In October 2013, Army Captain William Swenson received the Medal of Honor for actions in combat in September of 2009, during which he risked death repeatedly to recover wounded and dead comrades. While a Marine involved in the same incident also received a Medal of Honor in 2011, Swenson’s actions would go unrecognized in any form for four years—because the recommendation package had disappeared, and no one had any record of where it had gone.

It turns out that Swenson’s original recommendation, which by Defense Department recommendations should have been forwarded up the chain of command to the President as quickly as possible, got lost in e-mail at the headquarters of the Commander of US Forces Afghanistan (USFOR-A), shortly after it passed through the hands of then-USFOR-A commander Gen. David Petraeus. It would take the actions of a Marine—General John Allen—to revive the recommendation after Petraeus departed Kabul for his short-lived tenure as Director of the Central Intelligence Agency.

After Allen revived Swenson’s recommendation in 2011, an internal investigation at USFOR-A failed to uncover the fate of the original. Some said that Petraeus or others in the chain of command intentionally buried Swenson’s paperwork out of spite—an accusation that triggered a DOD Inspector General’s investigation.

The findings of that investigation, completed last October but just made public this week, pointed not to malice, but incompetence—and some classically bad information technology moves. And Swenson wasn’t the only soldier to get caught in what was, according to testimony to the IG’s investigation team, the sort of snafu-storm that the military is famous for.

The IG report’s final finding was that no one had intentionally blocked Swenson’s award. But the investigators found that the team at USFOR-A responsible for awards “had inadequate systems and unreliable processes, which may have contributed to the failure to fully process CPT Swenson's MoH recommendation.”

If Petraeus did intentionally lose Swenson’s recommendation in e-mail, it would be ironic given how the e-mails that he didn’t delete would come back to haunt him just two years later while he was Director of the Central Intelligence Agency. While Swenson, who had left the Army in 2011, expressed disappointment at the findings, he accepted them enough to receive his Medal of Honor—and has since returned to active duty.

Packets, paper, and PowerPoint

Swenson, who was assigned to the Army’s 10th Mountain Division, was attached to Task Force Chosin in Afghanistan, serving as part of a joint Army-Marine Corps team for training and advising Afghan Border Police troops. On September 8, 2009, Swenson was attached to a unit of Afghan National Security Forces (ANSF) troops as part of Operation Buri Booza II (Dancing Goat II)—an attempt to establish connections between the ANSF and local leaders in the valley of Ganjal Gar near the Pakistani border. The unit, which consisted of 104 troops from the Afghan National Army and the Afghan Border Police, as well as a small group of Marine and Army advisors, was ambushed as it entered a village. Swenson held off attackers with a grenade as he was performing first aid on one comrade and then exposed himself to fire repeatedly to recover wounded and dead American and Afghan troops.

After the battle, both Swenson and Marine Sergeant Dakota Meyer were recommended by their unit commanders for the Medal of Honor.

When it was originally submitted in December of 2009, Swenson’s Medal of Honor recommendation was sent as a collection of documents attached to a digitally signed e-mail from Task Force Chosin to the command group at Combined Joint Task Force 82 at Bagram Air Base. But the Army is not exactly an organization that has embraced digital workflows.

At each intervening echelon of the chain of command—just as with many bureaucratic processes in the Army—the documents were printed out for staff review, marked up on paper, and then optically scanned to be sent to the next echelon of command. (In my personal experience dealing with Army general officers, the ones I encountered never read e-mail on-screen—they had an administrative assistant print it out and put it in their physical in-box.)

After scanning, the hard copy would generally be shredded—since it often included classified information about operations, as well as personal information about those nominated. As a result, the electronic ghost of the hardcopy became the only archive of the process. And given that in 2010 the Army’s e-mail systems were a fragmented mess, there was no guarantee that anything could ever be recovered from them. Often, units track the status of awards recommendations in desktop databases, spreadsheets, or even PowerPoint charts.

By the summer of 2010, after bouncing back and forth for a few months for administrative reasons, Swenson’s recommendation arrived at the next level of command—USFOR-A headquarters. But the USFOR-A commander at that time, Gen. Stanley McChrystal, never had a chance to review the recommendation—he was called back to the White House and fired in June, after his controversial Rolling Stone profile hit the fan. Gen. Petraeus would be sent in to replace him in July.

The Kabul Triangle

At USFOR-A headquarters, the award vetting process (or what passed for a process) was supposed to work like this:

The award recommendation would come in via a shared e-mail box on the command’s secret-classified Exchange server in Kabul. A number of people had access to the mailbox, and would move the incoming messages for processing to their own mailboxes. The package would be printed out, put into a binder, and delivered to the deputy commander for support (at that time, Major General Timothy McHale), and then shuttled over to the commander (Petraeus). At each step through processing, the status of each awards package was supposed to be entered into an “awards tracker” database—a Microsoft Access database stored on the USFOR-A headquarters local network.

After being marked up, the binders would then be re-scanned, and their electronic versions e-mailed to another awards shared mailbox at US Central Command (CENTCOM). The date they were forwarded would be added to the Access database. The whole vetting process would be repeated again at CENTCOM, before the documents were forwarded to the Army’s Human Resources Command (and eventually, via the Chief of Staff of the Army, to the President).

Part of the problems in processing award recommendations came from how they were submitted, which was a haphazard and inconsistent process. Repeated printing and scanning caused hold-ups in the process. McHale told the IG investigation team that “some units submitted electronic copies, others used hard copies, and they often used the wrong endorsement chain. He also questioned the skills of some of the J-1 personnel.” McHale also recalled “instances when he had to ask the J-1 to ‘re-do’ awards because the multiple scans and reprints at each echelon reduced legibility,” according to the IG report.

According to the Access “awards tracker” database, Swenson’s award recommendation came into the USFOR-A J-1 office on June 21, 2010. It was put in front of McHale on July 3, and then sent to Petraeus on July 27—at the same time, in each instance, that another Medal of Honor recommendation for then-Specialist Ty Carter was being passed for review (though Petraeus told investigators he had no recollection of reviewing Swenson’s recommendation). The database also showed that Petraeus had recommended Swenson’s award be downgraded to an Army Distinguished Service Cross.

That decision was clearly communicated back down the chain of command. A series of PowerPoint charts tracking valor awards being kept by the J-1 staff at Combined Joint Task Force 101—which relieved CJTF-82 at Bagram shortly after Swenson’s recommendation was sent upstream—showed that in August of 2010, word had been received back from USFOR-A that Swenson’s award was “downgraded to a [Distinguished Service Cross]. USFOR-A is currently out of certificates but will process and return ASAP.”

But other than the database entries—which marked Swenson’s award as “complete” but had no date for transmittal to CENTCOM—there was no record of any of that information in USFOR-A’s J-1 office. While one staffer insisted that Swenson’s information had been forwarded to CENTCOM, there was no record of an e-mail being received by CENTCOM’s mailbox.

Another wrinkle in the investigation was that there was no trace, electronic or printed, of the award review—probably because all e-mail records of any awards activity had been lost in 2012. That’s because the messages were stored locally on computers in Outlook .pst files—and those files were deleted off of systems during a 2012 operating system update.

Situation normal…

Swanson wasn’t the only soldier affected by the snafus in the system. During the investigation, the DOD IG investigating officer found that most of the records associated with medal award recommendations before 2012 had been lost. A soldier assigned to the USFOR-A J-1 awards section testified that “USFOR-A lost awards ‘all the time,’" according to the DOD IG report:

[She] testified that when she arrived [at USFOR-A], there was a “huge backlog" and “it was a really ugly few weeks when we first got there, trying to get a handle on all the decorations that folks thought we had, that we had no record of obtaining.” She explained the [Access] database was outdated. She did not trust it and initially did not use it. She told us units frequently asked about awards and “every time we looked anything up (in the database), it was incorrect.” We asked [her] if awards ever got lost, and she said “Oh, yes sir.” She told us a unit would call and the database would indicate processing was complete, but she would search the computer drives and find only "bits and pieces." She testified they eventually began to use the database after they learned how to use it.

Another person who served at USFOR-A said that there were no standard operating procedures when she arrived:

…and likened the situation to “cowboys and Indians.” She told us they “absolutely” lost some awards. [She] testified that when she arrived there was a “huge backlog of awards” and no proper organization, staffing, processes, procedures, or tracking mechanisms. She said it was “such a mess” and took months “before we event got that a little bit under control.”

The problems with the process continued long after Swenson’s recommendation had been reconstructed and re-submitted. An officer with Combined Joint Task Force 1 told investigators that he continued to have problems in 2011 with USFOR-A losing award packages. “It got the point where we were having so many awards that were being misplaced, lost, whatever you want to call it, that I made them CC me on the e-mails they sent up,” he told investigators, so that he would have a record of the submission of every award recommendation package.