Whistleblower Protection: DOD Needs to Enhance Oversight of Military Whistleblower Reprisal Investigations
Released: 2015-05-07T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: Whistleblowers play an important role in safeguarding the federal government against waste, fraud, and abuse. However, reporting wrongdoing outside the chain of command conflicts with military guidance, which emphasizes using the chain of command to resolve problems. Whistleblowers who make a report risk reprisal from their unit, such as being demoted or separated. DODIG is responsible for conducting and overseeing military whistleblower reprisal investigations. GAO was asked to examine DOD's oversight of military whistleblower reprisal investigations.

This report examines the extent to which (1) DOD met statutory notification and internal timeliness requirements for completing military whistleblower reprisal investigations, (2) DODIG's whistleblower case management system supports oversight of reprisal investigations, and (3) DOD has processes to ensure oversight of service IG-conducted reprisal investigations. GAO analyzed DODIG and service IG data for cases closed in fiscal years 2013 and 2014 and cases open as of September 30, 2014, and reviewed a generalizable random sample of 124 military reprisal cases closed in fiscal year 2013.

section_title: What GAO Found
paragraphs: The Department of Defense (DOD) did not meet statutory military whistleblower reprisal 180-day notification requirements in about half of reprisal investigations closed in fiscal year 2013, and DOD's average investigation time for closed cases in fiscal years 2013 and 2014 was 526 days, almost three times DOD's internal 180-day requirement. In 2012, GAO made recommendations to improve investigation timeliness, and DOD has taken some actions to address those recommendations. However, based on a random sample of 124 cases, GAO estimated that there was no evidence that DOD sent the required notification letters in about 47 percent of the cases that DOD took longer than 180 days to close in fiscal year 2013. For cases in which DOD sent the required letter, GAO estimated that the median notification time was about 353 days after the servicemember filed the complaint, and on average the letters significantly underestimated the expected investigation completion date. DOD does not have a tool, such as an automated alert, to help ensure compliance with the statutory notification requirement to provide letters by 180 days informing servicemembers about delays in investigations. Without a tool for DOD to ensure that servicemembers receive reliable, accurate, and timely information about their investigations, servicemembers may be discouraged from reporting wrongdoing.

DOD's Office of Inspector General's (DODIG) newly developed case management system, which it established to improve monitoring, is separate from the service IGs' systems, limiting DODIG's ability to provide oversight of all military reprisal investigations. GAO found that DODIG's system did not have a record of at least 22 percent of service-conducted reprisal investigations that were closed in fiscal years 2013 and 2014 and investigations open as of September 30, 2014. DODIG officials stated that they plan to expand DODIG's case management system to the service IGs by the end of fiscal year 2016 to improve DODIG's visibility over investigations. However, DODIG does not have an implementation plan for the expansion, and service IG officials stated that they have unique requirements that they would like to have incorporated into the system prior to expansion. Expanding the case management system to the service IGs without developing an implementation plan that, among other things, addresses the needs of both DODIG and the service IGs, puts DOD at risk of creating a system that will not strengthen its oversight of reprisal investigations.

DOD does not have formalized processes to help ensure effective oversight of military whistleblower reprisal investigations conducted by service IGs. DODIG established an oversight investigator team to review service IG investigations, but it has provided oversight investigators with limited guidance on how to review or document service IG investigations. Specifically, GAO estimated that for about 45 percent of service investigations closed in fiscal year 2013, the oversight worksheets were missing narrative to demonstrate that the oversight investigator had thoroughly documented all case deficiencies or inconsistencies. GAO also found that these files did not include documentation of DOD's analysis of the effect of noted deficiencies on the investigation's outcome because DOD has provided limited instruction on how to review service IG cases. Without additional guidance on oversight review procedures and documentation requirements to formalize the oversight process, it will be difficult for DOD to ensure that reprisal complaints are investigated and documented consistently.

section_title: What GAO Recommends
paragraphs: GAO recommends that DOD develop a tool to help ensure compliance with the statutory notification requirement, develop an implementation plan for expanding DODIG's case management system, and issue guidance governing the oversight process, among other things. DOD concurred, but raised issues with GAO's presentation of its findings. GAO disagrees and addresses these issues in this report.

section_title: Letter
paragraphs: Whistleblowers play an important role in safeguarding the federal  government against waste, fraud, and abuse, and their willingness to  come forward can contribute to improvements in government operations.  However, reporting wrongdoing outside the chain of command conflicts  with military culture and service guidance, which emphasizes the  importance of using the chain of command to resolve problems. Once  military whistleblowers decide to make a report of wrongdoing they risk  reprisal from their unit, such as being demoted, reassigned, or separated.  According to the 2014 Federal Employee Viewpoint Survey, 18 percent of  Department of Defense (DOD) employees surveyed did not feel they  could disclose a suspected violation of any law, rule, or regulation without  fear of reprisal. Moreover, within the Department of Defense Office of  Inspector General (DODIG), a quarter of employees surveyed in 2014 did  not feel they could disclose a suspected violation of any law, rule, or  regulation without fear of reprisal.

In February 2012, we found that DODIG’s oversight of the military  whistleblower reprisal program faced challenges. For example, we found  that DODIG was not consistently or accurately recording key dates to  track the length of investigations, DOD was not meeting timeliness  requirements for reporting on military whistleblower reprisal  investigations, and DODIG did not report reprisal investigation timeliness  data to Congress. We recommended, and DOD concurred, that DOD needed to implement policies and procedures to ensure accurate and  complete recording and consistent tracking of total case-processing time,  track and analyze timeliness data, and regularly report investigation  timeliness to Congress, among other things. DOD has taken some action  to implement these recommendations, as discussed later in the report.

You asked us to examine DOD’s oversight of military whistleblower  reprisal investigations. Specifically, this report examines the extent to  which (1) DOD has met statutory notification and internal timeliness  requirements for completing military whistleblower reprisal investigations;  (2) DODIG’s whistleblower case management system supports oversight  of the military whistleblower reprisal program; and (3) DOD has  processes to ensure oversight of military whistleblower reprisal  investigations conducted by the service Offices of Inspectors General  (IG).

We also collected data from DODIG for cases closed in fiscal year 2012; however, we did  not use these data because DODIG transitioned to a new case management system in  December 2012 and as a result of the data migration the fiscal year 2012 data are not  reliable, according to DODIG officials. were sufficiently reliable for the purposes of this report. We also reviewed  relevant documentation, such as standard operating procedures and  investigative guidance from DODIG, and the service IGs for the Army, the  Navy, the Air Force, and the Marine Corps. Finally, we interviewed  officials from these offices about methods for tracking investigations and  processes for sending required notifications to servicemembers that  allege reprisal. We also spoke with officials from DODIG’s Information  Systems directorate to determine which variables to request from  DODIG’s case management system.

For the second objective, we collected and compared data from each of  the service IGs to DODIG’s data, to determine to what extent DODIG has  visibility of all ongoing military whistleblower reprisal cases and cases  closed from October 1, 2012, through September 30, 2014. Specifically,  we matched selected variables for all cases from DODIG’s data to the  service IG data for those cases in order to identify duplicate cases and  missing information. We selected the servicemember name, case  identifiers, open date, and closed date—the variables present in both  DODIG’s and the service IGs’ data—in consultation with DODIG and  service officials. We assessed the reliability of the service data by  reviewing related documentation and interviewing responsible service  officials, and we determined the data were sufficiently reliable for the  purposes of this report. In addition, we collected relevant documentation,  such as case management system user manuals, and interviewed  officials from the service IGs for the Army, the Navy, the Air Force, and  the Marine Corps about guidance available for using their respective  systems. Further, we reviewed documentation about the development of  DODIG’s case management system, including cost information for the  next phase of development, and DOD memorandums regarding the case  management system expansion. We also interviewed DODIG officials  responsible for the development of the case management system and the  proposed expansion of DODIG’s case management system, which  DODIG established to improve its monitoring of investigations. We  compared this information to relevant program-management criteria.

For our third objective, we selected a stratified random sample of 124  case files from the population of 498 case files retained by DODIG for  military whistleblower reprisal cases that DODIG closed in fiscal year  2013, that is, from October 1, 2012, through September 30, 2013. We  chose cases from this period for the file review because of DODIG’s case  management system transition in December 2012 and because the  National Defense Authorization Act for Fiscal Year 2014, effective  December 26, 2013, expanded the amount of time a servicemember has  to report a reprisal allegation from 60 days to 1 year. We reviewed each  selected case file to identify case characteristics, determine whether there  was documentation that DOD had oversight mechanisms in place, and  determine the extent to which the investigations aligned with quality  standards for investigations established by the Council of the Inspectors  General on Integrity and Efficiency (CIGIE). To complete the case-file  review, we developed a data-collection instrument to record case-file  information regarding general case characteristics, timeliness, case-file  completeness, and qualitative factors, such as investigation deficiencies  recorded on DODIG’s oversight worksheets. Two analysts independently  reviewed each case file to help ensure the accuracy of the information in  the data-collection instrument. These analysts discussed any areas of  disagreement and resolved the disagreement by identifying and reviewing  supporting documentation in the case files. We did not question DODIG’s  judgment in these cases. For example, we reviewed and assessed the  files, but did not question DODIG’s judgments, findings, or final  determinations regarding whether to substantiate a reprisal allegation in  any of the cases. We generalized the results of our sample to the  population of 498 cases closed in fiscal year 2013, and all estimates of  percentages presented in this report have a margin of error of plus or  minus 10 percentage points or fewer, unless otherwise noted. All  estimates of medians and averages presented in this report have a  relative error of plus or minus 20 percent of the estimate, unless  otherwise noted. We also interviewed all the investigators and  supervisors on DODIG’s military whistleblower reprisal oversight team,  and randomly selected investigators at the service IGs and field-level  investigators from the Army, the Navy, and the Air Force IGs to obtain  information on procedures for reprisal investigations and oversight. While  the information from the investigators is not generalizable to all  headquarters or field-level investigators, it provided us with additional  perspectives into the service-specific processes for reprisal  investigations. Further, we attended training sessions and reviewed  training materials and requirements for investigators as well as processes  for assessing investigator independence at DODIG and the service IGs.  Additional details about our scope and methodology are discussed in  appendix I.

We conducted this performance audit from April 2014 to May 2015 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.
subsections: section_title: Background
subsections: section_title: DOD Policies on Military Whistleblower Reprisal Are Governed by Statute
paragraphs: In 1988, Congress enacted the Military Whistleblower Protection Act to  provide protection to servicemembers who report wrongdoing within  DOD. According to DOD policy, a military whistleblower is a  servicemember who makes, prepares to make, or is perceived as making  or preparing to make a protected communication—that is, a report of a  violation of law or regulation, gross waste of funds, or abuse of authority,  among others, to an authorized individual or organization. An authorized  individual includes, among others, a Member of Congress, an IG, and any  person or organization in the servicemember’s chain of command.  Further, any lawful communication to a Member of Congress or IG is   Reprisal occurs when a responsible management official  protected.takes, threatens to take, withholds, or threatens to withhold a personnel  action because a servicemember made or was preparing to make a  protected communication. A personnel action is any action taken on a  servicemember that affects or has the potential to affect a  servicemember’s current position or career, such as an adverse  performance evaluation, letter of reprimand, or separation from service,  among others.

Servicemembers and former servicemembers may submit reprisal  complaints to DODIG or an IG within DOD. In 2013, Congress expanded  the time for servicemembers to file a reprisal complaint from 60 days to 1  year following the date on which the servicemember becomes aware of  the personnel action. While the law affords military whistleblowers certain protections, those who allege they have suffered reprisal generally  do not receive relief from the alleged reprisal until DOD has completed an  investigation and substantiated the claims of reprisal.

section_title: DODIG and Service IGs Have Responsibility for Investigating Military Whistleblower Reprisal Complaints
paragraphs: DODIG can conduct an investigation into a military reprisal complaint or  refer the investigation to the appropriate service IG; however, according  to DOD policy, no determination is complete without final approval from  DODIG. Whistleblower Reprisal Investigations is the directorate within  DODIG’s Administrative Investigations component that is responsible for  conducting and overseeing investigations of reprisal and restriction  complaints filed by servicemembers. According to DOD policy, the  Whistleblower Reprisal Investigations directorate is to approve service IG  recommendations to dismiss cases, review and approve the results of  investigations conducted by the service IGs, and initiate follow-up  investigations to correct any inadequacies in service IG investigations.  The majority of DODIG’s investigation workload for military reprisal cases  is related to oversight reviews of investigations conducted by the service  IGs. The directorate is also responsible for investigating reprisal  complaints filed by DOD civilian employees, and employees of DOD  contractors and subcontractors, among others. According to DODIG’s  semiannual reports to Congress, military whistleblower reprisal  complaints account for approximately 60 percent of the reprisal  complaints it receives. Figure 1 provides a summary of the investigation  process, as described in DODIG guidance.

section_title: DOD’s Military Whistleblower Reprisal Investigative Process Focuses on Identifying Four Elements of Reprisal
paragraphs: According to DODIG’s Guide to Investigating Military Whistleblower  Reprisal and Restriction Complaints, DODIG and service IG investigators  are to assess reprisal complaints by answering four questions to  determine whether the elements of reprisal are present. Specifically:  1.  Did the servicemember make or prepare to make a protected  communication, or was the servicemember perceived as having made  or prepared to make a protected communication?  2.  Was an unfavorable personnel action taken or threatened against the  servicemember, or was a favorable personnel action withheld or  threatened to be withheld, following the protected communication?  3.  Did the responsible management official have knowledge of the  servicemember’s protected communication or perceive the  servicemember as making or preparing to make a protected  communication?  4.  Would the same personnel action have been taken, withheld, or  threatened absent the protected communication?

During the complaint intake process, the investigator is to review the  complaint and timeline and conduct an interview with the servicemember  to determine whether (1) the servicemember made or prepared to make a  protected communication and (2) a responsible management official took  a personnel action against the servicemember. The investigator is to also  assess whether the allegation supports an inference that the responsible  management official had knowledge of the protected communication and  suggests a causal connection between the protected communication and  the personnel action, such as whether the personnel action closely  followed the protected communication. If the investigating officer  determines there was no protected communication, no personnel action,  or no inference of responsible management official knowledge or  causation, the investigating officer can recommend that DODIG dismiss  the case.

If a servicemember’s complaint contains a personnel action and a  protected communication, and an inference of knowledge and causation,  the case is to proceed to a full investigation, according to DODIG  guidance.official would have taken the personnel action if the servicemember had  not made a protected communication, the investigating officer is to  determine the official’s reasons for taking the action, the timing between  the protected communication and the personnel action, the official’s  motive, and whether the servicemember was treated differently than other  servicemembers who did not make protected communications. The  investigating officer is to determine the case outcome based on a  “preponderance of the evidence,” defined by DODIG as the degree of  relevant evidence that a reasonable person, considering the record as a  whole, would accept as sufficient to find that a contested fact is more  likely to be true than untrue.

When determining whether the responsible management  According to DODIG guidance, if the investigating officer finds: (1) that  the servicemember made a protected communication, and that the  responsible management official (2) took a personnel action against the  servicemember following the protected communication, (3) had  knowledge of the protected communication, and (4) would not have taken  the personnel action without the protected communication, the  investigator writes a report that substantiates the reprisal complaint. After  the investigator completes the report, it is subject to DODIG supervisory  and managerial review and approval, as well as a legal sufficiency review.  If the investigation is conducted by a service IG investigator, the service  IG headquarters reviews and forwards the report to DODIG for oversight  and final approval. In cases where DODIG substantiates a reprisal  complaint, the servicemember may take an additional step to petition the  appropriate Board for the Correction of Military Records for relief from the  personnel action.

section_title: DOD Did Not Always Meet Statutory Notification and Internal Timeliness Requirements for Completing Military Whistleblower Reprisal Investigations
paragraphs: DOD did not meet statutory notification requirements to inform  servicemembers about delays in investigations for about half of military  whistleblower reprisal investigations in fiscal year 2013. Further, in the  notifications that DOD sent, reasons about the delays were general in  nature and projected report completion dates were, on average,  significantly underestimated. In addition, DOD rarely met internal  timeliness requirements for completing military whistleblower reprisal  investigations within 180 days for cases that it did not dismiss at intake.  The average length of an investigation during fiscal years 2013 and 2014  was almost three times the DOD requirement.
subsections: section_title: DOD Did Not Meet Statutory Notification Requirements for about Half of Reprisal Investigations in Fiscal Year 2013
paragraphs: According to 10 U.S.C. § 1034 if, during the course of the investigation,  the IG determines that it is not possible to submit the report of  investigation to the Secretary of Defense and the service Secretary within  180 days after the receipt of the allegation, the IG shall provide to the  Secretary of Defense, the service Secretary concerned, and the  servicemember making the allegation a notice of that determination  including the reasons why the report may not be submitted within that  time and an estimate of the time when the report will be submitted.  DODIG considers its office to be in accordance with the statute as long as  it either completes the investigation within 180 days or submits a letter to  the servicemember within 180 days, according to a senior DODIG official.  In February 2012, we found that DODIG officials acknowledged that they  and the service IGs had not been making the required notifications, but  that they were taking steps to ensure that they met statutory notification  requirements. For example, in February 2012, DODIG issued policy  guidance to the service IGs reemphasizing the statutory requirement to  notify servicemembers if investigations are not completed within 180  days.are to determine whether the service IG sent the 180-day notification  letter as part of DODIG’s oversight review of service IG-investigated   Further, according to oversight investigators we spoke with, they  cases and in fiscal year 2013, it was included as an item on DODIG’s  oversight worksheet for oversight investigators to look for during their  oversight review. DODIG officials stated that they have taken additional  action to ensure they meet statutory notification requirements since fiscal  year 2013, which was the time frame covered by our case-file review.  Specifically, in fall 2013, DODIG assigned an oversight investigator to  periodically reconcile 180-day notification letters with the service IGs to  ensure that the service IGs have sent the required letters and that DODIG  has received a copy, according to DODIG officials. In addition, DODIG  developed a mechanism in its case management system to indicate  which cases are older than 180 days. However, DOD officials told us they  have not developed a tool, such as an automated alert, to proactively  ensure that they are in compliance with the statutory 180-day notification  requirement.

On the basis of our file review of a stratified random sample of 124 cases  closed by DODIG in fiscal year 2013, we found that DOD has made  improvements related to these reporting requirements and that some  case files that required letters contained evidence that DOD had sent the  letters. However, we estimate that about 47 percent of the files for cases  that DOD took longer than 180 days to close in fiscal year 2013 did not  contain evidence that the investigating IG sent the required letters to  servicemembers. In addition, we found that in cases in which DODIG or  the service IG sent the required letter, it typically did so after the case had  reached the 180-day mark. Based on our file review, we estimate that for  cases in which DODIG or the service IG sent a 180-day notification letter  to the servicemember to explain the delays in the investigation, the  median notification time was about 353 days after the servicemember  filed the complaint. In some service investigations, the investigating IG  did not send the required letter to the servicemember until it forwarded  the report of investigation to DODIG for review, more than 1 year after the  servicemember filed the complaint.

Further, the letters that DOD sent provided general reasons for the delay,  but, on average, significantly underestimated the date by which it would  complete the investigation. For example, reasons for the investigation  delay included case complexity, case volume, and delays that the service  IG experienced in coordinating information, witnesses, and testimony.  Based on the results of our file review, we estimate that the median time  for case completion stated by DODIG and the service IGs in the letters,  which they sent, on average, around 353 days into the investigation, was   However, we estimate that for cases in  about an additional 78 days.which the investigating IG sent the required letter, the median time for  case closure was actually 488 days, 57 days past the stated estimate for  case completion.

Service IG officials stated that, for most cases over 180 days, they  provide a standard estimate for case completion because it is difficult to  estimate the amount of time required for case completion due to the  unique characteristics of each case and the number of layers of review  prior to case closure. According to federal standards for internal control,  an agency must have relevant, reliable, and timely communications  relating to internal and external events in order to determine whether the  agency is achieving its compliance with various laws and regulations. On the basis of our file review, we estimate that, on average, the  notifications present in 53 percent of investigations closed in fiscal year  2013 in which they were required were untimely and contained unreliable  estimates. Figure 2 shows the median notification timeframes and  estimates for case completion for fiscal year 2013 cases over 180 days.

GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1  (Washington, D.C.: November 1999).

section_title: DOD’s Military Whistleblower Reprisal Investigations Took Almost Three Times DOD’s Internal Timeliness Requirement in Fiscal Years 2013 and 2014
paragraphs: DOD rarely met internal timeliness requirements for completing military  whistleblower reprisal investigations in fiscal years 2013 and 2014.  According to DOD Directive 7050.06, which implements the statute 10  U.S.C. § 1034 and establishes DOD policy, DODIG shall issue a  whistleblower reprisal investigation report—containing a thorough review  of the facts and circumstances, relevant documents acquired, and  summaries or transcripts of interviews conducted—within 180 days of the  receipt of the allegation of reprisal.

We found that the average investigation time for all cases that DOD (that  is, both DODIG and the service IGs) investigated and closed in fiscal  years 2013 and 2014 was 526 days. The average length of DODIG- investigated cases closed in fiscal years 2013 and 2014 was 443 days.  The average length of service IG–investigated cases during this time was  530 days, which is almost three times DOD’s internal timeliness  requirement. For cases DODIG dismissed after completing the  complaint intake process, the average processing time was 48 days.  See table 1 for details regarding case-processing times for cases closed  by DODIG and the service IGs in fiscal years 2013 and 2014.

In our total timeliness calculations for all DOD investigations, we did not  include complaints that DODIG or the service IGs dismissed at intake  because the IG determined that the complaint did not have sufficient  evidence to warrant an investigation. While the statute requires the  service IG receiving the reprisal allegation to promptly notify DODIG of  the allegation, services do not consistently provide DODIG notification  when they receive complaints that do not contain a protected  communication or personnel action, according to service IG officials and  guidance. Specifically, the Air Force IG’s guidance states that DODIG  must be notified when a complaint contains an allegation of reprisal.  However, the guidance states that a complaint does not contain a reprisal  allegation unless the first two elements of reprisal—a protected  communication and a personnel action—are present. DODIG officials  stated that any service determination that a complaint does not meet its  first two elements of reprisal must be submitted to DODIG for oversight.  However, officials from the two service IGs, which accounted for  approximately 80 percent of the service IG reprisal investigative workload  in fiscal years 2013 and 2014 told us that they do not track or report to  DODIG complaints that they dismiss at intake because they lacked a  protected communication or personnel action. Since DODIG does not  have data on cases that the services dismiss at intake, because the  services do not notify them of these cases, we did not have data on all  cases that were dismissed at intake. Therefore we reported the timeliness  of cases that DODIG dismissed at intake separately, and did not include  them in our overall timeliness calculations.

In fiscal years 2013 and 2014, DODIG investigated and closed a total of  39 cases and dismissed another 375 complaints after completing the  intake process. The service IGs closed a total of 674 cases during this  period. See table 2 for the number of cases closed by each investigating  organization in fiscal years 2013 and 2014.

DOD received a total of 640 reprisal complaints in fiscal year 2013 and  584 reprisal complaints in fiscal year 2014. As of September 30, 2014,  DODIG and the service IGs had a total of 822 open military whistleblower  reprisal cases. While the majority of these open cases were filed from  fiscal years 2012 through 2014, some of these cases had been open  since fiscal year 2008. We found that almost 20 percent of DOD’s open  military reprisal cases were filed in fiscal year 2012 and had been open  for at least 2 years. Further, approximately 33 percent of the open military  reprisal cases were filed in 2013 and had been open for at least 1 year.  Table 3 provides additional information on DOD’s open military reprisal  cases and when the servicemembers filed their reprisal complaints.  Appendix II provides information about substantiation rates and the  general characteristics of military whistleblower reprisal cases.

DOD officials described several factors affecting the timeliness of military  reprisal investigations and stated that they are taking steps to improve  investigation timeliness. For example, in addition to investigations,  DODIG’s workload includes completing the intake process for complaints  filed with DODIG. Intake requires staff to review complaints and  determine whether there is sufficient evidence for those complaints to  warrant an investigation. As we stated previously, DODIG dismissed 375  complaints after completing the intake process in fiscal years 2013 and  2014. Further, service IG officials indicated that the decentralized  investigation structure is a factor that affects the timeliness of their  investigations. For example, service IGs assign investigations to field- level investigators, which, according to officials, results in a multilayer  review process as the investigation is reviewed by each organizational  level of the service with each layer of review adding to case-processing  times. Additionally, all six field-level service investigators we interviewed  stated that, in their opinion,180 days was not a reasonable amount of  time to complete all investigations unless an investigator has no  competing responsibilities and is able to focus solely on one reprisal  investigation at a time. Service IG investigators further stated that in  addition to competing responsibilities, the complexity of cases, the  volume of cases, and low staffing numbers all affect the timeliness of  investigations. We found in February 2012 that DODIG also identified  staffing shortages as a factor affecting the timely processing of cases and  that staffing levels had not kept up with an increased reprisal caseload.

DODIG officials stated that they have increased their personnel levels to  accommodate the increased caseload. Specifically, DODIG’s  Whistleblower Reprisal Investigations directorate increased from 30 staff  in January 2012 to 53 staff in March 2015.

Further, DODIG officials stated that DOD leadership has made improving  the timeliness of administrative investigations—which include both  investigations of whistleblower reprisal and of other allegations made  against senior officials—a priority. Specifically, in an effort to improve the  timeliness of senior official investigations, including senior official  whistleblower reprisal cases, DODIG convened a timeliness task force in  coordination with the service IGs, which issued a report with  recommendations in November 2014. Specifically, the task force  recommended that DODIG expand its case management system to track  and manage the timeliness of senior official investigations. DODIG  officials stated that they believe the expansion of the case management  system will improve timeliness for all reprisal investigations. Following the  issuance of the task force’s report, in January 2015, the Deputy Secretary  of Defense issued a memorandum endorsing the findings of the report,  specifically stating that the service IGs should not impose any staffing  reductions on the investigation offices because they must be adequately  resourced when faced with multiple high-priority investigations.

GAO-12-362. the final outcome. DODIG officials stated that they use this metric to track  timeliness for service IG reprisal investigations. However, according to  officials, this calculation is inaccurate for cases opened prior to the case  management system being implemented in December 2012, which  accounts for approximately 24 percent of open investigations.  Specifically, based on the results of our file review, we estimate that the  timeliness metric in DODIG’s case management system underestimates  total case time for each case closed in fiscal year 2013 by at least 26  days on average, which limits DODIG’s ability to monitor the timeliness of  all service IG investigations. DODIG officials stated that they are able to  identify the cases that are affected by the inaccurate timeliness metric  and that they have implemented processes to manually calculate the  case age for these cases.

Further, as we discuss later in this report, DOD has not implemented  procedures to ensure accurate and complete recording of total case- processing time. DODIG collects timeliness information but cannot  analyze the data to identify potential reforms because the case  management system is under development and has limited reporting  capabilities. In addition, the service IGs have separate case management  systems; therefore the timeliness of all service investigative phases is not  maintained in DODIG’s case management system, which does not allow  DODIG to consistently track all case processing times. Finally, DODIG  responds to ad hoc congressional requests related to investigation  timeliness, but does not include overall timeliness information in its  semiannual reports to Congress, as we recommended in February 2012.  We continue to believe these recommendations are valid and should be  implemented.

section_title: DODIG’s New Case Management System Does Not Support Complete Oversight of Service Military Reprisal Investigations
paragraphs: DODIG implemented a new whistleblower reprisal investigation case  management system to improve its monitoring of investigations; however,  as of March 2015, the system is under development and has limited  reporting capabilities. In addition, DODIG has provided its staff with  limited user guidance on how to use and record information in the case  management system. Further, DOD’s use of multiple case management  systems hinders its visibility over total workload and investigative activity  at the service IG level, such as the number and status of military  whistleblower reprisal investigations in process at the service IGs. DOD’s  planned expansion of its reprisal case management system to the service  IGs may not result in improved visibility over its workload without further  planning and guidance.
subsections: section_title: DODIG’s New Case Management System to Improve Monitoring of Reprisal Investigations Is under Development
paragraphs: In February 2012, we found that DOD’s efforts to improve case  processing-times had been hindered by unreliable and incomplete data,  and, as previously discussed, we recommended that DOD implement  policies and procedures to ensure accurate and complete recording of   In  case-processing time. DOD concurred with this recommendation.December 2012, DODIG took steps to improve its military whistleblower  reprisal investigation data by implementing a new case management  system to monitor its administrative investigations, including senior official  and whistleblower reprisal investigations. We found the data from this  case management system reliable for our purposes of reporting the  average lengths of investigations for this report—an improvement since  February 2012, when we reported that similar data from DODIG’s  previous system were not reliable for our reporting purposes. According  to DODIG, the case management system is intended to streamline  processing, investigations, and service IG oversight reviews by serving as  an automated, real-time complaint tracking and investigative  management tool that electronically stores all case-file documentation.  However, as of March 2015, the case management system was under  development and according to officials has limited reporting capabilities.

According to a DODIG official, DOD selected an incremental process to  develop the case management system in order to incorporate user  feedback into each phase of development, and, in accordance with this  type of development, in December 2012 DODIG staff began using the  case management system prior to the completion of the system. DODIG  officials stated that they had planned to finish the development of the  case management system by February 2014; however, according to  these officials, DODIG delayed funding for the final development phase  until fiscal year 2015, delaying the completion of the case management  system. As a result of the delayed funding, DODIG has not been able to  incorporate all user feedback to ensure that the case management  system is fully functioning at the desired level, according to DODIG  officials. For example, according to DODIG officials, the case  management system’s reporting capabilities are limited. The case  management system contains the fields necessary to track the length of  various investigative phases for DODIG investigations as we  recommended in February 2012, such as the dates for the legal and  internal review processes, but according to a DODIG official, it cannot  track this information for service IG investigations. In addition, the case  management system contains dashboards for users to manage cases by  the whistleblower statutes for which DODIG is responsible. For example,  users can view the dashboards to determine the number of investigations  or oversight cases assigned to a particular investigator and the number of  DODIG investigations over 180 days, among other things.

DODIG can also determine the length of time it took to complete these  phases when users drill down to individual cases and review key dates for  these phases in the investigation and oversight events tabs. However,  according to DODIG officials, DODIG is not able to extract and aggregate  these data from its case management system for analysis and reporting  purposes, which would allow it to identify possible areas for implementing  case-processing reforms, as we recommended in February 2012. DODIG  officials stated that even though they have not completed the final  development phase of the case management system, using the system  has improved their ability to provide oversight of the service IG  investigations, allowing them to track the corrective actions that services  have taken in substantiated reprisal cases. Officials stated they can also  calculate overall case age, the number of days to complete the intake  phase, the number of days to complete the investigation phase, and the  number of days in oversight, in response to findings in our previous  report. However, DODIG can calculate these milestones only for cases  that it investigates, which is a small portion of the military reprisal  investigations on which this report focuses. In addition, as we previously  stated, we found the case management system’s field to calculate case  age was inaccurate because it underestimates total case time for cases  opened in the prior system and closed in fiscal year 2013 by at least 26  days on average.

Further, according to DODIG officials, DODIG spent approximately $2.22  million on the development of the case management system as of  February 2015, and plans to spend approximately $1.4 million to further  develop the case management system prior to the end of fiscal year  2015. DODIG officials stated that they plan to complete the final phase of  case management system development, which includes improvements to  reporting capabilities, by the end of fiscal year 2015. Other needed  improvements include restrictions on which cases users can access and  edit, as well as additional fields to better track specific types of case  outcomes, such as cases withdrawn by servicemembers, according to  DODIG officials. However, DODIG officials stated that they are unsure of  the extent to which they will be able to make improvements to the case  management system during the next phase of development given their  current funding levels. As a result, DODIG officials stated that they have  initiated a process to prioritize the improvements based on necessary and  desired changes.

section_title: DODIG Provides Limited Guidance to Case Management System Users
paragraphs: DODIG has provided limited guidance to case management system users  on how to populate case information into the new whistleblower reprisal  case management system. DODIG investigators have been using the  case management system to manage reprisal investigations since  December 2012. As previously discussed, according to officials, DODIG  planned to finish the final development phase for its case management  system in February 2014, but changed that benchmark to September  2015.

According to an official, when the case management system was  implemented, DODIG internally developed and provided its staff with a  user manual. According to oversight investigators, guidance on the case  management system is limited and does not include detailed operating  instructions, such as the type of information to enter into the case notes  fields. Further, one oversight investigator stated that the guidance DODIG  provided before the system was implemented was minimal and included  features of the system that were not yet operable. DODIG officials  provided documentation of two types of guidance, a draft user manual  created by Whistleblower Reprisal directorate staff with screen captures  of the system, and desk aids for various staff positions that provide  descriptions of the data fields the investigators are to complete. DODIG  officials noted that they have issued several versions of the desk aids  since they implemented the case management system. During our case  file review, we found that DODIG investigators had incorrectly coded  some cases in the case management system as fully investigated when  the service IG had dismissed the case prior to a full investigation.

Based on the results of our file review, we estimate that, in fiscal year  2013, about 43 percent of cases that DODIG investigators coded as fully  investigated were incorrectly coded in this way. Due to these miscoded  cases, we are unable to report on the number of military whistleblower  reprisal complaints that DOD fully investigated in fiscal years 2013 and  2014. In its semiannual reports to Congress, DODIG reports on the  number of military whistleblower reprisal investigations fully investigated  by DODIG and the service IGs. DODIG officials stated that they use their  case management system to compile information for these semiannual  reports. Based on our estimate of the number of cases affected by the  miscoding in fiscal year 2013, DODIG may have mischaracterized its  investigative work in its fiscal year 2013 semiannual reports to Congress.  DODIG officials stated that they were aware that DODIG staff had  improperly coded some reprisal cases as fully investigated when they  were dismissed prior to a full investigation, but that they were not aware  of the extent of the miscoding. Further, DODIG officials stated that they  are taking steps to ensure that future cases are coded properly. For  example, DODIG officials said that once they realized that DODIG staff  were coding cases incorrectly, they provided desk aids to users in March  2014 that describe how to code cases that were fully investigated and  those that were dismissed prior to a full investigation. However, during  our case-file review we found that DODIG staff were still coding cases  incorrectly as of April 2014. Further, in September 2013, DODIG assigned  an Investigations Analyst to monitor its whistleblower reprisal  investigations data. According to DODIG officials, the Investigations  Analyst uses a dashboard in the case management system which helps  identify missing data or entry errors, and then manually corrects them.

As previously discussed, DODIG’s case management system is to serve  as a real-time complaint tracking and investigative management tool for  investigators within its Administrative Investigations component. Further,  DODIG’s fiscal year 2014 performance plan for oversight investigators  notes that investigators should ensure the case management system  reflects current, real-time information on case activity. However, based on  our file review of a sample of 124 cases closed in fiscal year 2013, we  found that DODIG investigators were not using the case management  system for real-time case management as intended by DODIG officials.  Specifically, we estimate that DODIG personnel uploaded key case  documents to the case management system after DODIG had closed the  case in 77 percent of cases closed in fiscal year 2013. For example,  DODIG staff uploaded, among other things, reports of investigation,  oversight worksheets, 180-day letters, and copies of the servicemembers’  complaints after the case had already closed, indicating that the case  management system was not being used for real-time case management  at that time.

Further, we estimate that, for 83 percent of cases closed in fiscal year  2013, DODIG staff made changes to the case variables in the case  management system in 2014, at least 3 months after case closure. For  cases where DODIG made changes to the data, we estimate that about  68 percent had significant changes, such as changes to the date the  servicemember filed the complaint and the organization that conducted  the investigation, as well as the result code, which indicates whether the  case was fully investigated. In explaining why the changes were made,  DODIG officials stated that leadership from DODIG’s Whistleblower  Reprisal Investigations directorate instructed oversight investigators and  other DODIG staff to verify and correct the data as necessary for all  cases closed in fiscal years 2013 and 2014 by comparing case  management system data to case file documentation. DODIG officials  stated that this was necessary to ensure the reliability of DODIG’s  investigative data because the case management system was new to  investigators and they had not been consistently recording information.  Further, officials stated that prior to the implementation of the case  management system, investigators reviewed hard-copy case files of  service IG investigations and they did not immediately transition to  reviewing case files electronically when the case management system  was implemented in December 2012. The guidance DODIG has issued  for the new case management system does not include instructions that  the staff are to use the system for real-time case management and  investigation review or which types of events to record, both of which  could have helped guide the transition from hard-copy to electronic case  file review.

DODIG officials stated that they plan to further develop their draft manual  for the case management system expansion to the service IGs which they  anticipate will be complete by the end of fiscal year 2016, as discussed  later in the report. Officials further stated they will continue to update  internal desk aides, which contain only descriptions of the case  management system’s fields, as needed, but do not plan to issue  additional internal guidance for DODIG staff on the case management  system because they believe that the current guidance is sufficient.  However, DODIG’s draft user manual does not instruct users on how to  access the system, troubleshoot errors they may encounter, or monitor  their caseloads using the case management systems dashboards.  Further, DODIG’s Administrative Investigations manual, which provides  guidance to the Whistleblower Reprisal Investigations directorate staff, is  outdated because it refers only to DODIG’s prior case management  system, which was replaced in December 2012.

According to CIGIE quality standards for investigations, accurate  processing of information is essential to the mission of an investigative  organization. It should begin with the orderly, systematic, accurate, and  secure maintenance of a management information system. Written  guidance should define the data elements to be recorded in the system.  Further, management should have certain information available to  perform its responsibilities, measure its accomplishments, and respond to   DODIG officials stated that  requests by appropriate external customers.they plan to develop a user manual when they expand the case  management system to service IGs, as discussed later in the report.  Without updating and finalizing the internal user guidance from 2012 as  necessary until the case management system is complete, including  providing instructions on how to use the system as a real-time tracking  system in the meantime, DODIG will continue to face challenges in its  ability to report on the military whistleblower reprisal program. For  example, unless investigators update and upload case information during  the course of an investigation, DODIG will be unable to report on the real- time status of investigations and therefore may not be able to respond to  congressional requests for case information without significant efforts.  Further, DOD uses the case management system to compile information  for reporting to Congress on its military reprisal investigation workload  and thus may have inaccurately represented its workload—the number of  cases fully investigated—to Congress in its semiannual reports. Without  updating and finalizing internal guidance on how to correctly enter case  information into the case management system, DODIG cannot ensure the  reliability of its data without manually reviewing and correcting each case.

section_title: DOD Uses Multiple Decentralized Case Management Systems, Which Hinders Visibility, and Does Not Have an Implementation Plan for Expanding the DODIG Whistleblower Case Management System to the Service IGs
paragraphs: Each service IG conducts and monitors the status of military  whistleblower reprisal investigations in a different case management  system. Although DODIG has access to one of the service’s case  management systems, according to officials DODIG does not have  complete visibility over service investigations from complaint receipt to  investigation determination. As a result, DODIG may not know that some  servicemembers have filed reprisal complaints until the service IGs  forward the completed reports of investigation to DODIG for review.  Further, DODIG does not have knowledge of the real-time status of  service-conducted investigations and is unable to anticipate when service  IGs will send completed reports of investigation for review, according to  officials. DODIG is required to review all service IG determinations in  military reprisal investigations in addition to its responsibility for  conducting investigations of some military reprisal complaints. Without a  common system to share data, DODIG’s oversight of the timeliness of  service investigations and visibility of its own future workload is limited.

Our analysis indicates that DODIG’s case management system did not  have record of at least 22 percent of service investigations both open as  of September 30, 2014, and closed in fiscal years 2013 and 2014.  According to DOD officials, DOD’s decentralized structure for military  reprisal investigations, paired with the fact that servicemembers can  submit complaints to DOD or their respective service IG, or their chain of  command, contributes to the possibility of duplicate complaints or that  one IG fails to notify another of an ongoing reprisal investigation.  According to DOD Directive 7050.06, when the service IGs receive  reprisal complaints from servicemembers, those offices are required to  notify DODIG within 10 days; however, based on our file review, we  estimate that there was no evidence of this required notification in 30  percent of cases closed in fiscal year 2013 where the servicemember   In response, DODIG officials  filed the complaint with the service IG.noted that one of their oversight investigators was assigned to reconcile  DODIG’s open military reprisal investigations with the service’s open  reprisal investigations in fall 2013. According to service IG officials, this  reconciliation is conducted at various points throughout the year by  manually comparing lists of investigations from each IG’s respective case  management system.

Through our analysis we identified challenges reconciling DODIG and  services IG cases because the investigating organizations do not share a  common case identifier. In addition, in fiscal years 2013 and 2014 each  investigating organization did not consistently track the other  organization’s unique case identifier. DODIG officials stated that they  have since taken steps to ensure that DODIG tracks the service IGs’ case  identifiers in its case management system. For example, the oversight  investigator that DODIG assigned to reconcile cases updates service  case identifiers in DODIG’s case management system as part of the  reconciliation process. Further, service IG officials stated that there have  been instances where DODIG did not notify them that it was investigating  a reprisal complaint from one of their servicemembers and they did not  find out about the investigation until after DODIG had conducted the  investigation. Standards for internal control in the federal government  state that, for an entity to run and control its operations, it must have  relevant, reliable, and timely communications relating to internal and  external events.

DOD is taking steps to improve its visibility over service investigations. In  November 2014, a DODIG task force that focused on improving the  timeliness of DOD’s senior official investigations recommended that DOD  expand the case management system to the service IGs as a way to  improve investigation timeliness. According to DODIG officials, expanding  the case management system is also an effort to improve DODIG’s  visibility of administrative investigations conducted by the service IGs. In  January 2015, the Deputy Secretary of Defense endorsed the  recommendation to expand the case management system to the service  IGs, stating that an enterprise data system is essential to achieving a  more seamless and efficient processing of complaints and investigations  across the department. that they plan to expand the case management system to the service IGs  by the end of fiscal year 2016.

Deputy Secretary of Defense Memorandum, Report on Task Force to Improve  Timeliness of Senior Official Investigations.

However, DODIG does not have an implementation plan for the  expansion and has not yet taken steps to develop one. According to  DODIG officials, they are in the process of developing a strategy to  expand the case management system and are in the early stages of the  planning process. DODIG officials stated they have set an aggressive  time frame for the expansion because leadership has made investigation  timeliness a priority and they believe a common case management  system is part of the solution. Officials stated that they have completed  the process to classify the case management system as a defense  business system in April 2014 and that DODIG has been using the  system to process all whistleblower reprisal investigations since  December 2012. Further, officials stated that they developed a working  group comprising representatives of each of the service IGs to facilitate  planning for the expansion. The working group held its first meeting in  February 2015, and plans to meet bimonthly until the expansion is  complete. A DODIG official tasked with leading the expansion of the case  management system stated that he intends to refer to best practices for  project management to help facilitate the planning process for this  expansion project.

The Project Management Institute’s Guide to Project Management Body  of Knowledge (PMBOK® Guide) provides guidelines for managing  individual projects, including developing a project management plan. A  project management plan defines the basis of all project work, including  how the project is executed, monitored and controlled, and closed.  According to the PMBOK® Guide, project management plans should  include a scope—to describe major deliverables, assumptions, and  project constraints—project requirements, schedules, costs, stakeholder  roles and responsibilities, and stakeholder communication techniques,  among other things. Further, project management plans are to be  updated when issues are found during the course of the project, which  may modify project policies or procedures, and when actions are needed  to forestall negative effects on the project. Project management plans  also include methods to define and document stakeholder needs.  According to the Project Management Institute, detailed requirements  documentation is essential for stakeholders to understand what needs to  be (1) done to deliver the project and (2) produced as the result of the  project.

DODIG officials stated that, in coordination with the service IGs, they will  review and incorporate some needs of each service IG prior to expanding  the case management system, but they do not plan to fully customize the  case management system for each service IG, such as developing a  different interface for each service. Service IG officials expressed  concerns that they have requirements, such as specific data fields and  report capabilities to meet leadership needs to be incorporated into the  case management system prior to expansion. For example, service IG  officials stated that it is important that case management system user  roles are defined in a way that reflects how their organizations operate  and that case access is restricted according to the organizational level of  the user. Some service IG officials stated that they are concerned that  DODIG will expand the case management system without incorporating  all of their needs and that they will not be able to meet their respective  service leaderships’ reporting requirements as a result. These officials  stated that if DODIG’s case management system does not meet their  needs they may need to continue to use their current case management  systems, which would be duplicative.

Given DOD’s stated plans to expand the case management system to the  service IGs by the end of fiscal year 2016, doing so without developing an  implementation plan that addresses the needs of DODIG and the service  IGs, and defines project goals, schedules, costs, stakeholder roles and  responsibilities, and stakeholder communication techniques, puts DODIG  at risk of creating a system that will not improve its visibility over total  workload or investigation timeliness. Further, without such a plan, DODIG  may not be well-positioned to monitor the expansion and measure project  success. In addition, without developing a plan in coordination with the  service IGs that defines the roles and responsibilities of all stakeholders,  and sets expectations for communication, DODIG may not be able to  balance all stakeholder needs and interests. Further, as previously  discussed, DODIG has not completed the development of the case  management system and it does not meet DODIG user needs. Finally, in  the absence of an implementation plan that adequately addresses the  requirements of the service IGs, the service IGs may not know whether or  when their needs will be met and as a result they may unnecessarily  continue to use their own systems, which could be duplicative.

section_title: DOD Has Not Formalized Its Oversight Processes to Review Service IG Reprisal Investigations and to Help Ensure Investigation Quality and Independence
paragraphs: In 2011, DOD designated a team in DODIG’s Directorate for  Whistleblower Reprisal Investigations to review service-conducted  investigations on a full-time basis; however, DODIG has not formalized  the process for the review of military whistleblower reprisal investigations.  For example, it is unclear to what extent DODIG has incorporated the  relevant investigative standards into its process. Several factors affect the  quality of DOD’s oversight of service-conducted military whistleblower  reprisal investigations, including the absence of standardized guidance  and DODIG feedback to the service investigators. Finally, DOD does not  have a tool for investigators to certify their independence to ensure its  military whistleblower reprisal investigations are objective in fact and  appearance.
subsections: section_title: DODIG Established an Oversight Team to Review Service-Investigated Reprisal Complaints, but the Oversight Process Is Not Formalized
paragraphs: In September 2011, DODIG took steps to improve its oversight of service  IG investigations by establishing an investigator team that is solely  dedicated to the oversight review of service IG-conducted military reprisal  investigations, according to officials, but it has not formalized its process  by providing detailed guidance to its oversight team. DODIG is  responsible for reviewing and approving service determinations regarding  whistleblower reprisal complaints, including both (1) service  determinations that an investigation into a reprisal complaint is not  warranted, and (2) the results of completed service reprisal  investigations. To improve oversight, DODIG officials said that they  staffed the team with investigators who had experience at either DOD or  service IGs. The oversight investigators are to document their review  using an oversight worksheet, which captures information about how the  service investigation was conducted as well as the investigation’s findings  and conclusions. DODIG has used various versions of this oversight  worksheet since it established the oversight team. Our case-file review  included case files closed in fiscal year 2013, and during this period  DODIG’s oversight worksheet was designed to capture information about  (1) the servicemember’s allegations of reprisal, (2) the personnel action or  actions taken against the servicemember, (3) service investigation  thoroughness, (4) documentation, (5) timeliness, (6) objectivity, and (7)  whether there were any deficiencies or inconsistencies in the service  investigation report, among other things.
subsections: section_title: DODIG and Service IG Adherence to CIGIE Standards
paragraphs: DODIG adheres to CIGIE standards, but the extent to which it  incorporates these standards is unclear, and service IGs are not  members of CIGIE. CIGIE’s Quality Standards for Investigations provide  a framework to help ensure high-quality investigations are conducted by  member IG offices. CIGIE’s general standards apply to investigative  organizations and include investigator qualifications, independence, and  due professional care. CIGIE’s qualitative standards relate to how the  investigation is planned, executed, and reported, as well as how the  investigative information is managed. As a CIGIE member, DODIG is  expected to incorporate CIGIE’s quality standards into its operations  manuals or handbooks. Table 4 highlights some of the CIGIE standards  that DODIG has incorporated into its oversight worksheet that  investigators use to review service IG investigations.

We found that DODIG’s attestation to CIGIE standards, which is part of its  oversight review, was inconsistent. For example, DODIG has changed  the language on versions of its oversight worksheet between 2012 and  2014, and DODIG oversight investigators did not always attest to whether  the investigations in our fiscal year 2013 sample were conducted in  accordance with CIGIE standards. As a member of CIGIE, DODIG must  develop and document its quality-control policies and procedures in  accordance with its agency requirements, then communicate those  policies and procedures to its personnel, according to CIGIE standards.

The oversight worksheet that DODIG was using as of March 2015 did not  contain a block for CIGIE attestation, to indicate whether the investigation  was conducted in accordance with CIGIE standards, but the worksheet  asks whether the investigator gathered all relevant evidence and whether  the investigator demonstrated IG impartiality during interviews. In  contrast, the oversight worksheet that DODIG oversight investigators  used during the fiscal year 2013 time frame of our sample contained  template language for the oversight investigator to indicate whether the  service conducted the investigation in accordance with CIGIE standards,  but the worksheets in our sample did not consistently attest to whether  the approved investigation adhered to CIGIE standards, and the basis for  the determination was unclear. Specifically, of the 89 service IG  investigations in our sample, DODIG oversight investigators attested that  55 percent of them were conducted in accordance with CIGIE standards  as reflected on the oversight worksheet.

Further, the service IGs are not members of CIGIE, and the service IG  investigators are not subject or consistently trained to CIGIE standards. In  2012 DODIG hired a training officer and in 2013 developed a basic  whistleblower reprisal investigations course for DODIG and service IG  investigators. DODIG officials stated that they incorporated some CIGIE  standards into this and other trainings as well as in their semiannual  symposiums, but service IG officials stated that these DODIG-offered  trainings do not reach all field-level investigators. A senior DODIG official  stated that even though the service IGs are not subject to CIGIE  standards, DODIG would not approve a service IG investigation that did  not appear to adhere to CIGIE standards. Also, while DODIG’s  Administrative Investigations manual directs DODIG investigators to  follow CIGIE standards, none of the DODIG-conducted military reprisal  investigations in our sample included an attestation similar to the  statement on the oversight worksheet for service IG cases stating they  adhered to CIGIE standards. DODIG officials stated that the attestation  is not necessary for its own reprisal investigations because, as a CIGIE  member, all of its investigations adhere to CIGIE standards.

section_title: DODIG Oversight Guidance and Instruction
paragraphs: DODIG provided the oversight team with limited instructions on how to  review service IG cases. We interviewed each member of DODIG’s  oversight team to discuss their procedures for investigation review and  found that they have different approaches for how they review  investigations prior to completing the oversight worksheet. For example,  some read the allegation of reprisal first, while others begin their oversight  review by reading the service investigator’s report of investigation.  According to the oversight investigators we spoke to, once they review  the investigation documentation and complete the oversight worksheet,  they are to forward the package to their supervisors for discussion and  review. For some cases, before final approval, oversight investigators  discuss the oversight review during regular meetings with other oversight  investigators, and with Whistleblower Reprisal Investigation management,  according to officials. Finally, officials stated that management reviews  some case files before DODIG issues the approval memo back to the  service IG. DODIG officials stated that they have informal weekly  meetings with the oversight team to discuss cases and oversight  processes; however, some of the oversight investigators we spoke with  noted that they had not received any detailed guidance that was  specifically focused on how to conduct oversight of service IG military  reprisal cases.

For the 89 oversight files in our sample, DODIG rarely disagreed with the  service IG’s final determination of whether to substantiate the reprisal  allegation(s), even if the oversight investigator noted deficiencies in the  investigation documentation. We estimate that DODIG sent the case back  to the service IG for additional work in about 8 percent of service cases  closed in fiscal year 2013. DODIG disagreed with the service  determination of whether to substantiate the complaint, and took over the  investigation, in 2 of the cases in our sample. DODIG officials stated that  oversight investigators are in regular contact with the service IG  headquarters to correct inadequacies in service investigations, but that  these communications may not be documented in the case files.

During our case file review, we identified examples of DODIG oversight  investigators not consistently completing the oversight worksheet.  Specifically, from the results of our case file review, we estimate that for  about 45 percent of service investigations closed in fiscal year 2013,  DODIG oversight worksheets were missing narrative that indicated the  investigator had thoroughly documented all case deficiencies or  inconsistencies, as required on the oversight worksheet. In those 45  percent of cases, we noted issues that include the following:

Case deficiencies were not consistently documented: Some service  investigation case files did not contain all DODIG required elements,  such as required letters, interview transcripts or summaries, legal  reviews, and other supporting documentation, but the oversight  investigators did not note the missing documentation on the oversight  worksheet. Specifically, we estimate that in 19 percent of service  investigated cases, the oversight investigator indicated that there  were adequate transcripts or summaries of testimony; however,  documentation of those interview transcripts was not included in the  case file.

DODIG did not always note deficiencies that service IG headquarters  identified: We found instances in which DODIG investigators did not  document deficiencies that the service IGs had identified. For  example, a service IG-completed oversight worksheet, included in the  investigation case file the service IG forwarded to DODIG for review,  noted that the investigators did not appear fair and impartial in the  servicemember interview transcript. In this interview transcript the  investigator stated that in the military nothing is unbiased because  there is a chain of command; however, DOD oversight investigators  attested that the investigative file did not contain evidence of bias on  the oversight worksheet. DODIG officials stated that there is no  written requirement for oversight investigators to note deficiencies  identified by the service IGs; however on oversight worksheets for  other cases, the oversight investigators did note service IG-identified  deficiencies. Service IG officials also highlighted inconsistencies  between the oversight investigators. For example, service IG officials  stated that they prefer to work with certain DODIG oversight  investigators because they know what to expect from those oversight  investigators, and this speeds up the oversight review. In contrast,  these officials stated that they receive more questions about cases  from oversight investigators with whom they work less frequently.

DODIG did not always explain why deficiencies did not affect the  outcome of the service investigation: In the instances when the  DODIG oversight investigator identified deficiencies with the service  IG investigation, the oversight investigator typically included a  statement indicating that the noted deficiencies did not have a  material effect on the outcome of the investigation. However, the  oversight investigators did not always explain why the deficiencies did  not affect the outcome of the investigation. For example, on some  oversight worksheets that we reviewed, the oversight investigators  noted that the service IG investigator did not analyze a protected  communication or a personnel action as part of the investigation, but  that these items did not affect the outcome of the investigation.

We also found that the files in these cases lacked documentation of the  oversight investigators’ analysis of the effect of noted deficiencies on the  outcome of the investigation. Oversight investigators stated that when  they note any deficiencies in investigations, they typically discuss those  deficiencies with their supervisors in order to determine whether to  approve the case. DODIG officials stated that there are several gray  areas in reprisal investigations and that these types of discussions are  common practice when DODIG is deciding whether to approve a case;  however, we found in our case-file review that the results of these  conversations are not always documented on the oversight worksheet.  CIGIE standards state that reasonable steps should be taken to ensure  that pertinent issues are sufficiently resolved and that the results of  investigative activities should be accurately and completely documented  in the case file. Further, Standards for Internal Control in the Federal  Government provide that internal control and all transactions and other  significant events need to be clearly documented, and the documentation  should be readily available for examination.

Ensuring that oversight  investigators document the basis for their determinations regarding  independent decision making enables reviewers to ensure that such  determinations are appropriate.

Moreover, DODIG does not have detailed guidance that specifies the  steps and documentation requirements of the DODIG oversight  investigators’ review of service reprisal investigations, and whether or  how any noted investigation deficiencies would affect the outcome of the  investigation. DODIG has focused on its October 2014 issuance of the  updated Guide to Investigating Military Whistleblower Reprisal and  Restriction Complaints, which details best practices for reprisal  investigations, but does not specify the steps DODIG investigators are to  follow when conducting oversight of service IG investigations. In addition,  DODIG’s Administrative Investigations manual includes a 5-page  overview of oversight reviews. However, the manual is not specific to  oversight reviews of military whistleblower reprisal investigations and  encompasses investigations of senior officials, and does not state what  deficiencies are substantive and would affect the outcome of the  investigation.

Further, part one of DODIG’s Administrative Investigations manual refers  investigators to a forthcoming third portion of the manual for detailed  guidance on conducting oversight of military whistleblower reprisal  investigations, which has not been developed. However, as of January  2015, DODIG officials stated that they were no longer planning to issue  the third part of the manual and that they plan to incorporate some  additional oversight procedures into the existing manual. Officials did not  provide details on what procedures they plan to incorporate or when they  plan to make the changes. Without additional guidance for its oversight  investigator team, which would help formalize the oversight process,  DODIG will continue to face inconsistency in both its oversight  documentation and its review of service IG investigation outcomes. CIGIE  standards state that to facilitate due professional care, organizations  should establish written investigative policies and procedures. The  complexity of reprisal investigations paired with the decentralized service  IG structure underscores the importance of clear and consistent oversight  review procedures and documentation requirements to ensure  consistency across the department and that each reprisal complaint  receives due professional care.

Senior DODIG officials stated that DODIG’s Administrative Investigations  component is taking steps to implement quality-assurance processes and  that these processes will help prepare the component for an eventual  peer review. For example, a senior DODIG official said that on a quarterly  basis, DODIG completes an internal control checklist for 20 DODIG  whistleblower reprisal investigations and 20 oversight reviews of service  IG military whistleblower reprisal investigations to assess the  thoroughness of the case files and the completeness of the information in  the case management system, among other things. This official also  stated that they brief DODIG leadership on the results of these quarterly  quality-assurance checks. The Whistleblower Reprisal Investigations  directorate has undergone external reviews, but CIGIE has not  established peer-review criteria for administrative investigations, such as  whistleblower reprisal investigations, according to DODIG officials. Senior  DODIG officials stated that, if established, they would like to participate in  an eventual administrative peer review of their whistleblower reprisal  investigations. However, without documentation of the steps it took to  reach its case determinations and why any noted case deficiencies did  not affect the outcome of the investigation, as well as consistent  attestation of adherence to CIGIE standards, a third-party reviewer may  find it difficult to assess the quality of DODIG’s oversight process for  military whistleblower reprisal investigations.

section_title: DODIG Does Not Have Standardized Investigative Guidance and Provides Limited Feedback on Investigation Quality
subsections: section_title: DODIG and the Service IGs Do Not Have Standardized Guidance Regarding Investigation Stages
paragraphs: DODIG and the service IGs use different terms in their guidance to refer  to their investigation stages. DODIG took a step to improve guidance by  issuing an updated reprisal investigation guide for military reprisal  investigations for both DODIG and service IG investigators in October  2014. The guide discusses DODIG’s four questions that investigators  use to determine whether the four elements of reprisal are present;  various investigative steps; and, provides sample interview questions,  among other things. However, DODIG describes the guide as best  practices for conducting military reprisal intakes and investigations and,  according to DODIG officials does not explicitly direct the services to  follow DODIG’s preferred investigation process and stages. DODIG  officials stated that they have no role in the development of service IG  regulations.

DODIG guidance describes two investigation stages: (1) intake and (2)  full investigation. During the intake process, the investigator is to  determine whether the servicemember made a protected communication  and a responsible management official took a personnel action against  the servicemember. In addition, if the investigator determines that the  allegation supports an inference that the responsible management official  had knowledge of the protected communication as well as a causal  connection between the protected communication and the personnel  action, and the servicemember reported the alleged reprisal within 1 year,  the case is to proceed to a full investigation. According to DODIG’s  investigation guide, during the intake process an investigator is to review  the complaint, personnel action, and timeline; and interview the  servicemember to clarify the allegation. During a full investigation,  investigators are to formally interview the servicemember (and provide a  written record of the interview), obtain relevant documentation (of the  protected communication and personnel action, among other things),  interview knowledgeable witnesses, interview the responsible  management official who took the personnel action, and obtain a legal  review of the report of investigation.

Each of the service IGs has a stage between intake and full investigation,  commonly referred to as a preliminary inquiry or a reprisal complaint  analysis. DODIG does not have a similar in-between investigation stage,  and therefore DODIG officials stated that oversight investigators should  classify preliminary inquiries conducted by the service IGs as intakes in  the case management system, but there is no written guidance for  reviewing preliminary inquiries. We found that the service investigators  typically complete much more investigative work, such as interviewing  witnesses, when conducting a preliminary inquiry than DODIG requires  during the intake process.

Based on our case file review, we found that DODIG oversight  investigators were not consistently classifying the preliminary inquiries as  intakes, and classified many preliminary inquiries as full investigations in  the case management system. DODIG oversight investigators approved  cases as full investigations when those cases did not contain all elements  required for full investigations and approved the dismissal of cases that  were preliminary inquiries coded as full investigations, on a basis that can  only be determined by conducting a full investigation. Specifically, we  estimate that in 38 percent of preliminary inquiries closed in fiscal year  2013, service IGs dismissed cases because they determined that the  responsible management official would have taken the personnel action  absent the protected communication. In contrast, DODIG guidance states  that an investigator answers the question of whether the responsible  management official would have taken the personnel action absent the  protected communication during a full investigation, which requires an  interview with the responsible official to determine his or her reasons and  motive for taking the personnel action. In addition, a senior DODIG  official stated that an investigator must interview the responsible  management official to determine whether the personnel action would  have occurred absent the protected communication. However, there was  no evidence in these case files that the investigator interviewed the  responsible management official, and instead, investigators determined  that the responsible management officials took personnel actions as a  result of the servicemembers’ performance histories.

Further, we found through our file review that the service IGs’ preliminary  inquiry case files were less complete than the service IGs’ full  investigation case files, although DODIG oversight investigators approved  preliminary inquiries as full investigations. For example, based on our  sample results, we estimate that at least 79 percent of service preliminary  inquiries closed in fiscal year 2013 were missing at least one key  element, such as interviews with the servicemember. We estimate that  at least 23 percent of service full investigations closed in fiscal year 2013  were missing at least one element. Further, as previously discussed,  DODIG’s guidance requires investigators to interview the servicemember  for all complaints, during the intake process and if the case proceeds to a  full investigations; however, we estimate that 59 percent of service  preliminary inquiry case files compared to 10 percent of service full  investigation case files were missing evidence of a servicemember  interview.

CIGIE quality standards for investigations state that to facilitate due  professional care, organizations should establish written investigative  policies and procedures that are revised regularly according to evolving  laws, regulations, and executive orders. DODIG’s investigation guide  does not discuss preliminary inquiries or define any requirements for this  stage of investigation. DODIG officials have stated that they would like  the service IGs to stop preparing preliminary inquiries and to use  DODIG’s preferred investigation stages—intake and full investigation;  however, DODIG guidance does not explicitly direct the services to use  its preferred terms and stages. Additionally, a DODIG oversight  investigator stated that the service IGs’ varying interpretations of DOD  policy and inconsistent application of DODIG guidance makes it difficult  for oversight investigators to systematically review reprisal cases. The  oversight investigator also stated that DODIG should explicitly direct the  services to follow certain procedures currently included in DODIG  guidance, but DODIG officials stated the office does not have a role in the  development of service IG regulations. Further, in the absence of  standardized investigation stages, DODIG investigators miscoded  investigations in fiscal year 2013. We estimate that about 43 percent of  the cases that DODIG closed in fiscal year 2013 that staff coded as full  investigations were not fully investigated, and were instead preliminary  inquiries as indicated in the service report of investigation. DODIG  officials stated that this miscoding was likely the result of oversight  investigators wanting to recognize the amount of work that service IG  investigators completed, since those investigators typically complete the  steps of a full investigation, except for an interview with the responsible  management official and a legal review.

Without directing the service IGs to follow standardized investigation  stages and issuing guidance clarifying how the stages are defined, it will  be difficult for DODIG to ensure consistent program implementation. For  example, the service IGs may do more investigative work than DODIG  requires by conducting a preliminary inquiry, when DODIG would dismiss  the case at intake. On the other hand, the service IGs may dismiss cases  after conducting a preliminary inquiry when a DODIG investigator would  conduct a full investigation and collect additional testimonial evidence.  The amount of investigative work is inconsistent across DOD and is  dependent on which IG investigates the complaint, which could lead to  the perception that not all servicemember complaints are treated equally.  In addition, without standardized investigation stages and corresponding  guidance, investigators may be unclear about what elements are required  for each stage of investigation, resulting in incomplete reprisal case files.  Finally, without standardized investigative stages and agreement among  DODIG oversight investigators about how to classify preliminary inquiries,  DODIG may continue to miscode service preliminary inquiries in its case  management system. Since this system is the basis for DODIG’s  semiannual reports to Congress, DODIG may mischaracterize the  number of fully investigated complaints in these reports.

section_title: DODIG Does Not Consistently Provide Service IG Investigators with Feedback on Investigation Quality
paragraphs: DODIG has developed tools to assess service IG investigation quality and  to note any case deficiencies, but DODIG does not consistently provide  the service IGs with this feedback. As previously discussed, DODIG  oversight investigators are to document their reviews of service IG  investigations by completing an oversight worksheet. The worksheet  contains the criteria against which the reports of investigation are to be  evaluated to ensure that the investigations adhered to CIGIE professional  standards, such as independence and thoroughness. The worksheet also  includes spaces where the oversight investigator can include comments  regarding any criteria the investigation did or did not meet.

According to DODIG’s Administrative Investigations manual, which guides  how DODIG investigators conduct and perform oversight of reprisal  investigations, upon completion of the oversight review process,  investigators are to provide the service IGs with copies of the oversight  worksheet. The manual further states that this affords a good  mechanism for feedback to the services on the quality of individual cases,  in addition to valuable information on trends in systemic deficiencies in  investigations within their service. However, according to DODIG officials,  in 2012 DODIG stopped providing the service IGs with completed  oversight worksheets. Instead, these officials stated that they provide  summarized feedback in the closure memorandums that they send to the  service IGs once they approve a case. According to DODIG officials, the  oversight investigators complete the oversight worksheet when reviewing  service IG cases, but the worksheet is now used as an internal tool for  review.

Service IG officials stated that the primary feedback they receive is  DODIG’s summarized case analysis on the closure memorandum, which  discusses why it agreed with the service IG’s determination; however, the  closure memorandum, unlike the worksheet, does not include the criteria  against which the investigations are assessed. Further, service IG  officials stated that they upload DODIG’s closure memorandums to their  respective case management system, but they do not require the  investigating officers to go into the case management system to review  the closure memorandum. A DODIG oversight investigator noted that the  feedback oversight investigators provide on the worksheet is more  constructive than what they include on the closure memorandum, and a  service IG official stated that what investigators need is constructive  feedback, not just statements about what they did not do correctly. A  senior service IG official stated that receiving copies of the oversight  worksheets was beneficial to service investigators because the  worksheets helped investigators understand what DODIG was looking for  in its reviews of service investigations. Additionally, according to service  IG officials, DODIG rarely sends cases back to them for additional work  and rarely asks questions regarding cases they have sent to DODIG for  review. Service IG officials indicated that this lack of case-specific  feedback from DODIG is confirmation to them that they are meeting  DODIG’s expectations for investigations; however, DODIG oversight  investigators noted that the quality of service IG investigations could be  improved. Further, through our review of cases closed in fiscal year 2013,  after DODIG stopped providing copies of the oversight worksheets, we  found examples where oversight investigators were providing case- specific feedback intended for the service IG investigators. For example,  on some oversight worksheets the oversight investigator noted that the  feedback provided on the worksheet was intended to be a teach-and-train  vehicle to improve the quality and thoroughness of future reports;  however, per DODIG’s new practice, it is unclear whether DODIG  provided these oversight worksheets to the service IG investigators.

DOD officials have noted that feedback to service IG investigators is  important for various reasons. First, the DOD investigative process is  decentralized and lacks continuity. Many offices at various levels of the  service IGs investigate reprisal complaints. Further, in the Army and Air  Force—which accounted for approximately 80 percent of the service  investigative workload in fiscal years 2013 and 2014—military  investigators typically rotate every 3 years, according to service IG  officials. As such, these service IG military investigators may conduct few  reprisal investigations and may not have the opportunity to develop  experience, which according to DOD officials is essential to conducting  high-quality reprisal investigations. The service IGs have taken steps to  provide feedback to field-level investigators. For example, one service IG  holds quarterly video-teleconferences with field-level investigators to  share updates to reprisal policies and address any investigation trends.  Second, according to service IG investigators, they receive some required  training that is specific to conducting reprisal investigations when they are  assigned to the IG, but there is no additional mandatory reprisal-specific  training that investigators complete during the course of their careers.  Additionally, these investigators may not have opportunities to apply  lessons learned from that training immediately, and according to DOD  officials there is often a gap of over a year between training and reprisal  investigation assignment. According to CIGIE quality standards for  investigations, organizations should establish appropriate avenues for  investigators to acquire and maintain the necessary knowledge, skills,  and abilities. Service IG investigators noted that in addition to offered  training, case-specific feedback is a good way to learn skills for  conducting reprisal investigations; however, three of six field-level  investigators we interviewed stated that they had never received  feedback from DODIG on their reprisal investigations.

If the service IG investigators do not receive copies of the oversight  worksheet, they may not have knowledge of the criteria that DODIG uses  to conduct its oversight reviews and whether their investigative reports  are meeting the specific CIGIE standards that DODIG has incorporated  into its oversight review. For example, three of six field-level investigators  we interviewed had not seen a DODIG oversight worksheet, and two of  those three investigators did not know that DODIG used a worksheet to  conduct oversight. DODIG’s October 2014 guide for investigating reprisal  complaints includes a quality-assurance review checklist, modeled after  the DODIG oversight review worksheet, that investigators can use to  perform a quality-assurance review of their investigation. However, as  previously discussed, service IG investigators are not subject to or  consistently trained to CIGIE standards and therefore may not know how  to assess their investigations according to these standards. Without  receiving case-specific feedback, which relates to the CIGIE standards  against which DODIG assessed the investigation and notes any  deficiencies, service investigators may not be able to assess their own  subsequent investigations. Further, without coordination with the service  IGs to ensure that service investigators are receiving case-specific  feedback from DODIG, DODIG efforts to improve investigation quality  may continue to face challenges. Finally, without case-specific feedback,  service IGs may not be able to identify trends in systematic deficiencies  or specific CIGIE standards not being met, which otherwise might be  corrected in future investigations and incorporated into their feedback to  field-level investigators.

section_title: DOD Does Not Have a Process for Investigators to Certify Their Independence
paragraphs: DODIG and the service IGs have processes for investigators to recuse  themselves from investigations, but there is no process for investigators  to document whether the investigation they conducted was independent  and outside of the chain of command. CIGIE standards state that in all  matters relating to investigative work, the investigative organization must  be free, both in fact and appearance, from impairments to independence.  Impairments to independence include professional or personal  relationships that might weaken the investigative work in any way, and  preconceived opinions of individuals or groups that could bias the  investigation, among others.

In the absence of a process for investigators to certify their  independence, DODIG has incorporated various questions into its  oversight review in order to document the independence of the  investigator and to determine whether the investigation was conducted in  accordance with CIGIE standards. For example, DODIG oversight  investigators indicate whether the investigator was outside the chain of  command of the servicemember and responsible management official,  which is statutorily required. DODIG’s oversight investigators—of which  all but one has prior military experience—stated that they use their  experience and knowledge of the service’s organizational structures to  determine whether the investigator was outside the chain of command.  Oversight investigators further determine on the current version of the  oversight worksheet whether the investigator maintained professionalism  and demonstrated IG impartiality during interviews. Oversight  investigators stated that they can determine whether the investigator was  impartial during interviews only if the case has interview transcripts, which  the Administrative Investigations Manual instructs them to read if  necessary; however, DODIG will accept summarized interviews and does  not require that the service IGs provide verbatim transcripts for all  interviews. Based on our sample, we estimate that 43 percent of cases  closed in fiscal year 2013 have transcripts of interviews with the  servicemember alleging reprisal and 26 percent of cases have transcripts  of responsible management official interviews. In the absence of interview  transcripts, oversight investigators have limited tools to determine  whether the investigator demonstrated IG impartiality during interviews.

DOD officials stated that their recusal policies and decentralized  investigation structure, removing the investigator from the chain of  command, adequately address independence and that no further  documentation of independence is needed. However, during our case-file  review we reviewed oversight worksheets where DODIG oversight  investigators had noted potential impairments to investigator objectivity in  the report of investigation. For example, on one oversight worksheet, the  oversight investigator stated that the report gave the appearance of  service investigator bias, and further clarified that the report should state  whether the responsible management official’s actions were reasonable  and supported by facts, not whether the investigator would have taken the  same actions. In addition, on another oversight worksheet the DODIG  investigator stated that the investigator’s narrative in the report of  investigation contained comments that would bring into question whether  the analysis was impartial and unbiased, further noting that there was  evidence of bias. Further, one oversight worksheet stated that the  investigator was not outside the chain of command, as statutorily  required, but that it had no effect on the investigation. DODIG approved  these cases without documenting how it reconciled these case  deficiencies. We are not questioning DODIG’s judgment in these cases.

We noted that the files in these cases did not address the issues  identified by the oversight investigator beyond the final approval of the  case. However, Standards for Internal Control in the Federal Government  provides that internal control and all transactions and other significant  events need to be clearly documented, and the documentation should be  readily available for examination. Without documenting the basis for their  determinations regarding independent decision making, DODIG cannot  ensure that such determinations are appropriate.

One oversight investigator we interviewed stated that DODIG has  received investigations from the service IGs where the investigations  show clear signs of bias, even though the investigator was outside the  chain of command. According to this investigator, in these instances,  DODIG’s options include returning the case for additional investigation,  appointing a new investigator, or preparing additional case analysis  addressing the bias. Further, some service IG reviews of investigations  also noted potential impairments to objectivity. For example, a service IG  forwarded a completed investigation to DODIG for approval, noting that  the investigators did not appear fair and impartial in a servicemember  interview transcript; however, the oversight investigator stated that there  was no evidence of bias by the investigating officer. Service IG officials  stated that their review of field-level investigations is important because  they have received investigations that contain personal opinion and  statements that make it appear that the investigator was not impartial.  These officials stated that, through their review, they attempt to identify  and correct these statements, and that DODIG’s subsequent review of  the case should also catch any instances where an investigator did not  appear impartial. Service IG officials noted that, because investigators are  so close to the investigation, they can become invested in the  investigation and that this investment is sometimes evident in reports of  investigation.

Guidance for documenting independence is included in generally  accepted government auditing standards (GAGAS). While these  standards apply to audits, they can also provide guidance to service IGs  as a best practice on how to document decisions regarding independence  when conducting reprisal investigations. Documentation of independence  considerations provides evidence of the judgments in forming conclusions  regarding compliance with independence requirements. Further, GAGAS  notes that an organization should establish policies and procedures in its  system of quality control that address independence. While GAGAS  states that insufficient documentation of compliance with the  independence standard does not impair independence, documentation of  independence in a reprisal investigation could improve the quality of  DODIG’s investigations. Without a process for investigators to document  that the investigation was independent and outside the chain of  command, DODIG and the service IGs will be hindered in their efforts to  monitor the independence of investigations. DODIG oversight  investigators are responsible for assessing the independence of the  investigator and the investigation. Absent direction from DODIG to the  service IGs to provide certifications that the investigator was independent  and outside of the chain of command, DODIG oversight investigators  have few mechanisms to determine whether the investigation was  independent during the oversight process. With the pending expansion of  DODIG’s case management system to the service IGs, the certification  process could be incorporated, for example, into the case management  system. Further, such a certification process would serve as an  accountability mechanism for service IG investigators, should an  oversight investigator or service IG official note any potential impairments  to objectivity during their reviews of investigations. Finally, certification of  investigator independence could decrease the potential for bias in military  reprisal investigations and better ensure that servicemembers receive the  whistleblower protections provided by law.

section_title: Conclusions
paragraphs: Whistleblowers play an important role in safeguarding the federal  government against waste, fraud, and abuse, and their willingness to  come forward can contribute to improvements in government operations.  As a result, it is important that DOD have a process for investigating  whistleblower reprisal complaints that affected parties have confidence is  timely, effective, and impartial. One way in which such confidence can be  undermined is if investigations and related communications with the  servicemembers are not timely and accurate. Reducing delays in  investigations and notifications when the process will take longer than  180 days would provide servicemembers with information that may affect  their immediate work environment or personnel actions, which are  typically halted during an active investigation, since servicemembers  generally do not receive relief from reprisal until DODIG has approved a  substantiated investigation. Ultimately, the absence of regular status  updates, such as revised case-completion estimates when time frames  shift, may discourage servicemembers from coming forward to report  wrongdoing.

Another area in which DODIG processes are lacking is in data collection  and monitoring for oversight of investigations at the service IG level.  DODIG has made progress in this regard since our February 2012 report  by implementing a new case management system, but it remains under  development and, as of March 2015, does not yet meet DODIG’s full  reporting needs. Without additional internal guidance to staff on how to  use the case management system for real-time case processing, DODIG  cannot assure efficient reporting and that the data it collects are up to  date and accurate. Absent these actions, along with developing an  implementation plan for expansion of the case management system to  the service IGs, DODIG will not have complete visibility of service IG  workload and timeliness.

DODIG also cannot ensure that all military whistleblower reprisal  investigations adhere to quality standards. For instance, the complexity of  reprisal investigations underscores the need for clear and consistent  oversight review procedures and documentation requirements. DODIG  took a positive step by establishing a team of investigators that is solely  dedicated to the review of service IG investigations. However, without  additional guidance regarding how to review service IG investigations,  which would help to formalize the oversight process, DODIG cannot  ensure that it treats reprisal complaints consistently and with due  professional care. In addition, consistency across DODIG and service IG  investigations, especially in regard to investigation stages, will be limited  without guidance that clarifies the amount of investigative work an  investigator is to conduct at each stage and leads to the perception that  not all servicemember complaints are treated equally. Additionally,  without providing case-specific feedback that includes the criteria DODIG  oversight investigators use to assess service investigations, service  investigators may be limited in their ability to improve the quality of  subsequent investigations. Finally, DOD may not be able to enhance the  perception of fairness and increase accountability without taking steps to  develop and implement a process for investigators to certify their  independence when conducting investigations. Absent these actions,  DODIG will be limited in its ability to enhance the effectiveness of its  oversight, prepare for the eventual peer review in which senior leadership  would like to participate, and ensure that servicemembers receive the  whistleblower protections provided by law.

section_title: Recommendations for Executive Action
paragraphs: To improve the military whistleblower reprisal investigation process and  oversight of such investigations, we recommend that the Secretary of  Defense work in coordination with the Department of Defense Inspector  General (DODIG) to take the following seven actions: develop an automated tool to help ensure compliance with the  statutory 180-day notification requirement by providing  servicemembers with accurate information regarding the status of  their reprisal investigations within 180 days of receipt of an allegation  of reprisal;  issue additional guidance to investigators on how to use the case  management system as a real-time management tool, and update  and finalize the draft internal user guidance from 2012 as necessary  until the case management system is complete; working in coordination with the service IGs, develop an  implementation plan that addresses the needs of DODIG and the  service IGs, and defines project goals, schedules, costs, stakeholder  roles and responsibilities, and stakeholder communication techniques  for expansion of the case management system; issue additional guidance to formalize the DODIG oversight process; direct the services to follow standardized investigation stages and  issue guidance clarifying how the stages are defined; ensure that the mechanism it uses for feedback to service  investigators includes the criteria against which the investigation was  assessed and any deficiencies, and work with the service IG  headquarters to ensure that feedback is shared with the service  investigators; and develop and implement a process for investigators to document  whether the investigation was independent and outside of the chain of  command and direct the service IGs to provide such documentation  for review during the oversight process.

section_title: Agency Comments and Our Evaluation
paragraphs: In commenting on a draft of this report, DODIG concurred with each of  our seven recommendations. However, DODIG did not agree with the  manner in which we presented the findings in the report and raised  concerns that we did not include information relating to significant  progress made by DODIG since our February 2012 report. DODIG’s  comments are reprinted in appendix III. DODIG also provided technical  comments, which we considered and incorporated where appropriate.

We disagree with DODIG’s characterization of our report’s findings  because we included discussion of the improvements cited by DODIG  throughout our report. For example, we noted increases in staff levels,  DODIG’s development of a new case management system, DODIG’s  October 2014 issuance of a military whistleblower reprisal investigations  guide, and policy guidance to the service IGs regarding 180-day  notification requirements, among others. Further, in its comments, DODIG  stated that it takes its role in leading DOD’s whistleblower protection  program seriously and has invested significant resources, more so than  other federal agencies, to improve the timeliness and quality of its  investigations. In addition, DODIG highlighted the volume of complaints  that it processes. We agree that DOD’s program is large, and believe that  our current recommendations are critical to aid DODIG in attaining its  goal of being the model whistleblower protection program in the federal  government. Our responses to additional comments made by DODIG on  our report’s findings are included at the end of appendix III.

In concurring with our first recommendation that DODIG develop an  automated tool to help ensure DOD compliance with the statutory 180- day notification requirement, DODIG stated it had already implemented a  dashboard in its case management system that identifies investigations  pending for 180 days and that it would work toward an even more  automated notification process in the future. We believe that an  automated tool to help ensure DOD compliance with statutory  requirements is needed and that the dashboard alone does not serve this  intended purpose. Based on our case file review, we found that in the  estimated 53 percent of cases in which DOD sent the required 180-day  notification letters for cases closed in fiscal year 2013, the notifications  that DOD provided were sent after 180 days. Specifically, we estimated  that DOD’s median notification time was on average 353 days after the  servicemember filed the complaint, almost twice as long as the 180-day  requirement. The dashboard that DODIG uses to track cases does not  proactively alert DOD to send the 180-day letter. Importantly, as we  stated in our report, DODIG’s case management system did not have  record of at least 22 percent of service investigations both open as of  September 30, 2014, and closed in fiscal years 2013 and 2014. Without  knowledge of these cases, DODIG cannot ensure that the service IGs  sent 180-day notification letters for cases taking over 180 days to  complete. We believe that an automated tool that proactively alerts DOD  to send the required 180-day notification letter for all cases taking longer  than 180 day days could help to ensure DOD’s full compliance with  statutory notification requirements.

In concurring with our second recommendation that DODIG issue  additional guidance to investigators on how to use the case management  system as a real-time management tool, DODIG stated that we  misrepresented DODIG’s focused effort to migrate paper-based 2013  data into a new electronic system and correct data deficiencies in order to  ensure data reliability. We disagree. In our report, we note that DODIG  officials told us that the case management system is to serve as a real- time complaint tracking and investigative management tool for  investigators. Further, in its comments, DODIG highlights the guidance  and training it has implemented related to its case management system.  During our case file review, we found that personnel uploaded key case  documents to the case management system after DODIG had closed the  case in 77 percent of cases closed in fiscal year 2013 and made changes  to case variables in 83 percent of cases in 2014. DODIG staff made these  changes at least 3 months after case closure and at least a year after  DODIG implemented the database in December 2012, indicating that it  was not being used for real-time case tracking for cases closed in fiscal  year 2013. Further, despite DODIG’s stated efforts to train investigators  and ensure data consistency, we found significant instances of coding  errors where DODIG personnel were coding partially completed service  investigations as full investigations. Specifically, we estimate that for  cases closed in fiscal year 2013, 43 percent of cases that DODIG  investigators coded as fully investigated were only partially investigated.  As a result, we believe that additional guidance on how to use the case  management system may help ensure that DODIG has awareness of the  real-time status of cases and the reliability of DODIG’s data.

In concurring with our third recommendation that DODIG work in  coordination with the service IGs to develop an implementation plan for  the expansion of the case management system, DODIG stated that we  did not acknowledge the steps it has already taken to develop an  implementation plan. We disagree. As we note in the report, DODIG  officials stated during our review that they were developing an  implementation strategy for the expansion of the case management  system, but that they did not have an implementation plan. DODIG stated  that it has taken additional actions since January 2015 to plan for the  expansion of the case management system, such as developing a  demonstration environment to define the requirement gaps. We believe  that these actions are positive steps and that they will provide a strong  foundation for the development of an implementation plan, which could  help position DODIG to monitor the case management system expansion  and measure project success.

In concurring with our fourth recommendation that DODIG issue  additional guidance to formalize the DODIG oversight process, DODIG  stated that its investigations manual already provides formal guidance to  DODIG investigators for conducting oversight reviews of service IG  military reprisal investigations and that within the next 90 days it will  develop additional guidance on conducting oversight reviews, such as  how to evaluate and document deficiencies, including those that did not  affect the overall outcome of the investigation. We disagree that DODIG’s  investigations manual already provides formal oversight guidance. We  reviewed the 5-page chapter in DODIG’s manual on oversight of service  IG investigations, and we found that it does not detail the steps and  documentation requirements of an oversight review, is not specific to  military whistleblower reprisal investigations, and does not state what  deficiencies are substantive and would affect the outcome of an  investigation. We believe that DODIG’s stated plan to develop additional  guidance, including how to evaluate and document deficiencies, could  better ensure the consistency of DODIG’s oversight reviews and that all  reprisal complaints receive due professional care.

In concurring with our fifth recommendation that DODIG direct the  services to follow standardized investigation stages and issue guidance  clarifying how the stages are defined, DODIG stated that its October 2014  military whistleblower reprisal investigations guide describes DODIG’s  intake process and that its Directive 7050.06, which was reissued in April  2015, establishes a timeline for completing the intake process in 30 days.  We disagree that the guidance provides the needed instructions for  investigators. We acknowledged in the report that DOD’s issuance of  updated guidance is a positive step; however, DODIG describes its guide  as a best practice for conducting military reprisal intakes and  investigations and does not explicitly direct the services to follow  DODIG’s preferred stages. In addition, it does not discuss the service IGs’  use of preliminary inquiries to dismiss cases after only a partial  investigation, a practice DODIG stated it ended 3 years ago. We believe  that standardized investigative stages may better ensure consistent  program implementation and that all servicemember complaints are  treated equally.

In concurring with our sixth recommendation that DODIG ensure that  feedback to service investigators includes the criteria against which the  investigation was assessed and any deficiencies, and that feedback is  shared with the service investigators, DODIG stated that within the next  60 days it will resume its prior practice of sending oversight worksheets to  the service IGs. Those worksheets will include the criteria against which  the service’s intake or investigation was reviewed as well as clear  explanations of deficiencies and whether they affected the outcome of the  case. DODIG also stated that it will work with the services to develop a  mechanism by which results will be shared with service investigators. We  believe that the steps DODIG noted in its response could improve the  quality of future service IG investigations and better ensure that  investigative reports meet the CIGIE standards that DODIG has  incorporated into its oversight review.

In concurring with our seventh recommendation that DODIG develop and  implement a process for investigators to document whether the  investigation was independent and outside of the chain of command,  DODIG stated that within the next 60 days it will develop and implement  such a process. Specifically, it stated that the process will require service  investigators to attest in writing that they are outside the immediate chain  of command of both the servicemember alleging reprisal and the alleged  responsible management officials. Although such an attestation is a  positive step, we believe that the service investigators should also attest  to whether the investigation was independent. DODIG oversight  worksheets we reviewed noted impairments to investigator objectivity in  reports of investigation even though the service investigator was outside  of the chain of command. We believe that an attestation that the  investigation is both independent and outside of the chain of command  could help serve as an accountability mechanism for service IG  investigators and decrease the potential for bias in military whistleblower  reprisal investigations.

We are sending copies of this report to the Secretary of Defense; the  Department of Defense Inspector General (DODIG); the Inspectors  General (IG) of the Air Force, the Army, the Marine Corps, and the Navy;  and appropriate congressional committees. In addition, the report is  available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-3604 or farrellb@gao.gov. Contact points for our Offices   of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made major contributions to this report  are listed in appendix IV.

section_title: Appendix I: Scope and Methodology
paragraphs: To address our objectives, we used two primary sources of data,  including (1) closed military whistleblower reprisal case data from the  Department of Defense Office of Inspector General’s (DODIG) case  management system and (2) a randomly selected sample of DODIG’s  closed military whistleblower reprisal case files. DODIG provided us with  information for all military whistleblower reprisal cases closed from  October 1, 2011, through September 30, 2014, and all cases open as of  October 1, 2014. We were unable to report the fiscal year 2012 data  because DODIG transitioned to a new case management system in  December 2012, and data from fiscal year 2012 were not reliable as a  result of the data migration, according to DODIG officials. In addition,  DODIG officials told us that they verified and corrected data as necessary  for all cases closed in fiscal years 2013 and 2014 because the case  management system was new and investigators had not been  consistently recording information. We assessed the reliability of DODIG’s  fiscal years 2013 and 2014 data—by reviewing related documentation,  interviewing knowledgeable officials, and comparing selected fields, such  as open and closed dates, with case file records from our sample—and  concluded that the data were sufficiently reliable for reporting the average  lengths of investigations.

Further, we used the data for cases closed in fiscal year 2013 to select  the sample for our case-file review, discussed below. We chose cases  from this period for the file review because of DODIG’s case management  system transition in December 2012 and statements from DODIG officials  that data from cases closed in the old case management system were not  as complete as data from cases closed in the new case management  system. We also chose this period because the National Defense  Authorization Act for Fiscal Year 2014, effective December 26, 2013,  expanded the amount of time a servicemember has to report a reprisal  allegation from 60 days to 365 days. We selected a stratified random  sample of 135 cases from the 538 cases closed in fiscal year 2013. We  stratified the population into six strata by combining three categories of  case status and two categories of investigation status (see table 5 below).  We calculated the sample sizes to achieve a desired precision of plus or  minus 10 percentage points or fewer for a percentage estimate of the  total population (N=538) at the 95 percent confidence level. We then  adjusted the sample sizes to achieve a desired precision of plus or minus  10 percentage points or fewer for a percentage estimate at the 95 percent  confidence level for DODIG Oversight cases (N=344, strata 3 and 4) and  Fully Investigated cases (N=203, strata 1, 3, and 5).

During the course of our review, we removed 11 out-of-scope cases,  which reduced the original sample size from 135 to 124, because we  found that 2 of the cases were open, 1 of the cases was classified and  had limited documentation to review, and 8 cases were investigations of  improper mental health examinations and not reprisal. This reduced  sample of 124 cases is generalizable to the estimated population of in- scope cases. We generalized the results of our sample to the estimated  population of 498 cases DODIG closed in fiscal year 2013. All estimates  of percentages presented in this report have a margin of error of plus or  minus 10 percentage points or fewer, unless otherwise noted. Further, all  estimates of medians and averages presented in this report have a  relative error of plus or minus 20 percent of the estimate, unless  otherwise noted.

To determine the extent to which the Department of Defense (DOD) has  met statutory notification requirements and internal timeliness  requirements for completing military whistleblower reprisal investigations,  we calculated the timeliness of cases using case data from DODIG’s case  management system for military whistleblower reprisal cases closed in  fiscal years 2013 and 2014 and compared the average timeliness to the  regulatory 180-day requirement. We removed one closed case from the  timeliness calculations because the record produced a negative case  processing time because the closed date preceded the open date. In  addition, for all cases that were open as of September 30, 2014, we  analyzed how long the cases had been open, according to the fiscal year  in which the complaints were received. To determine the extent to which  DOD met the statutory requirement to notify servicemembers in cases  lasting longer than 180 days about delays in the investigation in fiscal  year 2013, we reviewed the 124 case files in our sample for evidence that  DOD had sent the required letter in cases lasting longer than 180 days.  For cases where there was evidence that DOD had sent the required  letter, we recorded the reasons provided for the delay as well as the  estimated completion date. We calculated the median estimated time  frame in the letters and compared this to the median completion date for  these cases to determine the accuracy of DOD’s estimated time frames.  In order to assess the reliability of DODIG’s data, we used case file  documentation to determine the open and close dates of the 124 cases in  our sample and calculated total case time for each case. We then  compared the total case time we recorded for the sample cases to the  total case time for those cases in DODIG’s data and we found a mean  difference of 2 days. We further assessed the data through discussions  with officials responsible for the data and concluded that the data were  sufficiently reliable for reporting the average lengths of investigations.  Further, we reviewed relevant documents including 10 U.S.C. § 1034, as  amended, and its implementing directive on military whistleblower  protections, DOD Directive 7050.06, Military Whistleblower Protection  (July 23, 2007). After we sent our draft report for comment, DODIG  issued an updated Directive on April 17, 2015, which we also reviewed.  Finally, we interviewed officials about methods for tracking investigations  and processes for sending required notifications to servicemembers that  allege reprisal. We also collected relevant documentation, such as  standard operating procedures and investigative guidance from DODIG,  and the service Inspectors General (IG) for the Air Force, the Army, the  Marine Corps and the Navy. We also spoke with officials from DODIG’s  Information Systems directorate to determine which variables to request  from DODIG’s case management system.

To determine the extent to which DODIG’s whistleblower case  management system supports oversight of the military whistleblower  reprisal program, we obtained and analyzed closed case data from each  of the service IGs for cases closed from fiscal year 2012 through fiscal  year 2014. We assessed the reliability of service IG data from fiscal years  2013 and 2014—by reviewing related documentation and interviewing  knowledgeable officials—and concluded that the data were sufficiently  reliable for our purposes. We compared selected variables for all cases  by matching DODIG’s data to the service IG data to identify duplicate  cases and missing information, and to determine whether DODIG has  visibility of all ongoing and closed military whistleblower reprisal cases.  We selected the variables present in both DODIG’s and the service IGs’  data to compare for matching cases in consultation with DODIG and  service officials, and those variables include servicemember name, case  identifiers, open date, and closed date. Further, we interviewed DODIG  officials responsible for the development of the case management system  and the proposed expansion of the case management system to the  service IGs and collected supporting documentation. We also reviewed  DOD memorandums regarding the case management system expansion  and cost information for the next phase of case management system  development and compared these documents to relevant program  management criteria. In addition, we interviewed officials from DODIG’s  Administrative Investigations component as well as its Whistleblower  Reprisal Investigations and Investigations of Senior Officials directorates,  and service IG officials regarding the case management system  expansion.

To determine the extent to which DOD has processes to ensure oversight  of military whistleblower reprisal investigations conducted by the service  IGs, we used our stratified random sample of 124 case files retained by  DODIG for military whistleblower reprisal cases that DODIG closed from  October 1, 2012, through September 30, 2013. Based on our review of  whistleblower reprisal investigation policies and procedures and quality  standards for investigations established by the Council of the Inspectors  General on Integrity and Efficiency (CIGIE), we created a data-collection  instrument to identify the key characteristics of whistleblower reprisal  cases, determine the reliability of various fields in the case management  system, and assess the completeness and quality of files. We also  developed a standard approach to electronically review files, using  DODIG’s new case management system, to ensure we reviewed all  cases consistently. For example, for all cases, we reviewed the original  complaint followed by the report of investigation and interview transcripts,  among other things. We refined this data-collection instrument and our  approach by first reviewing 12 pilot case files selected by DODIG that  were not part of the 135 originally identified in the sample. Specifically,  the pilot consisted of cases that DODIG approved in the first three  quarters of fiscal year 2014, including 3 cases investigated by DODIG, 3  cases investigated by the Army, 2 cases investigated by the Air Force, 2  cases investigated by the Navy, and 2 cases investigated by the Marine  Corps. Of those 12 cases, 11 were fully investigated and 6 were  substantiated.

After the pilot, our methodology for reviewing the randomly sampled  cases required each case to be reviewed first by one analyst and then  reviewed by a second analyst who noted any disagreement with the first  analyst’s assessment. Analysts discussed the areas of disagreement and  resolved any disagreement by identifying and reviewing supporting  documentation in the case files. Further, two GAO investigators with  professional investigative experience reviewed a portion of the sample  and concurred with the analysts’ assessment of the cases, in accordance  with CIGIE guidelines for quality-assurance reviews. We did not question  DODIG’s judgment in these cases.

To assess case-file completeness, we reviewed DODIG’s process, 10  U.S.C. § 1034, directive, and other guidance and consulted with DODIG  officials and identified 13 elements to include in our case-file review.  These 13 elements support the conclusions reached in the case, indicate  compliance with the law or directive, or manage the internal  communication not specifically outlined by law or directive. The 13  elements we included for our case file review are the following:  1.  notification to DODIG from the service IG that received the complaint,  2.  evidence supporting the recommended outcome,  4.  report of investigation or other written product,  6.  interview with servicemember,  7.  interview with responsible management official,  8.  DODIG oversight worksheet,  9.  correspondence between DODIG and the servicemember regarding  investigations taking longer than 180 days,  10. correspondence between DODIG and the Secretary of Defense  regarding investigations taking longer than 180 days,  11. record of corrective action taken,  12. correspondence between DODIG and the service IGs regarding the  final case outcome, and  13. correspondence between DOD and the servicemember regarding the  final outcome of the case.

Some of these elements included specific documents. For example, the  DODIG oversight worksheet (item 8 above) was a specific document.  Other elements could be reflected in multiple documents. For example,  the evidence supporting the recommended outcome (item 2 above) could  be in a larger report, be in a summary, or be its own document. We  determined the completeness of each case file selected in our sample  individually since not all 13 elements were necessary in every case. For  example, some of the 13 elements would only need to be present in a file  if an investigation was conducted by a service IG or was a full  investigation. We adjusted the required number of elements based on the  specific circumstances of each case and calculated completeness based  on that adjusted baseline. We categorized the case files by the average  number of elements missing for each type of case, dismissed DODIG  intakes, service IG preliminary inquiries, service IG full investigations, and  DODIG full investigations.

We also interviewed investigators and supervisors on DODIG’s oversight  team and officials at each of the service headquarters IGs. In addition, we  interviewed six field-level investigators from the Army, the Navy, and the  Air Force IGs regarding required training, available guidance, and  investigative processes, including assessing independence. We used  data provided by each of the services for cases closed in fiscal year 2014  to select investigators for interviews. We used a simple random sampling  technique to select investigators for interviews. We selected 12  investigators from the 216 investigations closed by the Army, 10  investigators from the 35 investigations closed by the Navy, and 10  investigators from the 110 investigations closed by the Air Force. Since  field-level service IG investigators typically rotate every 2 to 3 years, we  were able to contact and speak with two investigators from each service  IG. In addition, we reviewed training materials, guidance, and  requirements for investigators from DODIG and each of the service IGs  as well as their processes for assessing investigator independence. We  also attended training sessions related to conducting military  whistleblower reprisal investigations at DODIG and the Army IG as well  as 2 DODIG Administrative Investigations training symposia, which  contained sessions on whistleblower reprisal investigations, and  interviewed an official from CIGIE’s Advanced Training Institute.  Additionally, we compared DOD’s independence processes to CIGIE  quality standards for investigations and Generally Accepted Government  Auditing Standards (GAGAS).

We conducted this performance audit from April 2014 to May 2015 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.

section_title: Appendix II: General Information on Case Characteristics for Military Whistleblower Reprisal Investigations
paragraphs: This appendix provides information on the characteristics of military  whistleblower reprisal cases based on our case file review of 124 cases  closed from October 1, 2012, through September 30, 2013, as well as  data from the Department of Defense Office of Inspector General’s  (DODIG) case management system for cases closed in fiscal years 2013  and 2014.
subsections: section_title: Servicemember Characteristics for Closed Cases
paragraphs: Generally, the service affiliations of the servicemembers that alleged  reprisal did not match the overall proportions in the military population.  See figure 3 for a comparison of the servicemember population proportion  by service compared to the proportion of reprisal cases closed.

Through our file review of cases closed in fiscal year 2013, we estimate  that the majority of servicemembers filed reprisal complaints with a  service Inspector General (IG) (70 percent). Servicemembers also filed  reprisal complaints with the DODIG Hotline (23 percent) and through  Members of Congress (6 percent).

section_title: Protected Communication Characteristics
paragraphs: According to Department of Defense (DOD) Directive 7050.06, a  servicemember who makes or prepares to make a protected  communication is a whistleblower. Based on our review of case files  closed in 2013, we estimate that the primary reasons for making a  protected communication are to report allegations of a violation of law or  regulation (49 percent), abuse of authority (39 percent), or a general  communication to the IG (23 percent). Other reasons for making a  protected communication included funds or resource waste (14 percent),  public health or safety danger (11 percent,) and sexual assault (8  percent), among others. DOD officials told us that regulations cover  virtually every aspect of military life, including how to conduct personnel  ratings, so servicemembers often cite violations of regulations in their  complaints. About 40 percent of cases in our sample included a protected  communication regarding a personnel regulation violation. Figure 4 shows  the reasons servicemembers made protected communications by  frequency.

Further, based on our case file review, we estimate that the primary  authorized recipients of protected communications for cases closed in  fiscal year 2013 were the chain of command (62 percent), Inspectors  General (53 percent), and Members of Congress (18 percent). DOD  officials told us that the inclusion of the chain of command in the list of  authorized protected communication recipients has resulted in an  increase in the number of servicemembers that qualify as whistleblowers  because reporting issues to the chain of command is a standard military  procedure. Figure 5 shows the authorized recipients to whom  servicemembers made protected communications by frequency.

section_title: Unfavorable Personnel Action Characteristics
paragraphs: A whistleblower reprisal complaint must also include an allegation that an  action was taken in reprisal against a servicemember. DOD Directive  7050.06 defines reprisal as taking or threatening to take an unfavorable  personnel action, or withholding or threatening to withhold a favorable  personnel action, for making or preparing to make a protected  communication. Based on our file review of cases closed in fiscal year  2013, we estimate that the most common forms of reprisal alleged by  servicemembers were that they received a poor performance evaluation  (44 percent), disciplinary action (39 percent), or an unfavorable  assignment or reassignment (27 percent). Figure 6 shows the frequency  of the various types of personnel actions.

section_title: Reasons for Closing Cases
paragraphs: DODIG evaluates cases and generally closes them based on the answers  to four questions, which investigators use to determine whether a case  has all of the elements of reprisal. Specifically:  (1) Did the servicemember make or prepare to make a protected  communication, or was the servicemember perceived as having  made or prepared to make a protected communication?  (2) Was an unfavorable personnel action taken or threatened  against the servicemember, or was a favorable personnel action  withheld or threatened to be withheld following the protected  communication?  (3) Did the responsible management official have knowledge of  the servicemember’s protected communication or perceive the  servicemember as making or preparing to make a protected  communication?  (4) Would the same personnel action have been taken, withheld,  or threatened absent the protected communication?

Based on our review of randomly selected case files closed in fiscal year  2013, we estimate that the most common reason for closing a case was  that DODIG determined that the responsible management official would  have taken the personnel action absent the protected communication  (question 4—37 percent), which means that the servicemember’s  protected communication did not have an effect on the responsible  official’s decision to take the personnel action. DODIG also closed cases  because the servicemember did not make a protected communication  (question 1—4 percent), there was no personnel action (question 2—9  percent), or the responsible management official who took the personnel  action had no knowledge that the servicemember made or prepared to  make a protected communication (question 3—3 percent). Additional  reasons DODIG closed cases included timeliness—the servicemember  did not file a reprisal complaint within 60 days of gaining knowledge of the  personnel action—nonresponsive servicemembers, and withdrawals,   See figure 7 for DODIG’s reasons for closing  among other reasons.military reprisal cases by frequency.

Further, based on our case-file review of cases closed in fiscal year 2013,  we estimate that the service IGs closed the majority of cases in fiscal year  2013 (70 percent) after conducting a preliminary inquiry and prior to a full  investigation.

section_title: Substantiation Rates
paragraphs: Our analysis of DODIG data on military whistleblower reprisal cases  closed in fiscal year 2014 shows that DODIG substantiated 9 percent of  the cases that were fully investigated by DODIG investigators. In addition,  our analysis shows that the service IGs substantiated 6 percent of cases  that proceeded past the intake phase. DODIG officials stated that they  calculate substantiation rates by the number of cases substantiated out of  the number of cases fully investigated; however, as discussed in the  report, we are unable to report on the total number of cases fully  investigated by the service IGs because DODIG’s data were not reliable  for this purpose. As such, we report the service IGs’ substantiation rates  out of the number of cases that proceeded to further investigation after  meeting the general intake requirements—a personnel action following a  protected communication. See table 6 for fiscal year 2013 and 2014  substantiation rates.

section_title: Appendix III: Comments from the Department of Defense
subsections: section_title: GAO Comments
paragraphs: The following are GAO’s comments on the Department of Defense  Inspector General’s (DODIG) letter dated May 1, 2015, in addition to our  evaluation of agency comments on page 50.  1.  We disagree with DODIG’s statement comparing the timeliness of  its intake process because we were not able to compare the  timeliness of cases by case type in our 2012 report with this report  due to DODIG data limitations. Specifically, in our 2012 report, we  found that DODIG’s data were not reliable for the purposes of  reporting investigation lengths and therefore used sample data to  report the timeliness of cases DODIG closed between January 1,  2009 and March 31, 2011. We reported on the number of cases  closed before full investigation and cases that were full  investigations, which we determined by reviewing the case file  documentation. In this report, we found DODIG’s timeliness data  reliable for our purposes of reporting the average lengths of  investigations; however, we were not able, using DODIG’s data, to  distinguish between the number of cases that were fully  investigated by the service IGs and the number of cases that the  services closed with some investigative work, but prior to a full  investigation. DODIG’s data were not reliable for these purposes  due to DODIG coding errors.  2.  We disagree with DODIG’s statement that it met statutory  notification requirements in the majority of closed cases because it  did not always meet those requirements. Specifically, in 2012, we  found that DOD had stopped providing any notifications to  servicemembers. In 2015, we found that DOD notified  servicemembers about the status of investigations that took longer  than 180 days in an estimated 53 percent of the cases that  required notification. In those instances where the letters were  provided to servicemembers, we estimated that DOD’s median  notification time was on average 353 days after the  servicemember filed the complaint, almost twice as long as the  180-day requirement. We acknowledge that DOD’s decision to  reestablish the practice of sending 180-day notification letters is a  positive step; however, we continue to believe that notifying  servicemembers about half of the time is not in accordance with  statutory requirements and that DOD should send the letters  within 180 days of receipt of an allegation of reprisal, not on  average of 353 days after receipt.   3.  We disagree with DODIG’s statements regarding our  characterization of its case management system, because we  concluded that DODIG does not have complete oversight of all  service reprisal investigations. Specifically, a large amount of  detailed information about the cases, such as investigative events,  resides in the services’ case management systems. Further, we  found that DODIG’s system did not have record of at least 22  percent of service investigations both open as of September 30,  2014, and closed in fiscal years 2013 and 2014. DODIG is  responsible for the oversight of these cases. In addition, we  believe that DODIG’s agile development of the case management  system—and the large gaps between development phases—may  be the cause of some of the issues we found. DODIG officials told  us that the length between phases of development was longer  than originally intended by DODIG, and the system still needs to  refine some of its capabilities, such as aggregating and extracting  data for reporting purposes. DODIG intended to complete the  system in February 2014 and still has not done so over a year  later.

Further, we found that DODIG made changes to its data in March  and April of 2014, after it was notified of our audit. We believe that  DODIG should have been making sure its data were reliable on an  ongoing basis. DODIG also stated that we did not address its  approaches for ensuring data reliability; however, we did include a  discussion of some of these approaches in our report, such as its  dashboards to identify errors, and its quarterly quality assurance  processes, on pages 24 and 37. Finally, DODIG listed system  capabilities, such as the ability to track overall case age, which we  incorporated into the report and about which we noted limitations  where relevant.  4.  We disagree with DODIG’s statements regarding feedback it  provides to service IG investigators because DODIG’s Council of  the Inspectors General on Integrity and Efficiency (CIGIE)  trainings do not reach all field-level investigators, as we stated in  our report. In addition, the sample case-closure memorandum that  DODIG provided to us did not contain such criteria. Further, in our  report, we define the criteria against which DODIG oversight  investigators assess service IG investigator independence.  However, we found that in the absence of interview transcripts,  which were present for servicemember interviews in only 43  percent of cases closed in fiscal year 2013, oversight investigators  have limited tools to determine whether the investigator  demonstrated IG impartiality during interviews.   5.  We disagree with DODIG’s comment that we did not include  information related to DODIG’s progress since 2012 because we  addressed DODIG’s stated improvements on the following pages  in our report: (1) DODIG’s staffing increases, p. 19; (2) new case  management system, p. 21; (3) data clean-up to ensure data  reliability, p. 25; (4) issuance of policy guidance to the service IGs  regarding the 180-day notification requirements, p.11; (5)  Administrative Investigations manual, pp. 42; (6) issuance of  October 2014 military whistleblower reprisal investigations guide,  p. 38; and (7) reissuance of DOD Directive 7050.06. The directive  was issued on April 17, 2015, after we sent our draft report to  DOD for agency comments, and we incorporated it into our final  report as necessary, p. 52. However, the directive dated July 2007  was in place during the scope of our review and, as such, we used  it for criteria where applicable.

section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Lori Atkinson (Assistant Director),  James Ashley, Tracy Barnes, Gary Bianchi, Molly Callaghan, Sara  Cradic, Cynthia Grant, Robert Graves, Christopher Hayes, Erica Reyes,  Mike Silver, Amie Steele, and Erik Wilkins-McKee made significant  contributions to this report.

section_title: Related GAO Products
paragraphs: Whistleblower Protection: Additional Actions Needed to Improve DOJ’s  Handling of FBI Retaliation Complaints. GAO-15-112. Washington, D.C.:  January 23, 2015.

Whistleblower Protection Program: Opportunities Exist for OSHA and  DOT to Strengthen Collaborative Mechanisms. GAO-14-286.  Washington, D.C.: March 19, 2014.

Whistleblower Protection: Actions Needed to Improve DOD’s Military  Whistleblower Reprisal Program. GAO-12-362. Washington, D.C.:  February 22, 2012.

Tax Whistleblowers: Incomplete Data Hinders IRS’s Ability to Manage  Claim Processing Time and Enhance External Communication.   GAO-11-683. Washington, D.C.: August 10, 2011.

Criminal Cartel Enforcement: Stakeholder Views on Impact of 2004  Antitrust Reform Are Mixed, but Support Whistleblower Protection.   GAO-11-619. Washington, D.C.: July 25, 2011.

Whistleblower Protection: Sustained Management Attention Needed to  Address Long-Standing Program Weaknesses. GAO-10-722.  Washington, D.C.: August 17, 2010.

Defense Contracting Integrity: Opportunities Exist to Improve DOD’s  Oversight of Contractor Ethics Programs. GAO-09-591. Washington,  D.C.: September 22, 2009.

Whistleblower Protection Program: Better Data and Improved Oversight  Would Help Ensure Program Quality and Consistency. GAO-09-106.  Washington, D.C.: January 27, 2009.

Justice and Law Enforcement: Office of Special Counsel Needs to Follow  Structured Life Cycle Management Practices for Its Case Tracking  System. GAO-07-318R. Washington, D.C.: February 16, 2007.

U.S. Office of Special Counsel: Strategy for Reducing Persistent Backlog  of Cases Should Be Provided to Congress. GAO-04-36. Washington,  D.C.: March 8, 2004.

The Federal Workforce: Observations on Protections From Discrimination  and Reprisal for Whistleblowing. GAO-01-715T. Washington, D.C.: May  9, 2001.

Whistleblower Protection: VA Did Little Until Recently to Inform  Employees About Their Rights. GAO/GGD-00-70. Washington, D.C.: April  14, 2000.


Question-summary annotations: questions: question: What requirements did the DOD fail to meet in 2013?
answer: The Department of Defense (DOD) did not meet statutory military whistleblower reprisal 180-day notification requirements in about half of reprisal investigations closed in fiscal year 2013, and DOD's average investigation time for closed cases in fiscal years 2013 and 2014 was 526 days, almost three times DOD's internal 180-day requirement.
child_questions: question: What steps did DOD take to address this after GAO's 2012 report?
answer: In 2012, GAO made recommendations to improve investigation timeliness, and DOD has taken some actions to address those recommendations.
child_questions: question: What data did GAO find indicating DOD's failure to address internal issues?
answer: However, based on a random sample of 124 cases, GAO estimated that there was no evidence that DOD sent the required notification letters in about 47 percent of the cases that DOD took longer than 180 days to close in fiscal year 2013. For cases in which DOD sent the required letter, GAO estimated that the median notification time was about 353 days after the servicemember filed the complaint, and on average the letters significantly underestimated the expected investigation completion date.

question: What could DOD do to address these issues?
answer: DOD does not have a tool, such as an automated alert, to help ensure compliance with the statutory notification requirement to provide letters by 180 days informing servicemembers about delays in investigations. Without a tool for DOD to ensure that servicemembers receive reliable, accurate, and timely information about their investigations, servicemembers may be discouraged from reporting wrongdoing.

questions: question: What limits DODGI's ability to provide oversight?
answer: DOD's Office of Inspector General's (DODIG) newly developed case management system, which it established to improve monitoring, is separate from the service IGs' systems, limiting DODIG's ability to provide oversight of all military reprisal investigations.
child_questions: question: What issues did GAO find with DODIG's case management system?
answer: GAO found that DODIG's system did not have a record of at least 22 percent of service-conducted reprisal investigations that were closed in fiscal years 2013 and 2014 and investigations open as of September 30, 2014.

question: How does DOD plan to improve DODIG's case management system?
answer: DODIG officials stated that they plan to expand DODIG's case management system to the service IGs by the end of fiscal year 2016 to improve DODIG's visibility over investigations.
child_questions: question: What issues did GAO find with DOD's plans for the expansion?
answer: However, DODIG does not have an implementation plan for the expansion, and service IG officials stated that they have unique requirements that they would like to have incorporated into the system prior to expansion.
child_questions: question: What issues might the lack of an implementation plan cause?
answer: Expanding the case management system to the service IGs without developing an implementation plan that, among other things, addresses the needs of both DODIG and the service IGs, puts DOD at risk of creating a system that will not strengthen its oversight of reprisal investigations.

questions: question: What does DOD lack formalized processes for?
answer: DOD does not have formalized processes to help ensure effective oversight of military whistleblower reprisal investigations conducted by service IGs.
child_questions: question: How has DODIG failed to ensure thorough documentation?
answer: DODIG established an oversight investigator team to review service IG investigations, but it has provided oversight investigators with limited guidance on how to review or document service IG investigations. Specifically, GAO estimated that for about 45 percent of service investigations closed in fiscal year 2013, the oversight worksheets were missing narrative to demonstrate that the oversight investigator had thoroughly documented all case deficiencies or inconsistencies.

question: What details does DOD's documentation lack?
answer: GAO also found that these files did not include documentation of DOD's analysis of the effect of noted deficiencies on the investigation's outcome because DOD has provided limited instruction on how to review service IG cases.

question: What issues might a lack of additional guidance cause?
answer: Without additional guidance on oversight review procedures and documentation requirements to formalize the oversight process, it will be difficult for DOD to ensure that reprisal complaints are investigated and documented consistently.

questions: question: Why are whistleblowers important?
answer: Whistleblowers play an important role in safeguarding the federal government against waste, fraud, and abuse.
child_questions: question: How are whistleblowers expected to report wrongdoing?
answer: However, reporting wrongdoing outside the chain of command conflicts with military guidance, which emphasizes using the chain of command to resolve problems.

question: What risks do whistleblowers take in reporting wrongdoing?
answer: Whistleblowers who make a report risk reprisal from their unit, such as being demoted or separated.

question: How does DODIG protect whistleblowers?
answer: DODIG is responsible for conducting and overseeing military whistleblower reprisal investigations.

question: What was GAO asked to examine?
answer: GAO was asked to examine DOD's oversight of military whistleblower reprisal investigations.