most 

serious of incidents—those involving death, serious injury, or property damage over $10,000−be 

investigated is not working as described in the fragmentary order. To test whether the required 

Army Regulation 15-6 investigations are being conducted for those type incidents, we reviewed 

the CONOC database to identify incidents that appeared to meet the most serious incident

criteria. We identified 47 serious incidents involving casualties (as a result of road traffic 

accidents, negligent discharge, small arms fire, and other incidents such as personal injuries, 

suicide, and electrocution) and/or property damage from May 1, 2008, through February 28, 

2009. We reviewed the ACOD database for the 47 incidents and found 21, or less than half. The 

database indicated the following status for the 21 incidents: 7, no further action; 8, commander 

reviewed and endorsed; 2, Army Regulation 15-6 investigation; 1, letter sent to PSC; 1, forward 

a copy of report to the Defense Contract Management Agency; 1, DoS action; and 1, criminal 

investigation.

We asked ACOD for an explanation and an ACOD official told us ACOD does not require 

investigations of incidents that are caused by the enemy, which do not involve local nationals

and/or result in minor injuries. The official further stated that ACOD provides no oversight of 

incidents caused by enemy action unless the PSC did not follow requirements. The official 

described an incident where the PSC exchanged fire with Iraqi Army and Iraqi police at an Iraqi 

check point after an improvised explosive device attack on their convoy. As a result of the 

PSC’s actions, ACOD directed a commander’s inquiry and issued a letter of concern to the PSC.

In our review of ACOD’s database, we also found that nine Army Regulation 15-6 investigations 

and four criminal investigations had been completed from May 2008 through February 2009.

Differing Use of Security Cameras

Although DoS PSCs performing Tier 2 missions are to report serious incidents to the CONOC, 

any incident investigations are the RSO’s responsibility. The May 2008 Embassy policy 

directive states that the RSO will generally investigate incidents involving (1) a confirmed or 

likely death or serious injury or (2) possible criminal misconduct. According to an RSO official, 

incidents involving the use of deadly force, property damage, injury, death, or an indication of a 

 

38Army Regulation 15-6 is used as the basis for many investigations that require detailed facts to be gathered and 

analyzed and recommendations to be made based on those facts.
23

law violation are automatically investigated. Other incidents may be investigated based on a 

judgment call. Investigations are performed by the Force Investigation Unit within the RSO. 

The Unit was established in response to a recommendation by the Kennedy Panel,39 a special 

panel tasked by Secretary of State Condoleezza Rice to review DoS’s security practices in Iraq 

following the Blackwater incident. According to data provided by the RSO, five investigations 

were done from January 1, 2008, through December 31, 2008. 

Although we did not review the RSO serious incident investigation process, we noted that the 

Kennedy panel also recommended that the RSO be provided with video equipment for each 

security vehicle. In December 2008, the U.S. Department of State and the Broadcasting Board 

of Governors, Office of Inspector General, Middle East Regional Office, reported on the status 

of the recommendations.40 The report, which provides DoS’s response to the recommendations, 

states that as of July 2008, video recording systems had been installed in 191 mission vehicles 

throughout Iraq and the remaining installations had been funded and were planned for 

completion by December 2008. The Office of Inspector General reported that the benefit of the 

cameras and tracking systems is broader in scope than documenting shooting incidents. The 

Embassy has used mission tapes to determine whether vehicles cited by Iraqi officials as being 

involved in traffic accidents were or were not physically present or involved. According to the 

RSO, the video equipment was installed in government-owned vehicles used by the three 

contractors that perform Tier 1 missions−Blackwater, Triple Canopy, and DynCorp.

However, the equipment is not installed in vehicles used by these same contractors that perform

Tier 2 missions. We also noted that MNF-I’s fragmentary order has no requirement for DoD

PSCs to use security cameras in their vehicles. One Tier 2 contractor we spoke with said that 

they have installed the equipment in their vehicles and have found it very helpful in documenting 

incidents for internal investigative reports. In late April 2009, we were informed that as of April 

1, 2009, the Government of Iraq requires that PSCs place cameras on all vehicles in convoys.

 

39 The Panel was headed by Ambassador Patrick F. Kennedy and thus is referred to as the Kennedy panel. 

40 Status of the Secretary of State’s Panel on Personal Protective Services in Iraq Report Recommendations

(MERO-IQO-09—01, 12/2008).
24

The Department of Defense Incident Remediation 

Process and the Different Approaches to Payments for 

Serious Incidents

For incidents involving wrongful death, injury, or serious property damage to Iraqis, MNF-I 

requires PSCs involved pay an appropriate amount as soon as possible. According to ACOD 

officials, MNF-I’s Office of Staff Judge Advocate has determined that PSCs are responsible for 

such payments. DoD provides no guidance on what would constitute an appropriate amount of 

payment. In contrast, the Embassy is authorized to make payments of $10,000 for death, $5,000 

for injury, and $2,500 for property damage. An RSO official said that he is not aware of 

payments being made for incidents involving Tier 2 PSCs.

As stated earlier, DoD PSCs are to conduct internal investigations of each incident, take 

corrective actions when needed, and submit their final reports within 96 hours. In an earlier 

report on DoD’s contracts with Aegis Defence Services, Limited,41 we presented the following 

examples of two serious incidents involving traffic accidents for which Aegis took corrective 

actions:

In March 2008, the lead vehicle in an Aegis mission attempted to overtake a slowmoving vehicle, and the driver either lost control or struck the median, which resulted in 

the death of the driver, injury to two passengers, and the loss of the government-provided

vehicle valued at over $170,000. The Aegis board of inquiry found that the vehicle 

driver was speeding, the decision to overtake the other vehicle was unwarranted, the 

vehicle driver was not wearing a helmet and possibly not a seat belt, and the team 

leader’s supervision was poor. In response to the accident, Aegis inspected equipment 

and systems for failures, reemphasized existing procedures regarding requirements to 

wear protective equipment and devices, and terminated the contracts of both the vehicle 

commander and team leader.

In April 2008, an Aegis-driven vehicle hit a civilian truck as it was passing, which would 

likely cause the government-provided vehicle, valued at over $170,000, being removed 

from the fleet and replaced. Aegis found the driver negligent, relieved him of his driving 

duties until he executed a supervised driver assessment, and fined the driver and his team 

leader five days’ pay. Aegis was not required to pay for the vehicles from this and the 

March accident, despite the negligence, because the contract does not require the 

contractor to reimburse the government for the lost vehicle.

When the requiring activities’ commanders or ACOD consider the actions insufficient to remedy 

the situations, they can request the PSC to take further action or impose penalties. Such penalties 

may include temporary or permanent withdrawal of arming authorizations or corrective action 

reports to the PSCs requiring them to take action.

 

41 Oversight of Aegis’s Performance on Security Services Contracts in Iraq with the Department of Defense (SIGIR09-010, 1/14/2009).
25

An ACOD official explained that the arming authorization is withdrawn if an individual is 

involved in a negligent weapons discharge incident. Fragmentary Order 09-109, Annex H,

provides policies and procedures pertaining to reported negligent weapons discharges by armed 

contractors. The guidance states that an individual’s arming authority will be withdrawn for a 

negligent weapons discharge. The guidance also states that the authorization may be restored if a

subsequent investigation finds that a weapon malfunctioned or for a reason other than fault of the 

individual. After 6 months, the arming authorization may be reinstated at the PSC’s request in 

cases of a simple negligence; however, after an employee’s second negligent weapons discharge, 

the arming authorization will be permanently revoked. Our review of the ACOD database found 

nine negligent weapons discharge incidents for which ACOD revoked individuals’ arming 

authorization. The following examples illustrate actions taken in a few negligent weapons 

discharges:

On October 22, 2008, a guard at a military camp was in a perimeter tower and waiting for 

the shift change. He cleared his weapon while in the guard tower instead of at a clearing 

barrel and discharged his M4 weapon. The bullet missed another perimeter tower by 2 

feet. No injuries or fatalities occurred, but the incident was considered a negligent 

discharge. The PSC stated that the guard did not adhere to standard practice, as guards 

are instructed and trained to clear their weapons properly at a clearing barrel. The PSC

took corrective action by terminating the guard’s contract and began retraining the tower 

guard force on the proper handling of weapons and clearing procedures. ACOD’s 

records indicate that an arming revocation letter was issued to the PSC for the negligent 

guard.

On October 18, 2008, two guards were changing shifts with two additional guards inside 

a guard shack. As one guard exchanged a fully loaded weapon with a replacement guard,

two rounds were fired into the ground because the guard had not properly cleared his 

weapon. The PSC terminated the guard at fault, and the Defense Contract Management 

Agency investigated whether the weapons exchange process that was used was a 

contractual violation. On October 19, 2008, ACOD issued an arming revocation letter to 

the PSC for the two guards.

Other incidents may result in wrongful death, injury, or serious property damage to Iraqis. 

According to a PSC representative, the Arabic culture usually requires expressions of regret and 

sorrow, and a payment for blood--called ―Fidia‖-- is usually expected. In such instances, MNF-I 

requires that the PSCs involved pay an appropriate amount as soon as possible. According to 

ACOD officials, MNF-I’s Office of the Staff Judge Advocate said that PSCs are responsible for 

such payments. According to ACOD officials, their only role in the process is to encourage the 

PSCs to make the payments as soon as possible after an incident occurs. ACOD does not follow 

up to determine whether the payments were made. An ACOD official noted that ACOD 

forwards to the Iraqi Ministry of Interior the information concerning a PSC’s involvement in an 

incident that involves damage or injury to an Iraqi. We were told by ACOD officials that PSCs 

negotiate directly with the families regarding solatium42 payments. According to an ACOD 

official, PSCs have paid for various incidents, and the payments were made either on the spot or 

within a day or two depending on the facts of the incident. We were told of one incident 

 

42 A compensation given as solace for suffering or loss.
26

involving a PSC and the son of an affluent Iraqi. The son was injured and the father sued the 

PSC for wrongful action. According to a PSC representative, the PSC eventually paid $50,000 

in compensation from company funds. The negligent driver’s contract was terminated as a result 

of the incident.

In contrast to the MNF-I guidance, DoS has a Claims and Condolence Payment Program in Iraq 

to address the issue of PSCs involved in incidents where Iraqis have been killed or injured or 

where property has been damaged. The program was approved in August 2005 to make ex 

gratia payments43where payment to an individual is determined to be necessary for urgent 

foreign policy reasons, regardless of fault or legal liability. According to Embassy standard 

operating procedures for condolence payments,44 the Embassy is authorized to make payments of 

$5,000 for death, $2,500 for injury, and $2,500 for property damage.

45

 However, for two high 

profile incidents involving Tier 1 PSCs that occurred on August 13, 2007, and September 16, 

2007, the Embassy authorized an increase in payments to $10,000 for death, $5,000 for injury, 

and $2,500 for property damage. An RSO official said that he is not aware of condolence 

payments for incidents involving Tier 2 PSCs.

 

43 Payments made when there are no obligations or liabilities to make them.

44 The procedures were approved in September 2008.

45 In December 2008, the amounts for death and personal injury were increased to $10,000 and $5,000, respectively.
27

Conclusions, Recommendations, and Lessons Learned

Conclusions

The U.S. military and the U.S. Embassy have improved their information sharing on PSC 

operations and serious incident reporting. They have established policies for reporting serious 

incidents and have assigned responsibility to specific organizations for ensuring that serious 

incidents are reported and investigated. These improvements are significant; nevertheless, we 

identified a number of opportunities to improve the accuracy and consistency of the serious 

incident information, the analysis of that information, and the consistency of policies and 

procedures pertaining to investigating and remediating incidents. These specific improvements 

should help DoD and DoS achieve their overall program goals and objectives:

The CONOC and RSO databases do not capture all reported serious incidents and do not 

present a complete picture of the serious incidents they are tasked to track. This could be 

caused by database management problems or the failure of the PSCs to follow reporting 

requirements. 

ACOD judgmentally decides which incidents to track even though it is responsible for 

ensuring that all serious incidents received by the CONOC are reported, tracked, and 

investigated. ACOD is applying a more limited definition of a serious incident than that 

contained in MNF-I guidance. 

MNF-I guidance has a more expansive definition of a serious incident than Embassy 

guidance. 

ACOD and CONOC have established their own databases even though they are supposed 

to be tracking the same incidents, although for different purposes. As a result, 

information for the same incidents is inconsistent, which raises questions about 

information accuracy. 

ACOD has performed analyses but has not developed formal lessons learned even though 

it is responsible for lessons learned. The limited incidents that ACOD tracks do not 

represent a complete picture of what PSCs are reporting, and its limited analyses may be 

impacting its ability to develop lessons learned.

No organization appears to have visibility of subcontractor PSCs, which is a potential gap 

in PSC incident reporting processes.

DoD and DoS have different approaches and policies for condolence payments to Iraqis 

for the same types of incidents. Consequently, the United States is not presenting a 

uniform approach to the Iraqi people and government.

Recommendations

To improve the accuracy and consistency of the serious incident information, the analysis of that 

information, and the consistency of policies and procedures pertaining to investigating and 

remediating incidents, SIGIR recommends that the Commanding General, MNF-I, and the U.S. 

Ambassador to Iraq take the following actions as they relate to their respective responsibilities:
28

1. Require CONOC and RSO to institute a process to periodically compare serious incident 

data on Tier 2 missions to identify PSCs that may be unaware of, confused about, or not 

complying with the dual reporting requirements.

2. Require ACOD and RSO to jointly establish a standard definition of serious incidents and 

incorporate that definition in guidance for their PSCs.

3. Require ACOD and RSO to jointly establish or use an existing contractor working group 

to share information with PSCs and to solicit their views and concerns.

4. Require CONOC and ACOD to establish a joint database for serious incidents that both 

can use to capture the information they need to fulfill their responsibilities.

5. Require ACOD to track all serious incidents, include data on all incidents in its analyses, 

perform more extensive analyses of serious incidents, and develop lessons learned from 

those analyses.

6. Task supporting organizations, such as the Defense Contract Management Agency, to 

identify all PSC subcontractors that support DoD and DoS contracts.

7. Task contract audit organizations to periodically review the prime contractors’ oversight 

of subcontractor PSCs’ compliance with incident reporting requirements.

Lessons Learned

Over time, DoD and DoS have learned important lessons in Iraq pertaining to PSCs. Those 

lessons have been applied incrementally to improve oversight of PSCs and coordination between 

MNF-I and the U.S. Mission. In other contingency operations, where extensive use is made of 

private security contractors, such as Afghanistan, the overarching lesson learned is that DoD and 

DoS need to establish core standards, policies, and procedures early in the contingency. Specific 

lessons related to that action include the need to develop:

a memorandum of agreement to jointly develop, implement, and follow core standards, 

policies, and procedures regarding PSCs

a common definition and common reporting requirements for serious incidents

mechanisms to share information on incidents between the U.S. Embassy and the military 

command

a common approach to condolence payments

audit mechanisms to ensure that PSCs at all levels understand and comply with incident 

reporting requirements

Management Comments and Audit Response

SIGIR received management comments from MNF-I, the U.S. Embassy’s Regional Security 

Office, and the Department of State’s Bureau of Diplomatic Security. MNF-I concurred with 

seven recommendations, partially concurred with recommendation 5 and non-concurred with 

recommendation 9. With regards to recommendation 5, MNF-I stated that the Armed 
29

Contractor Oversight Branch46 reviews all serious incidents it receives from the CONOC and 

forwards serious incident reports needing further attention to requiring activity commanders. It 

further stated that ACOD developed fragmentary orders throughout its tenure in response to 

lessons learned. Moreover, the Branch, in partnership with the U.S. Embassy RSO, will 

endeavor to develop joint ―lessons learned‖ of general applicability to all PSCs operating in the 

Iraq. MNF-I did not concur with recommendation 9. It stated that DoD is legally prohibited 

from making condolence payments on behalf of contractors and that is the reason for the 

perceived lack of a common policy for condolence payments in Iraq. Moreover, it states that 

PSCs are generally required to possess liability insurance by the terms of their contracts and that 

the insurance premiums on ―cost type‖ contracts are reimbursed as long as the charge is 

reasonable, allocable, and allowable.

With regards to MNF-I’s comments on recommendation 5, the report recognizes ACOD’s 

position that it used lessons learned to produce fragmentary orders. SIGIR continues to believe 

that ACOD needs to track all serious incidents, include data on all incidents in its analyses, 

perform more extensive analyses of serious incidents, and develop lessons learned from those 

analyses. Concerning recommendation 9, MNF-I said that although it is prohibited from making 

condolence payments directly, it is indirectly paying for those costs by reimbursing contractors 

for liability insurance. Based on MNF-I’s position, we did not include the draft recommendation

in the final report. We continue to believe that DoD and DoS should have a common approach 

to condolence payments as noted in SIGIR’s lessons learned. 

The Embassy RSO concurred with recommendation 1, concurred in principal with 

recommendation 2, and did not concur with recommendations 3, 8, and 9. With regards to 

recommendation 2, the RSO stated that establishing a standard definition of a serious incident 

should be accomplished at the Washington, D.C. level by appropriate DoS and DoD legal and 

contracting experts, with input from the Embassy and MNF-I. Although it non-concurred with 

recommendation 3, the RSO stated the recommendation could be best accomplished through the 

Embassy/DoD Contractor Working Group which could ensure that cross cutting information and 

actions are properly shared and coordinated within the context of ongoing U.S. government and 

Government of Iraq bilateral efforts to resolve issues and problems with U.S. government 

affiliated contractors in Iraq. With regards to recommendation 8, the RSO stated that a joint 

group to study the installation of video recording equipment in PSC vehicles is unnecessary. 

Instead, confirmation that video recording equipment is a Government of Iraq requirement is 

sufficient for incorporating this requirement into contracts and grants and other agreements. 

Concerning recommendation 9, the RSO stated that the recommendation is not feasible due to 

funding requirements and foreign policy concerns. It stated that the Embassy’s condolence 

program is funded by DoS funds for ex gratia payments determined to be necessary to further 

foreign policy objectives and that a common inter-agency policy for condolence payments in 

Iraq may not always comport with the Embassy’s foreign policy concerns. Moreover, DoS and 

DoD private security contractors do not always perform similar functions, and a common interagency policy is untenable for this reason as well.

With regards to recommendation 3, SIGIR recognizes that an existing working group of U.S. 

government officials and contractor representatives could accomplish the objectives of the 

 

46 In April 2009, ACOD became the Armed Contractor Oversight Branch under the MNF-I Protection Division.
30

recommendation. Our final recommendation reflects this change. Concerning recommendation 

8, SIGIR received confirmation on April 23, 2009, that the Government of Iraq, Ministry of 

Interior, will require that cameras be placed on all vehicles of a PSC convoy. As a result of this 

requirement, SIGIR deleted the draft recommendation from the final report. Concerning

recommendation 9, SIGIR believes the foreign policy implications of serious incidents involving 

death, serious injury, or property damage by DoD PSCs can be as significant as those involving 

DoS PSCs. Also, some DoD PSCs do perform the same types of missions as those performed by 

DoS PSCs. However, SIGIR recognizes that funding may be an issue since MNF-I states that it 

is legally prohibited from making condolence payments whereas DoS has funds for such 

payments. As stated above, SIGIR’s draft recommendation is not included in the final report. 

However, the report does include a lesson learned related to this issue.

The Bureau of Diplomatic Security provided a number of technical and clarifying comments. 

Concerning recommendation 6, the Bureau stated that it is already discussing with the 

Department’s Office of Acquisition Management the need to identify all PSC subcontractors that 

support DoS contracts and grants. According to the Bureau, this effort is to ensure the Bureau 

identifies 100% of the Tier 2 PSCs and is a follow-on effort to several data calls conducted by

the U.S. Embassy Baghdad over the last 6 months, which are also designed to identify these 

firms. Most of the other comments relate to the definition and use of the terms Tier 1 and Tier 2. 

The Bureau states that the term Tier applies to PSCs as opposed to missions. Specifically, the 

Bureau states that DoS considers contractors providing services to DoS under the Worldwide 

Personal Protective Services contract to be Tier 1 contractors regardless of the nature of the 

missions these contractors are performing. All other DoS affiliated PSCs, including 

subcontractor PSCs, are considered by DoS to be Tier 2 contractors regardless of the missions 

being conducted. SIGIR could find no formal definition of Tier 1 and Tier 2. It describes Tier 1 

and Tier 2 in terms of missions in the report because a CONOC document shows that the three 

PSCs under the Worldwide Personal Protective Services contract─Blackwater, Triple Canopy, 

and DynCorp—can perform both Tier 1 and Tier 2 missions and that Tier 1 PSCs perform 

missions that directly support the Chief of Mission whereas Tier 2 PSCs perform missions that 

indirectly support the Chief of Mission. Moreover, in commenting on SIGIR’s description of 

Tier 1 and Tier 2, an RSO representative provided the following distinction: All U.S. 

government direct hire employees and certain others that fall under the Chief of Mission 

authority and are not under the security responsibility of MNF-I are transported as Tier 1. U.S. 

Agency for International Development, Department of State, and other DoS contractors, 

grantees, and other employees that do not fall under the Chief of Mission authority are 

transported under Tier 2. Therefore, we continue to believe describing Tier 1 and Tier 2 in terms 

of missions of the contractors is appropriate.
31

Appendix A—Scope and Methodology

Scope and Methodology

In January 2009, the Special Inspector General for Iraq Reconstruction (SIGIR) initiated Project 

9008 to examine the Department of Defense’s (DoD) oversight of serious incidents by private 

security contractors (PSC) in Iraq. Specifically, SIGIR examined DoD’s (1) policies, 

procedures, and practices for reporting, investigating, and remediating those incidents and (2) 

efforts to identify trends and lessons learned. Because Department of State (DoS) PSCs on Tier 

2 missions are required to report serious incident to both the Embassy’s Regional Security Office 

(RSO) and DoD channels, we reviewed pertinent DoS policies and procedures related to that 

reporting. The U.S. Embassy’s process for investigating serious incidents is addressed in the 

DoS Office of Inspector General report, Status of the Secretary of State’s Panel on Personal 

Protective Services in Iraq Report Recommendations, MERO-IQO-09-01, 12/2008. SIGIR 

conducted its work from January through March 2009 in Arlington, Virginia, and Baghdad, Iraq.

This audit was performed by SIGIR under the authority of Public Law 108-106, as amended, 

which also incorporates the duties and responsibilities of inspectors general under the Inspector 

General Act of 1978. It was conducted in accordance with generally accepted government 

auditing standards. Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions 

based on our audit objectives. We believe that the evidence obtained provides a reasonable basis 

for our findings and conclusions based on our audit objectives.

To examine the DoD and DoS incident reporting process, we compared the incident reporting 

requirements in the fragmentary orders issued by the Multi-National Force-Iraq (MNF-I) and the 

policy directive issued by the U.S. Embassy. We discussed reporting procedures with officials in 

the Contractor Operations Cells (CONOC), the Armed Contractor Oversight Division (ACOD), 

and the RSO. To determine whether the reporting policies and procedures were being followed, 

we compared the serious incidents in databases maintained by the CONOC, ACOD, and RSO. 

Moreover, we obtained serious incident reports from seven PSCs and compared those reports to 

the serious incidents recorded in the CONOC’s and RSO’s databases. We requested evidence 

from PSCs, such as copies of emails, that their incident reports had been submitted. We also 

discussed with ACOD officials the reasons why fewer incidents are recorded in ACOD’s

database than the CONOC database.

To examine the DoD incident investigation process, we reviewed the appropriate fragmentary 

orders pertaining to incident investigations. We discussed the incident investigation process with 

ACOD officials to determine the criteria they use to identify incidents that require investigation. 

We compared ACOD’s criteria with fragmentary order requirements to see if they were 

following the fragmentary orders. We also selected serious incidents from the CONOC database 

that appeared to meet the fragmentary order criteria for an Army Regulation 15-6 investigation 

and compared those to the incidents that were investigated. For incidents that were not 

investigated, we obtained ACOD’s rationale.
32

To examine DoD’s incident remediation process, we discussed the process with ACOD officials. 

We discussed with ACOD officials the actions they take if the contractors’ actions are not 

sufficient and reviewed documentation supporting those actions. We discussed with ACOD 

officials MNF-I’s policies regarding condolence payments to Iraqis. We obtained the U.S. 

Embassy’s operating procedures for condolence payments and compared the Embassy’s policy 

with MNF-I’s policy.

To determine ACOD’s efforts to identify trends with serious incidents and apply lessons learned,

we asked ACOD for the trends noted and the lessons learned as a result of its analyses. We also 

reviewed the Joint Incidents Review Board’s minutes for trends and lessons learned.

To analyze the serious incident trend data, we obtained a copy of the CONOC database and 

performed analyses of those data. We also obtained copies of the incident reports submitted by 

the PSCs. We compared the incident reports to the information in the databases. When we 

discovered inconsistencies between the database and reports, we sought to correct those data 

elements through discussions with CONOC and ACOD officials.

Use of Computer-Processed Data

We obtained serious incident data from databases maintained by the CONOC, ACOD, and RSO. 

When we found inaccuracies with the data we planned to use, we corrected those inaccuracies to 

the extent possible by using the actual incident reports or through discussions with 

knowledgeable individuals. The report discloses the weaknesses and limitations in those data. 

We also made recommendations for improving the databases.

Internal Controls

We reviewed the specific controls used in managing the serious incidents that are required to be 

reported through DoD channels. This included reviewing management controls related to the 

reporting, investigating, and remediating of incidents. The report focuses on weaknesses in those 

controls and provides recommendations for improving them. 

Prior Coverage

We reviewed the following applicable reports issued by SIGIR; the U.S. Agency for 

International Development’s Office of Inspector General; the Department of State and 

Broadcasting Board of Governors’ Office of Inspector General, Middle East Regional Office; the 

Government Accountability Office; the Congressional Research Service; and the Congressional 

Budget Office. 

Special Inspector General for Iraq Reconstruction

Oversight of Aegis’s Performance on Security Services Contracts in Iraq with the Department of 

Defense, SIGIR-09-010, 1/14/2009.

Agencies Need Improved Financial Data Reporting for Private Security Contractors, SIGIR-09-

005, 10/30/2008.
33

Compliance with Contract No. W911S0-04-C-0003 Awarded to Aegis Defence Services Limited,

SIGIR-05-005, 4/20/2005.

U.S. Agency for International Development, Office of Inspector General

Audit of USAID/Iraq’s Oversight of Private Security Contractors in Iraq, E-267-09-002-P, 

3/4/2009.

U.S. Department of State and the Broadcasting Board of Governors, Office of Inspector 

General, Middle East Regional Office

Status of the Secretary of State’s Panel on Personal Protective Services in Iraq Report 

Recommendations, MERO-IQO-09-01, 12/2008.

U.S. Government Accountability Office

Rebuilding Iraq: DOD and State Department Have Improved Oversight and Coordination of 

Private Security Contractors in Iraq, but Further Actions Are Needed to Sustain Improvements,

GAO-08-966, 7/31/2008.

Rebuilding Iraq: Actions Still Needed to Improve the Use of Private Security Providers,

GAO-06-865T, 6/13/2006.

Rebuilding Iraq: Actions Needed to Improve Use of Private Security Providers, GAO-05-737, 

7/28/2005.

Congressional Research Service

Private Security Contractors in Iraq: Background, Legal Status, and Other Issues,

8/25/2008.

Private Security Contractors in Iraq: Background, Legal Status, and Other Issues,

6/21/2007.

Congressional Budget Office

Contractors’ Support of U.S. Operations in Iraq, 8/2008.
34

Appendix B—Acronyms

Acronym Definition

ACOD Armed Contractor Oversight Division

CONOC Contractor Operations Cells

DoD Department of Defense

DoS Department of State

GoI Government of Iraq

JCC-I/A Joint Contracting Command-Iraq/Afghanistan

MND Multi-National Division

MNF Multi-National Force

MNF-I Multi-National Force-Iraq

PSC Private Security Contractor

RSO Regional Security Office

SIGIR Special Inspector General for Iraq Reconstruction

USAID U.S. Agency for International Development
35

Appendix C—Serious Incidents Reported by 

Contractors (2/24/2008-2/28/2009)

Contractor

Number of 

Serious Incidents

Aegis Defence Services, Limited 224

EOD Technology Inc. 171

ArmorGroup 63

Hart Group 58

Special Operations Consulting-Security 

Management Group 41

Threat Management Group 40

Olive Group FZ LLC 37

Sabre International Security 28

Reed Incorporated 17

Falcon Group 15

Universal Security 11

Triple Canopy, Inc. 10

Blue Hackle Middle East 10

Unity Resources Group 9

Securiforce International 7

Safenet Security 7

Sallyport Global Holdings 6

DynCorp International, LLC 5

Sandi Group 4

Erinys International 3

SALRisk Group Ltd. 3

CSS Global Inc. 3

Osprey 2

Babylon Gates 1

Blackwater Worldwide 1

Tetra Tech 1

Motorola Joint Venture AIEE 1

Edinburgh International 1

ITAS 1

AISG 1

Military Professional Resources Inc. 1

CMSS 1

Garda World 1

Total 784

Source : SIGIR compiled from CONOC database.
36

Appendix D—Audit Team Members

This report was prepared and the review was conducted under the direction of David R. Warren, 

Assistant Inspector General for Audit, Office of the Special Inspector General for Iraq 

Reconstruction.

The staff members who conducted the audit and contributed to the report include:

Michael A. Bianco

Robert L. Pelletier

Nadia Shamari
37

Appendix E─Management Comments

Multi-National Force−Iraq
38
39
40

Management Comments

U.S. Embassy – Baghdad, Iraq
41
42
43
44

Management Comments

Department of State – Bureau of Diplomatic Security
45
46
47
48
49
50
51
52
53
54

SIGIR’s Mission Regarding the U.S. reconstruction plans, programs, and 

operations in Iraq, the Special Inspector General for Iraq 

Reconstruction provides independent and objective:

oversight and review through comprehensive audits, 

inspections, and investigations

advice and recommendations on policies to promote 

economy, efficiency, and effectiveness

deterrence of malfeasance through the prevention and 

detection of fraud, waste, and abuse

information and analysis to the Secretary of State, the 

Secretary of Defense, the Congress, and the 

American people through Quarterly Reports

Obtaining Copies of SIGIR 

Reports and Testimonies

To obtain copies of SIGIR documents at no cost, go to 

SIGIR’s Web site (www.sigir.mil).

To Report Fraud, Waste, and 

Abuse in Iraq Relief and 

Reconstruction Programs

Help prevent fraud, waste, and abuse by reporting 

suspicious or illegal activities to the SIGIR Hotline:

Web: www.sigir.mil/submit_fraud.html

Phone: 703-602-4063

Toll Free: 866-301-2003

Congressional Affairs Hillel Weinberg

Assistant Inspector General for Congressional

 Affairs

Mail: Office of the Special Inspector General

 for Iraq Reconstruction

 400 Army Navy Drive

 Arlington, VA 22202-4704

Phone: 703-428-1059

Email: hillel.weinberg@sigir.mil

Public Affairs Daniel Kopp

Director for Public Affairs

Mail: Office of the Special Inspector General

 for Iraq Reconstruction

 400 Army Navy Drive

 Arlington, VA 22202-4704

Phone: 703-428-1217

Fax: 703-428-0818

Email: PublicAffairs@sigir.mil