Defense Department investigators examining accidental shipments of live anthrax from a U.S. Army lab in Utah to facilities in eight countries did not pinpoint a single reason that the facility shipped live samples of the deadly virus over a span of 12 years.

Instead, the investigation found that procedural errors at Dugway Proving Ground likely caused the problem, from the process designed to kill the live spores to the process designed to ensure they were were dead, according to a report released Thursday.

In a Pentagon news conference Thursday, Deputy Defense Secretary Bob Work said the review found that of the four DoD labs that handle anthrax, Dugway's procedures, which differed from those used at the other sites, "didn't work."

"This was a massive institutional failure with a potentially deadly biotoxin," Work said.

Since 2003, DoD labs have handled 149 batches of live anthrax and reported them as inactivated. According to Work, 53 are no longer in the DoD inventory, and defense officials have instructed any facility with samples from those batches to destroy them.

DoD then tested samples from the 96 remaining batches, and found that 17 — half of 33 three batches produced at Dugway — tested positive for live spores.

"Obviously, when over half of those batches were proved to contain live spores, we have a major problem," Work said.

The report found that no individual or individuals are to blame, and said employees followed the established protocols at Dugway.

But investigators added that Dugway's procedures were flawed, to include improper irradiation, poor sampling to test verification and too short a timeframe between irradiation and verification, all of which combined to allow live samples to slip through.

Each military lab developed its own procedures for handling the anthrax, Work said, and all seem to be following those procedures.

Work said the lack of a standard scientific protocol for inactivating and testing anthrax remains a key concern.

DUGWAY, UT - MAY 28: A car approaches the main gate of the Dugway Proving Ground on May 28, 2015 in Dugway, Utah. According to reports from the Army, that it mistakenly shipped live Anthrax to several government and commercial labs in the U.S. and Korea. Dugway is a highly secure and secret military testing lab in the middle of the Utah desert. (Photo by George Frey/Getty Images

A car approaches the main gate of the Dugway Proving Ground on May 28, 2015, in Dugway, Utah.

Photo Credit: George Frey/Getty Images

Processing of anthrax at Dugway has been on hold since the problem was discovered in late May. Defense Secretary Ash Carter has ordered the Department of the Army to conduct an investigation into accountability at Dugway and draft a plan for implementing recommendations made by the investigative committee.

The investigation, led by Under Secretary of Defense for Acquisition, Technology and Logistics Frank Kendall, made several recommendations to improve the process, to  include: establishing standard operating procedures for handling anthrax; reviewing biosafety policies and protocols; and more closely tracking the irradiation and verification procedures.

The problem was discovered May 22 when an employee at a civilian research lab managed to cultivate live anthrax from a shipment of supposedly dead spores shipped from Dugway.

According to the Pentagon, 86 labs in 20 states and the District of Columbia, as well as facilities in the United Kingdom, South Korea, Australia, Canada, Japan, Italy and Germany, received the live samples.

Work said the numbers may grow as the Centers for Disease Control and Prevention continues to investigate shipments of the DoD-made samples between civilian laboratories.

Pentagon officials have said the general public remains at "zero risk" for exposure, since the samples were boxed and shipped carefully in liquid form in low concentrations, rather than the more lethal dry spores.

No one has developed anthrax as a result of the mishap.

DoD distributes anthrax to commercial, academic and government facilities to be used in research and to calibrate biological weapons sensors.

Following release of the report, the House Armed Services Committee issued a statement saying lawmakers are "dissatisfied with the timeliness and the level of detail in this report."

"The report has few meaningful explanations and fails to answer important questions," said committee spokesman Claude Chafin. "In the end, this reads like a report that spent more time getting scrubbed in the E-Ring ( of the Pentagon) than investigated in the field."

Work said DoD will move quickly to improve the processes for manufacturing and monitoring all biological agents in its stockpiles.

"We are shocked by these failures," he said. "We are implementing changes … that will prevent such a biohazard safety failure from ever happening again."

Army Secretary John McHugh said he was troubled by the report's findings and pledged to work with DoD and the Navy to ensure facility safety.

McHugh "immediately ordered that a corrective plan be developed and an investigation be conducted to determine whether there were any failures of leadership," said Col. David Doherty, an Army spokesman.

About Patricia Kime

Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.

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