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TABLE OF CONTENTS
I. (U) BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
A. (U) Administrative Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1. (U) Appointing Authority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. (U) Brief Description of the Incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
B. (U) Constraints and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
C. (U) Format of the Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
II. (U) ATMOSPHERICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
A. (U) Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
B. (U) Local Security Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1. (U) Iraq . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2. (U) Baghdad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3. (U) Route Irish . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
C. (U) Known Insurgent Tactics, Techniques, and Procedures . . . . . . . . . . . . . . 5
1. (U) Methods of Attack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2. (U) Insurgent TTPs for IEDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3. (U) Insurgent TTPs for VBIEDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
4. (U) Effectiveness of Attacks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
D. (U) Recent Incidents in the Vicinity of Checkpoint 541 . . . . . . . . . . . . . . . . . . 8
E. (U) Unit Experience in the Baghdad Area of Responsibility . . . . . . . . . . . . . . . 8
1. (U) Third Infantry Division . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2. (U) Second Brigade, 10th Mountain Division . . . . . . . . . . . . . . . . . . . . . . . . . 9
3. (U) 1-69 Infantry Battalion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
4. (U) 1-76 Field Artillery Battalion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
F. (U) Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
III. (U) TRAFFIC CONTROL POINTS, BLOCKING POSITIONS,
AND TRAINING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
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A. (U) Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
B. (U) Traffic Control Points and Blocking Positions . . . . . . . . . . . . . . . . . . . . . 12
C. (U) Standing Operating Procedures in use on 4 March 2005 . . . . . . . . . . . . . 12
1. (U) Doctrinal Discussion of TCPs and Roadblocks . . . . . . . . . . . . . . . . . . . 13
2. (U) 3ID TCP SOP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3. (U) 2/10 MTN TCP SOP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
4. (U) 1-69 IN TCP SOP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
5. (U) Rhino Bus Run TTP Background Information . . . . . . . . . . . . . . . . . . . 17
D. (U) Training of BP 541 Soldiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
E. (U) Rules of Engagement Training Received by BP 541 Soldiers . . . . . . . . . . 19
F. (U) Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
G. (U) Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
IV. (U) THE INCIDENT AT BP 541 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
A. (U) Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
B. (U) Site Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
C. (U) Personnel Involved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
D. (U) The Mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
1. (U) Receipt of the Mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2. (U) Establishing the Blocking Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3. (U) The Duties of the Soldiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4. (U) Communications Regarding the Mission Duration . . . . . . . . . . . . . . . . 28
E. (U) The Incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
F. (U) Post-Incident Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
G. (U) Forensic Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
1. (U) 5 March 2005 Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2. (U) 11 March 2005 Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3. (U) 14 March 2005 Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4. (U) BP 541 Traffic Samples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
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5. (U) Number of Rounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
H. (U) Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
I. (U) Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
V. (U) COORDINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
A. (U) Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
B. (U) MNF-I/MNC-I Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
C. (U) Captain Green . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
D. (U) Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
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I. BACKGROUND
A. (U) Administrative Matters
1. (U) Appointing Authority
(U) I was appointed by LTG John R. Vines, Commander, Multi-National Corps-Iraq (MNC-I) on 8 March 2005 to investigate, per U.S. Army Regulation 15-6 (Annex 1B), all the facts and circumstances surrounding the incident at a Traffic Control Point (TCP) in Baghdad, Iraq on 4 March 2005 that resulted in the death of Mr. Nicola Calipari and the wounding of Ms. Giuliana Sgrena and Mr. Andrea Carpani. Lieutenant Colonel Richard Thelin, USMC was appointed as my legal advisor for this investigation. I was directed to thoroughly review (1) the actions of the Soldiers manning the TCP, (2) the training of the Soldiers manning the TCP, (3) TCP procedures, (4) the local security situation, (5) enemy tactics, techniques, and procedures (TTPs), (6) the Rules of Engagement (ROE) employed during the incident, and (7) any coordination effected with the Soldiers at the TCP or their higher levels of command on the transport of Ms. Sgrena from Baghdad to Baghdad International Airport (BIAP). (Annex 1A).
(U) The appointing letter (Annex 1A) refers to the location of the incident as being a Traffic Control Point (TCP). As will be further explained in this report, the Soldiers involved were actually manning a former Traffic Control Point, but executing a blocking mission. This mission took place at a southbound on-ramp from Route Vernon (also known as Route Force on MNF-I graphics) onto westbound Route Irish, the road to BIAP. The intersection of these two routes has been designated as Checkpoint 541. For purposes of this report, the position will be referred to as Blocking Position 541 (BP 541).
2. (U) Brief Description of the Incident
(U) On the evening of 4 March 2005, personnel of A Company of 1-69 Infantry (attached to 2d Brigade Combat Team, 10th Mountain Division), were patrolling Route Irish, the road linking downtown Baghdad with BIAP. Seven of those Soldiers were then assigned the mission of establishing and manning a Blocking Position (BP) on the southbound on-ramp off Route Vernon to westbound Route Irish. They were to man the BP until relieved, which was anticipated to be after a convoy transporting the U.S. Ambassador to Camp Victory had passed and arrived at its destination.
(U) The Soldiers established the BP by approximately 1930 hours and began executing their mission. At approximately 2050 hours, the car carrying Mr. Calipari, Mr. Carpani, and Ms. Sgrena, traveling southbound on Route Vernon, approached the on-ramp to enter westbound Route Irish. For reasons that are examined later in this report, the car came under fire. The shooting resulted in the wounding of the driver (Mr. Andrea Carpani), and Ms. Sgrena, and the death of Mr. Nicola Calipari. The Commanding
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General, Third Infantry Division directed a commander’s inquiry/preliminary investigation be conducted that night.
B. (U) Constraints and Limitations
(U) Ideally, the scene of the incident would have been preserved as it existed immediately after the shooting was over and the car had stopped. Doing so would have allowed the initial investigators to get precise measurements on the distances and locations of the significant objects involved in the event. An initial on-site investigation was conducted, but a number of circumstances that occurred on the site prevented the incident site from being treated as a sterile site. Both HMMWVs involved in the blocking position were moved to transport Ms. Sgrena to the Combat Support Hospital in the International Zone. Further, the scene was not deemed to be a crime scene, and efforts were made to clear the roadway. As a result, the car was moved from its position, per the unit’s Standing Operating Procedure on Consequence Management, before a location using a global positioning system could be obtained. At the direction of the Commander, 2d Brigade, 10th Mountain Division the car was placed back in the position that was thought to be its actual stopping point based on eyewitness testimony and digital photographs taken of the car before its initial removal from the scene.
(U) A further constraint was the inability to reconstruct the event so as to provide accurate data for forensic analysis of bullet trajectory, speed of the vehicle, and stopping distance due to the inherent danger in the vicinity of the incident location. This was made evident during a site visit by the Joint Investigation Team when a hand grenade was thrown (from the Route Vernon overpass) at the Team’s vehicles as members were boarding, injuring one Soldier.
(U) These factors limited the forensic team’s ability to conduct an on-site, in-depth analysis, although extensive tests were performed on Camp Victory. As a result, the forensic studies of the car could not be as conclusive as they normally would be.
(U) Other limitations include the removal and disposal of the shell casings to allow free operation of the turret in the blocking vehicle. Additionally, the cell phones involved in the incident were returned to Mr. Carpani before he left the scene. (Annex 4M). More importantly, while sworn statements were provided by all the key U.S. personnel involved in the incident, the Italian personnel provided only unsworn statements as they are not required under Italian law to swear to statements until appearing before a judge.
C. (U) Format of the Report
(U) This report is divided into five sections; (1) Background, (2) Atmospherics, including a historical overview of attacks along Route Irish and prevailing enemy Tactics, Techniques, and Procedures (TTPs), (3) Discussion of TCP and BP tactical
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missions and training received by BP 541 personnel, (4) Events and actions at BP 541 on the evening of 4 March 2005, and (5) Coordination effected pertaining to the hostage recovery. Each section will review the pertinent facts, set forth findings, and, as appropriate, provide recommendations for future action. Additionally, documentary evidence used in preparing this report is included in annexes.
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II. ATMOSPHERICS
A. (U) Introduction
(U) This section examines the local security situation as of 4 March 2005, known insurgent Tactics, Techniques, and Procedures (TTPs), and recent events occurring in the vicinity of Checkpoint 541. The previous experience of the Soldiers manning the BP that night, their parent unit, and their higher headquarters units in the Baghdad Area of Responsibility (AOR), is also examined. The purpose of this section is to present a full picture of the conditions facing the Soldiers manning BP 541 that night.
B. (U) Local Security Situation
1. (U) Iraq. From July 2004 to late March 2005, there were 15,257 attacks against Coalition Forces throughout Iraq. The U.S. considers all of Iraq a combat zone. (Annex 8E).
2. (U) Baghdad. Baghdad is a city of six million people and is home to a large number of suspected insurgents and terrorists operating both in the city and its environs.
(S//NF) From 1 November 2004 to 12 March 2005 there were a total of 3306 attacks in the Baghdad area. Of these, 2400 were directed against Coalition Forces. (Annex 8E)
3. (U) Route Irish. Route Irish is an East-West road along south Baghdad. It is approximately 12 kilometers long and runs from the International Zone in downtown Baghdad to BIAP. The highway is a four-lane road with a 50 meter wide median. (Annexes 8E, 144K).
(U) Route Irish has six major intersections. Each of these has been assigned a corresponding checkpoint number by Coalition Forces to facilitate command and control. Entry Control Point 1 (ECP 1) is located at one end of the highway near BIAP. Checkpoints 539-543 follow the road east going into downtown. (Annex 141K).
(U) Checkpoint 541 refers to the intersection of Route Irish with Route Vernon (also known as Route Force), which runs North-South. (Annex 142K).
(U) Route Irish is commonly referred to as “the deadliest road in Iraq” by journalists, Soldiers, and commanders. There is no corresponding alternative route from downtown Baghdad (and the International Zone) to BIAP, which gives the route a heavy traffic flow and causes Coalition convoy movement to become more predictable. These conditions make Route Irish a lucrative target area for insurgents to employ improvised explosive devices (IEDs) of varying types and to achieve effects in terms of casualties. Soldiers in 1st Cavalry Division and 3d Infantry Division have come to refer to Route Irish as “IED Alley.” (Annex 8E).
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(S//NF) Between 1 November 2004 and 12 March 2005, there were 135 attacks or hostile incidents that occurred along Route Irish. These included 9 complex attacks (i.e., a combination of more than one type of attack, e.g., an IED followed by small arms fire or mortars), 19 explosive devices found, 3 hand grenades, 7 indirect fire attacks, 19 roadside explosions, 14 rocket propelled grenades (RPGs), 15 vehicle borne explosive devices, and 4 other types of attacks. (Annexes 1E, 8E).
(S//NF) The attack density for the period 1 November 2004 to 12 March 2005 is 11.25 attacks per mile, or a minimum of one attack per day along Route Irish since November. (Annex 8E).
(S//NF) The highest concentration of IED attacks occurs at 1000 hours, with the second highest concentration of attacks occurring at 1600 hours. These times correspond to convoys departing from or arriving at the Victory Base complex, the largest Coalition military facility in Baghdad. (Annex 5E).
(S//NF) Approximately 66 percent of all night time attacks along Route Irish occur between the hours of 1900 and 2100. (Annex 8E). The incident at BP 541 occurred between 2030 and 2100 hours on 4 March 2005.
(U) The majority of IED and VBIED attacks occur in and around three overpasses (CP 540, CP 541, and CP 543) and the turnoff to the International Zone. As mentioned earlier, CP 541 is the location where the incident occurred on 4 March 2005. (Annex 3E).
C. (U) Known Insurgent Tactics, Techniques, and Procedures
1. (U) Methods of Attack
(U) Insurgent attacks throughout the Iraqi Theater of Operation fall into one of several categories, all of which have occurred along Route Irish in the past year. They include:
Improvised Explosive Devices (IEDs), Unexploded IEDs, Hand Grenades, Indirect Fire (mortars, rockets, and unidentified indirect fire), Rocket-Propelled Grenades (RPGs), Small Arms Fire (SAF), Vehicle-Borne Improvised Explosive Devices (VBIEDs), and Complex Attacks. The most common attacks along Route Irish are IEDs, VBIEDs, and SAF. (Annex 8E).
2. (U) Insurgent TTPs for IEDs
(U) A large number of evolving techniques have been adopted by the insurgents in placing IEDs along Route Irish. Examples of currently used techniques are listed below:
• (S//NF) Explosives positioned alongside guard rails. The large number of guard rails on the road make these devices difficult to detect and relatively
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easy to emplace by staging equipment in vehicles or near overpasses, and, in a matter of minutes, having the IED armed and in the desired location.
• (S//NF) Explosives wrapped in a brown paper bag or a plastic trash bag. This is a particularly easy method of concealment, easy to emplace, and has been used effectively against Coalition Forces and civilians along Route Irish.
• (S//NF) Explosives set on a timer. This technique is new to the Route Irish area, but is being seen more frequently.
• (S//NF) Use of the median. The 50 meter wide median of Route Irish provides a large area for emplacing IEDs. These can be dug in, hidden, and/or placed in an animal carcass or other deceptive container.
• (S//NF) Surface laid explosives. The enemy will drop a bag containing the explosive onto the highway and exit the area on an off-ramp with the detonation occurring seconds or minutes later depending on the desired time for the explosion.
• (S//NF) Explosives on opposite sides of the median. Devices have been found along both sides of the median that were apparently designed to work in tandem, to counter Coalition Force tactics to avoid the right side of the highway while traveling Route Irish.
• (S//NF) Explosives hidden under the asphalt. Insurgents pretend to do work on the pavement, plant the explosives, and repair the surface. These are usually remote-detonated devices.

(Annex 11E).
3. (U) Insurgent TTPs for VBIEDs
(U) There are two basic types of car bombs, i.e., suicide (where the car is moving) and stationary (where the car is parked). Both can be either command or remote-detonated. (Annex 8E).
(S//NF) The enemy is very skillful at inconspicuously packing large amounts of explosives into a vehicle. The most commonly used detonation materials are plastic explosives and 155mm artillery shells. When moving, these VBIEDs are practically impossible to identify until it is too late. (Annex 8E).
(U) The techniques for employing VBIEDs continue to evolve. Some of the more commonly used techniques include:
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• (S//NF) Multiple suicide vehicles. The first vehicle either creates an opening for a second, more powerful vehicle, or acts as bait to draw other personnel, such as medics and other first responders, into the kill zone of the first vehicle. As people respond, the second VBIED engages the responders.
• (S//NF) Suicide VBIEDs are typically used against convoys, Coalition Force patrols, or Coalition checkpoints where they can achieve maximum damage. Such vehicles will rapidly approach the convoy from the rear and attempt to get in between convoy vehicles before detonating.
• (S//NF) Stationary VBIEDs are typically parked along main supply routes, like Route Irish, and often have been found near known checkpoints. These are usually remotely operated and may be employed in conjunction with a suicide VBIED.
• (S//NF) A particularly devious technique is for a driver to approach a checkpoint and claim that he has injured people in his vehicle. The VBIED is then detonated when Coalition Soldiers approach.

(Annex 8E).
4. (U) Effectiveness of Attacks
(U) The number of IED detonations from 15 June 2003 through 4 March 2005 (the date of the incident), has steadily increased. Although the effectiveness of those detonations has decreased over that timeframe, the overall average number of casualties during that period is nearly one per IED detonation. (Annex 4E).
(S//NF) The week of the incident saw 166 IED incidents, with 131 detonations and 35 IEDs rendered safe. There were 82 casualties from those incidents. (Annex 4E).
(U) The number of VBIED detonations from 15 June 2003 through 4 March 2005 has also seen a relatively steady increase. Similar to the decrease in the effectiveness of IEDs, the effectiveness of VBIEDs has also decreased over that period, but there have been spikes for particular VBIED events that have produced large numbers of casualties.
(Annex 4E).
(S//NF) There were 17 VBIEDs detonated during the week of the incident with five rendered safe. The average casualty per VBIED detonation that week was 23 due to the large number of casualties that resulted from a VBIED detonation in Al Hillah. The Al Hillah attack was widely publicized and caused all Coalition Forces concern as they patrolled Baghdad and its environs. Any intelligence gained on potential VBIEDs was passed in the form of a BOLO (Be On the Look Out) message to units on patrol via FM radio. (Annex 4E).
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D. (U) Recent Incidents in the Vicinity of Checkpoint 541
(U) Overpasses like Checkpoint 541 are particularly susceptible to attacks. Such sites provide excellent early observation in all directions, easy escape routes, and high speed access to Route Irish. The latter factor is particularly evident at Checkpoint 541 where there is a long (380 meter) exit lane coming off of southbound Route Vernon leading to the on-ramp to Route Irish. (Annex 5E).
(S//NF) Checkpoint 541 has been the site of 13 attacks between 1 November 2004 and early March 2005. Two of those attacks involved VBIEDs. Other attacks included mortars, small arms fire, and IEDs. (Annex 1E).
(U) On the evening of the incident, there were at least two cases of small arms fire in the immediate vicinity, one before and one after the incident. Also, as mentioned earlier, while the Joint Investigation Team was examining the site, a hand grenade was tossed at the personnel from the Route Vernon overpass. This site is under the observation of insurgents in the adjoining housing complex and local neighborhoods anytime a position is established at Checkpoint 541. (Annex 1E).
(S//NF) The two adjoining Route Irish checkpoints, numbers 540 and 542, were also the target of attacks during the 1 November 2004 to early March 2005 period. Checkpoint 540 had 15 attacks, with three of those attacks being VBIEDs. Similarly, Checkpoint 542 had 12 attacks during that period, with two of those attacks being VBIEDs. (Annex 1E).
(U) Furthermore, two days before the incident, two Soldiers from the same unit (1-69 IN) were killed by an IED at Checkpoint 543. The Commander, A Company, 1-69 IN lost a very close friend in that attack. (Annexes 1E, 74C).
E. (U) Unit Experience in the Baghdad Area of Responsibility
1. (U) Third Infantry Division (3ID)
(U) The Division returned to Iraq in early February 2005. It conducted a formal Transfer of Authority with the 1st Cavalry Division and assumed responsibility for MND-Baghdad on 27 February 2005. (Annex 15E).
(S//NF) The Division consists of seven U.S. Brigades and one Iraqi Brigade. Since their arrival, units of 3ID have conducted 14,463 patrols throughout the Baghdad area, to include 33 Rhino Bus escort missions (See Section III.C.5. of this report for background information on the Rhino Bus), through 25 March 2005. (Annex 15E).
(S//NF) In its first month since TOA, 3ID has received 422 attacks from insurgents resulting in 13 killed and 60 wounded. (Annex 15E).
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2. (U) Second Brigade, 10th Mountain Division (2/10 MTN)
(U) The Second Brigade has been in Iraq for nearly eight months. (Annex 65C).
(U) From 12 August 2004 to 11 March 2005, 2/10 MTN Soldiers conducted approximately 50,000 patrols. The Soldiers also conducted 5,237 Traffic Control Points (TCPs) during that period. (Annex 4E).
(U) Between 15 December 2004 and 13 March 2005, 2/10 MTN Soldiers conducted 712 TCPs in support of Rhino Bus operations. There were usually eight such TCPs conducted per night in support of Rhino Bus movements. (Annex 4E).
(U) The “TCPs” that were conducted for the Rhino Bus movements are more properly called hasty Blocking Positions (BPs). (See Section III.B. of this report for a discussion of the difference between TCPs and BPs).
3. (U) 1-69 Infantry Battalion (1-69 IN)
(U) 1-69 IN arrived in the Iraqi Theater of Operations on 4 November 2004. The unit first served in Taji, north of Baghdad where they spent approximately three months. While in Taji, the primary mission of 1-69 IN was to conduct patrols in search of insurgents responsible for firing rockets and mortars at Coalition bases. (Annex 10E).
(U) In February 2005, 1-69 IN relocated to Baghdad under the command and control of 2/10 MTN. The Commander, 1st Cavalry Division assigned the unit the mission of patrolling and securing Route Irish as of 15 February 2005. (Annex 65C).
(U) Through early April 2005, 1-69 IN had conducted over 2000 patrols in Iraq. About two-thirds of those patrols were dismounted patrols requiring the Soldiers to leave their vehicles. About one-third of the patrols were conducted at night. (Annex 10E).
(U) The unit has conducted over 1000 Traffic Control Points (TCPs) since arriving in Iraq. Most of those occurred along Route Irish. Other than the subject incident, there was only one incident involving civilians (one wounded civilian in Taji). (Annex 10E).
(S//NF) Since arriving in Iraq, 1-69 IN has experienced 19 roadside explosive devices, 38 incidents of small arms fire, 4 RPGs, 3 VBIEDs, 3 hand grenades, 16 indirect fire attacks, and 2 complex attacks. (Annex 10E).
(S//NF) Five attacks against 1-69 IN in November resulted in two fatalities and three wounded. Five detonations in December resulted in one fatality and three wounded. In January 2005, 1-69 IN received six detonations that resulted in seven fatalities and three wounded. The seven fatalities all came in one attack involving 10 buried 155mm artillery rounds. After relocating to Baghdad in February, the unit received one attack
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with no fatalities or wounded. Through early March, 1-69 IN has received four detonations resulting in three fatalities and three wounded. (Annex 10E).
(S//NF) Overall, 1-69 IN suffered 10 fatalities and 9 wounded while in Taji, followed by 3 fatalities and 3 wounded while conducting security operations on Route Irish. All 13 of the unit’s combat related fatalities in theater have come as a result of IEDs. (Annex 10E).
4. (U) 1-76 Field Artillery Battalion (1-76 FA)
(U) 1-76 FA was new to the Baghdad AOR, having arrived on 21 February 2005. Their Right Seat/Left Seat Ride program began on 22 February 2005. 1-76 FA personnel were in the last night of their Right Seat/Left Seat Ride program with 2-82 FA and in charge of VIP security operations on the evening of 4 March 2005. The Transfer of Authority occurred the next day, 5 March 2005. (Annexes 59C, 63C).
(U) 1-76 FA is responsible for security inside the International Zone as well as U.S. Embassy VIP movement security along Route Irish. (Annex 58C).
(U) 1-76 FA has Direct Liaison Authorized (DIRLAUTH) to coordinate directly with 1-69 IN for security along Route Irish. This is the same level of coordination previously authorized by 1st Cavalry Division to 2-82 FA. When executing DIRLAUTH, 1-76 FA directly coordinates an action with units internal or external to its command and keeps the 3ID commander informed. The 1-76 FA TOC passes all coordination efforts through the 4th Brigade TOC to 3ID JOC. (Annex 58C).
F. (U) Findings
(U) Route Irish and its checkpoints, particularly the ones at the three overpasses (CP 540, CP 541, and CP 543), are continually subject to attacks from IEDs, VBIEDs, SAF, and other methods of attack. It is a road filled with dangers that can kill, maim, and injure Soldiers and civilians. (Annexes 3E, 5E, 8E).
(U) The insurgents are continually adjusting their methods of attack along the Route Irish corridor. (Annex 11E).
(U) The long straightaway off southbound Route Vernon leading to the on-ramp to westbound Route Irish provides an excellent opportunity for a suicide VBIED to build up speed and threaten Soldiers in their positions. (Annex 5E).
(U) The Soldiers of 1-69 IN had suffered a significant number of deaths in the four months that they had been in Iraq as of 4 March 2005, including two Soldiers that were killed by an IED at Checkpoint 543 two days before the incident. (Annexes 1E, 10E).
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(U) 1-69 IN Soldiers were experienced in patrolling, providing route security, and conducting TCPs. (Annex 10E).
(U) Due to it being their first full day on shift, 1-76 FA Soldiers lacked experience in issuing operational orders and in battle tracking security forces during execution of blocking missions. (Annexes 59C, 63C).
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III. TRAFFIC CONTROL POINTS, BLOCKING POSITIONS, AND TRAINING
A. (U) Introduction
(U) This section examines TCPs, BPs, and training matters. It first discusses the difference between a TCP and a BP. Standing Operating Procedures (SOPs) for the various units involved regarding TCPs and BPs are assessed, and the Rhino Bus TTP is outlined. This is followed by a review of the training on TCPs, BPs, weapons, and Rules of Engagement (ROE) that the Soldiers manning BP 541 had received before 4 March 2005. The ROE that were in effect that night are explained. The section concludes with findings and recommendations.
B. (U) Traffic Control Points and Blocking Positions
(U) Task Force 1-69 IN had received missions to establish TCPs and blocking positions numerous times in the past. Although the terms are used interchangeably (Annex 65C), there are subtle, but distinct, differences in approach to establishing the two positions. (Annex 96C).
(S//NF) A traffic control point involves (1) the stopping of a vehicle, (2) a search of that vehicle, and (3) the authorized passage of the vehicle through the control point. (Annexes 66C, 68C, 70C, 72C). TCPs can be of limited or extended duration. (Annex 97C).
(S//NF) A blocking position, in contrast, does not involve the search of a vehicle. Ideally, the underlying intent of a blocking position involves no contact with a vehicle. In Iraq, the purpose of a BP is twofold: (1) to prevent vehicles from gaining access to the protected location, and (2) to prevent VBIEDs from getting close enough to kill or injure Soldiers or civilians. Blocking positions are neither intended nor designed to allow traffic to pass. The intent is to achieve maximum standoff from approaching vehicles and force them to turn around. (Annexes 66C, 68C, 70C). Blocking positions can be temporary or for longer durations. (Annex 97C). As indicated to 1-69 IN during Relief in Place operations, patrols must be prepared to execute hasty BPs when required.
C. (U) Standing Operating Procedures in use on 4 March 2005
(U) SOPs are designed to serve as guidelines for specific operations and are not prescriptive in nature. They provide a baseline for acceptable operations from which commanders can derive principles and techniques and adapt them to their current mission. (Annexes 44C, 65C, 72C, 96C, 98C).
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1. (U) Doctrinal Discussion of TCPs and Roadblocks (Army Field Manual 3-21.9,
Chapter 7)
(U) Construction and manning of checkpoints and roadblocks are high frequency tasks for an infantry company and subordinate elements when they must establish area security during stabilization operations. (Annex 5F).
(U) A checkpoint is a predetermined point used as a means of controlling movement, such as a place where military police check vehicular and pedestrian traffic, to enforce circulation measures and other law, order, and regulations. (Annex 5F).
(U) A roadblock is used to limit the movement of vehicles along a route or to close access to certain areas or roads. Checkpoints and roadblocks can be either deliberate or hasty. The primary difference is the extent of planning and preparation conducted by the establishing force. (Annex 5F).
(U) Checkpoints and roadblocks may be established to:
• (U) Check and/or inspect and register all personnel and vehicles in and out of the controlled area.
• (U) Deter illegal movement.
• (U) Create an instant roadblock.
• (U) Control movement into the area of operations or on a specific route.
• (U) Prevent smuggling and contraband.

(Annex 5F).
(U) The layout, construction, and manning of checkpoints and roadblocks should reflect the considerations of Mission, Enemy, Terrain, Troops Available – Time, Civilians (METT-TC), especially the time available for emplacing them. (Annex 5F). The following factors should be considered in establishing a checkpoint or roadblock:
• (U) Position the checkpoint or roadblock where it is visible and where traffic cannot turn back, get off the road, or bypass without being observed.
• (U) Place obstacles in the road to slow or canalize traffic into the search area.
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• (U) Position a combat vehicle off the road, but within sight, to deter resistance to Soldiers manning the checkpoint. It must be able to engage vehicles attempting to break through or bypass a checkpoint.

(Annex 5F).
(U) Many items are used to reinforce a roadblock or a checkpoint. These include: barrels filled with sand, water, or heavy concrete blocks (emplaced to slow and canalize vehicles), concertina wire (emplaced to control movement around the checkpoint), and signs stating the speed limit into and out of the checkpoint (in both English and the local language.) (Annex 5F).
2. (U) 3ID TCP SOP
(S//NF) In 3ID’s published Field Standard Operating Procedures (FSOP), there is a section directly addressing traffic control points. A TCP is defined as a “Structured Engagement Area.” The 3ID FSOP does not include guidelines for positions with a blocking mission (i.e., blocking positions). (Annex 1F).
(S//NF) The TCP SOP calls for an Alert Line, a Warning Line, a Stop line, a Search Area, and an Overwatch Area. (Annex 1F).
(S//NF) The Search Area should be a well-lit checkpoint, provide standoff from neighborhood structures, allow a sufficient area to accommodate more than one search team, the establishment of warning signs with sufficient distance for drivers to react, the use of physical barriers to force vehicles to slow down, and other barriers like tire poppers, to block movement of vehicles attempting to continue through the search area. (Annex 1F).
(S//NF) The Warning Line and Alert Line should provide maximum standoff for oncoming traffic. (Annex 1F).
(S//NF) Soldiers should fire into engine blocks before engaging the driver. (Annex 1F).
(S//NF) The equipment for a TCP includes warning signs, triangles, sawhorses, traffic cones, and/or tire poppers. (Annex 1F).
(S//NF) Minimum leader requirements for executing a TCP are listed as (1) map reconnaissance, (2) mission briefing, (3) safety briefing, and (4) back brief to the commander or designated representative. Position selection considerations are not specifically addressed. (Annex 1F).
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3. (U) 2/10 MTN TCP SOP
(S//NF) The 2/10 MTN’s published Tactical Standing Operating Procedures (TACSOP) addresses checkpoint operations. The TACSOP does not provide guidance on blocking positions. (Annex 2F).
(S//NF) A unit establishes checkpoints to control its area of responsibility, deny the enemy freedom of movement, and contribute to security of military units as well as the populace. They must be established to ensure that the position cannot be bypassed. (Annex 2F).
(S//NF) The 2/10 MTN TACSOP distinguishes between vehicle checkpoints (VCPs) and personnel checkpoints (PCPs). These are further divided into three types: deliberate, hasty, and flying. (Annex 2F).
(S//NF) Deliberate checkpoints are permanent or semi-permanent. They are used near operating bases or along Main Supply Routes (MSRs). (Annex 2F).
(S//NF) Hasty checkpoints are planned in advance and will be maintained for a set period of time of short duration. Hasty checkpoints are frequently employed during the conduct of vehicle or foot patrols. (Annex 2F).
(S//NF) Flying, or immediate, checkpoints are conducted when specific intelligence indicates that a checkpoint will hinder the enemy’s freedom of movement at a specific time and place. They are conducted immediately and often with little or no planning. (Annex 2F). Although not a TCP mission, the mission given to 1-69 IN to block Route Irish on 4 March 2005 fell into this category.
(S//NF) Vehicle checkpoints should consist of four zones: canalization zone, turning or deceleration zone, search zone, and safe zone. (Annex 2F).
(S//NF) The canalization zone uses natural obstacles and/or artificial obstacles to canalize the vehicles into the checkpoint. It usually consists of disrupting or turning obstacles, such as serpentines and other barrier systems. Warning signs should be placed at least 100 meters in front of the checkpoint. (Annex 2F).
(S//NF) The turning or deceleration zone forces vehicles to make a rapid decision, i.e., decelerate, make slow hard turns, or maintain speed and crash into obstacles. (Annex 2F).
(S//NF) The search zone is a relatively secure area where personnel and vehicles are positively identified. (Annex 2F).
(S//NF) The safe zone is the assembly area for the checkpoint that allows personnel to eat, sleep, and recover in relative security. (Annex 2F).
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(S//NF) The use of radios or cell phones should be limited to essential communications and/or entirely prohibited as their transmissions may detonate any IEDs present. (Annex 2F).
(S//NF) The SOPs used by 2/10 MTN originated with the 1st Armored Division, and then were adopted by the 1st Cavalry Division, and in turn by 3ID. (Annexes 66C, 67C). It is noted that the SOP is not prescriptive, i.e., there is no requirement for signs, only a suggestion. (Annex 2F). Soldiers and leaders alike acknowledged using this SOP as a reference for establishing blocking positions, adopting certain procedures and equipment as required. (Annexes 65C, 66C, 98C).
4. (U) 1-69 IN TCP SOP
(S//NF) The 1-69 IN has its own Tactical Standard Operating Procedures (TACSOP). It is a modified version of the 256th Brigade TACSOP. (Annexes 72C, 98C, 3F). It addresses checkpoint operations, but not blocking positions. (Annexes 72C, 96C, 3F). In addition, there are checklists for equipment to be used at TCPs. (Annex 3F).
(S//NF) The TCPs described in the 1-69 TACSOP are of a more enduring nature than those described in 2/10 MTN’s TACSOP. Even hasty checkpoints are more like 2/10 MTN’s deliberate checkpoints. There is no similar position as the flying or immediate TCP described by the 2/10 MTN SOP. (Annex 3F).
(S//NF) The Battle Drill for TCP occupation described in the 1-69 IN TACSOP is the same as that found in 3ID’s FSOP. (Annexes 1F, 3F).
(S//NF) The Battalion considers barriers as mandatory equipment for blocking positions (Annexes 96C, 97C, 98C). These can be existing barriers on site or other obstacles such as concertina wire. (Annexes 96C, 98C). The team at BP 541 considered the on-site Jersey barriers as meeting this requirement. (Annexes 74C, 77C).
(S//NF) Signs are required for TCPs. (Annex 96C). Signs were not used at BPs by 4-5 Air Defense Artillery (ADA), 1-69 IN’s predecessor. Based on their experience, the opinion of the BP 541 Soldiers was that signs had been marginally effective for TCPs conducted in the daytime in Taji. They were less effective at night. During both day and night operations, the signs were easily bypassed. (Annexes 79C, 87C).
(S//NF) The Soldiers have found concertina wire to be effective at TCPs in the daytime. Wire becomes quite ineffective at night as motorists cannot see it, even when chemlights are attached to it. Furthermore, the BP 541 Soldiers believed that the emplacement of concertina wire exposes them to additional risk. (Annexes 79C, 87C).
(S//NF) The signs that A Company, 1-69 IN Soldiers had used in Taji had not been available since their move to Baghdad on 5 February 2005. (Annexes 81C, 112C). On or about 12 February 2005, the signs were unloaded and stored next to a conex. There were
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approximately 25 signs in this shipment. These were TCP signs that said “Stop and Wait to be called forward.” Other signs that had been for the rear of vehicles said “Stay back 100 meters or you will be shot.” The last part of that phrase “or you will be shot” was to be covered with tape. (Annex 112C). The signs had not been modified, and, therefore, not reissued as of 4 March 2005. (Annex 95C).
5. (U) Rhino Bus Run TTP Background Information
(U) Since October 2004, there had been significant insurgent contact on Route Irish. Most of the contacts were RPGs, SAF, IEDs, and VBIEDs. These attacks prompted a re-assessment of the Coalition’s responses for operations along Route Irish.
(S//NF) Route Irish is the primary route to BIAP for U.S. Embassy personnel, and there was routinely at least one convoy each day. Rhino buses (armored buses) were procured to provide better protection for passengers. Additionally, a series of briefings and plans were developed to address the insurgent situation along Route Irish. The result was the Rhino Bus Run Program. (Annex 65C).
(S//NF) Under the Rhino Bus Run Program, 1-76 FA escorts two or three Rhino armored buses and one or two baggage trucks to and from the Embassy staging area in the International Zone and the BIAP passenger terminal twice nightly, seven days a week. Each run consists of up to 65 escorted passengers. This is the standard TTP 1-76 FA learned during the Right Seat/Left Seat Ride program conducted by 2-82 FA as part of Relief in Place operations. 1-76 FA’s higher headquarters, Fourth Brigade, coordinates attack helicopter support to conduct route reconnaissance ahead of the convoy and Close Air Support in the event of an attack. (Annex 59C).
(S//NF) Under the Rhino Bus Run TTP, 1-76 FA identifies the escort platoon. Once the escort platoon leader receives the number of passengers for transport at the staging area, and has established communications with the attack helicopters, the 1-76 FA TOC requests clearance from the 3ID TOC (the battlespace owner) through 4th Brigade TOC to move the convoy. Once 4th Brigade receives clearance from 3ID TOC, the 1-76 FA Battle Captain contacts 1-69 IN Battle Captain and requests that they establish blocking positions along Route Irish. Once the 1-69 IN Battle Captain notifies the 1-76 FA Battle Captain that the units are set in position, the convoys depart from the staging area. Once the convoy has passed ECP 1, the 1-76 FA Battle Captain contacts the 1-69 IN Battle Captain and clears the units to open their blocking positions. The same process is followed for the reverse trip. (Annex 59C).
(U) There is no written SOP that covers Rhino Bus operations. The TTPs that 1-76 FA used on 4 March 2005 are the same TTPs employed by 2-82 FA. (Annex 59C).
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D. (U) Training of BP 541 Soldiers
(U) The Soldiers manning BP 541 on 4 March 2005 received SOP training on TCPs at Fort Hood and the National Training Center (NTC). (Annexes 72C, 96C, 97C, 98C). The training at Fort Hood was part of mobilization training, and was conducted by the Battalion leadership and the Mobilization Assistance Team, while the training at NTC occurred as part of the Mission Rehearsal Exercise. (Annex 96C).
(S//NF) The Soldiers were trained to the following standards for TCPs: (1) 360 degree security, (2) one element controls traffic entry to the TCP, and (3) one element conducts searches and operates the detainee holding area. Soldiers are to control traffic effectively and efficiently, keep Soldiers safe, and accomplish the mission. (Annex 96C).
(S//NF) The Battalion Commander gave verbal guidance at Fort Hood on using M4s as the primary weapon for firing warning shots. This was intended for mounted mobile operations as a TTP for clearing overhead passes instead of static blocking positions due to difficulty in traversing the gunner’s turret. (Annex 73C).
(S//NF) There is no evidence to indicate that the Soldiers were trained to execute blocking positions before arriving in theater. TTPs for blocking positions and other operations were learned and practiced during the Right Seat/Left Seat Ride exercises as part of the Relief in Place/Transfer of Authority process with the Soldiers of 4-5 ADA from 5 to 15 February 2005. Gunners and leaders were able to watch tasks being performed before they had to perform these tasks themselves under the supervision of 4-5 ADA. (Annexes 72C, 96C, 97C, 98C, 9G). These TTPs were accepted by the 1-69 IN Battalion Commander as approved higher headquarters sanctioned guidance. (Annex 72C).
(S//NF) The 4-5 ADA blocking position TTP called for one vehicle, either a HMMWV or a Bradley Fighting Vehicle, to pull up next to the last Jersey barrier (closest to Route Irish). The Soldiers at the BP would then use a hand-held spotlight and laser pointer to get drivers’ attention, and make them stop and turn around. Normally, these blocking positions, which were hasty in nature, would be held for 10-15 minutes before the TOC would order the road opened. Signs were not used by 4-5 ADA. (Annexes 74C, 83C).
(S//NF) As demonstrated by 4-5 ADA previously, the standard practice by Alpha Company, 1-69 IN personnel at blocking positions is for the gunner to use the spotlight, while the HMMWV commander or Truck Commander operates the laser pointer. If the gunner must fire his weapon, M4 or M240B, he drops the hand-held light to engage the threat with well-aimed fire using both hands. (Annexes 74C, 79C). There is no specific training for operating the spotlight and the M240B simultaneously. (Annex 66C).
(U) Based upon the fact that two 1-69 IN Soldiers were killed by an IED two nights before at Checkpoint 543, his experience, training, and risk assessment, the Alpha
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Company Commander chose to augment the 4-5 ADA TTP on 4 March 2005 by placing two HMMWVs at BP 541 for additional force protection. Force protection was paramount in his mind because of the threat of IEDs and VBIEDs. (Annex 74C). As a result, Second Lieutenant Acosta tasked the overwatch vehicle gunner to operate the green laser pointer rather than have Staff Sergeant Brown, the Truck Commander do so. (Annexes 77C, 87C).
E. (U) Rules Of Engagement (ROE) Training Received by BP 541 Soldiers
(U) The Soldiers were trained on ROE as part of their deployment preparation at Fort Hood and the National Training Center (NTC), as well as in Kuwait and Iraq. (Annexes 111C, 128C, 134C). The training at Fort Hood and NTC centered on basic ROE concepts of the escalation of force, hostile intent, hostile act, and positive identification. Specifically, Soldiers were briefed on the right of self defense, which allows them to defend themselves and Coalition Forces with all necessary force to negate the potential threat. Soldiers also received training in graduated force, which is designed to allow them to employ escalating measures of non-lethal force to properly discern hostile intent and prevent accidental civilian injury. Soldiers were briefed on positive identification (PID), which requires Soldiers to have a reasonable certainty that the object of attack is a proper military target. Soldiers were also briefed on the protections afforded detainees and civilians, their duty to care for the wounded and sick, military necessity, proportionality, discrimination, and collateral damage1 . (Annexes 111C, 1G, 3G).
(U) While at NTC, judge advocates from the Center for Law and Military Operations (CLAMO) conducted impromptu interviews with the Soldiers, including Soldiers from 1-69 IN, where they were questioned about basic ROE principles. ROE is a key aspect of training at NTC and Soldiers are challenged with difficult, real world scenarios that emphasize ROE issues, such as, the use of force and properly identifying hostile intent. (Annexes 111C, 1G).
(U) The Soldiers of the BP 541 team had received formal refresher ROE training approximately one month before the incident. (Annexes 129C, 132C, 133C, 137C). This training included vignettes on TCP operations, fixed site security, and patrols, and emphasized the use of graduated force and how and when to use non-lethal measures of force. Specifically, the vignettes highlighted how to discern hostile act and hostile intent from innocuous civilian activity. (Annexes 111C, 1G). 19
(S//NF) 1  Military necessity requires that all targets are proper military targets, i.e., they possess a military attribute, the destruction of which provides a military advantage. Proportionality refers to whether any expected collateral damage is excessive in comparison to the overall military value of the target. Discrimination requires Soldiers to employ force in a manner that properly distinguishes between lawful targets and unlawful targets. Collateral damage encompasses any death or injury to civilians and damage or destruction of civilian property.
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(U) The entire battalion, including every member of the BP 541 team, received an in-depth review of a recent AR 15-6 investigation involving a shooting incident that further reinforced proper execution of ROE. (Annex 133C). The investigation involved the wounding of a civilian at a TCP, in which the vehicle was driving at a high rate of speed and the Soldiers at the TCP engaged the vehicle. The brief discussed the use of signs, chemical lights, spotlights, and graduated force as it applies to fixed position operations. Failure to follow the SOP was discussed and how proper use of the SOP can help a Soldier to discern hostile intent. Escalation of force to discern hostile intent was emphasized. (Annexes 111C, 1G, 2G, 3G).
(U) Furthermore, the Soldiers were briefed on ROE before going out on patrol each day. They were so briefed on 4 March 2005. (Annexes 83C, 129C, 130C, 132C, 134C, 135C).
(S//NF) The 1-69 IN TACSOP ROE defines a Hostile Act as “a use of force against 1-69 IN or friendly forces, or persons or property under the protection of 1-69 IN forces that is likely to cause serious permanent injury or death or significant property damage.” (Annex 3F).
(S//NF) The 1-69 IN TACSOP ROE defines Hostile Intent as “a threat of imminent use of force against 1-69 IN or friendly forces, or persons or property under the protection of MNC-I forces that is likely to cause serious permanent injury or death or significant property damage. Hostile intent may be judged by the threatening force or individual’s capability and preparedness to inflict damage, or by evidence, particularly intelligence, that clearly indicates that a surprise strike is imminent.” (Annex 3F).
(S//NF) The 1-69 IN TACSOP ROE allows the use of deadly force if a Soldier, his unit, other U.S. forces, or designated friendly forces are attacked or threatened with imminent attack. (Annex 3F).
(S//NF) The ROE taught to the Soldiers was shout, show, shove, shoot. (Annexes 129C, 130C, 131C, 132C, 133C). The 1-69 IN TACSOP ROE also provides for shout, show, shove, shoot. (Annex 3F). For the night of 4 March 2005 at BP 541, the Soldiers were told the ROE was: Shout, i.e., use the spotlight on an approaching vehicle as far in advance of the Alert Line as possible; Show, i.e., use the green laser light, aimed at the driver, at the Alert Line; Shove, i.e., fire warning shots; and Shoot, i.e., disabling shots first, then, if necessary, shoot to kill. (Annexes 77C, 81C).
F. (U) Findings
(U) The leaders and Soldiers understood their mission to block vehicle access to Route Irish on the evening of 4 March 2005. They were knowledgeable of the Rules of Engagement to be employed in that mission. (Annexes 74C, 77C, 83C).
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(U) The Soldiers at BP 541 had been trained, and routinely refreshed on, the Rules of Engagement since their arrival in theater. (Annexes 77C, 81C, 111C).
(U) There is no written SOP or TTP in 3ID, 2/10 MTN, or 1-69 IN for the execution of the blocking mission and establishing a blocking position. (Annexes 1F, 2F, 3F). The procedure was passed on from the departing unit (4-5 ADA) to the incoming unit (1-69 IN) during the Relief in Place/Transfer of Authority, where leaders observed the execution of the mission one week, and executed the mission the following week under the supervision of the outgoing unit (Right Seat/Left Side Ride). The only training received by 1-69 IN Soldiers on blocking positions was that employed along Route Irish during after-curfew Rhino Bus Runs, and occurred during the Left Seat Right Seat Ride process with 4-5 ADA. (Annexes 72C, 96C, 97C, 98C, 9G). It is clear that these BPs were not established as TCPs.
(U) There is no clear guidance in these units on what equipment is required for establishing a blocking position (e.g., different road signs). (Annexes 1F, 2F, 3F).
(U) Requiring the gunner in a blocking position to operate the hand-held spotlight as well as his crew-served weapon is an accepted practice in 1-69 IN. (Annexes 72C, 74C).
G. (U) Recommendations
(U) Recommend that all Major Subordinate Commands (MSCs) review the inherent differences between the blocking mission and any other mission involving TCPs. Given the nature of the environment in Iraq, recommend that blocking positions be addressed separately in unit SOPs.
• (S//NF) Soldiers and leaders must understand that in a BP, the goal is to achieve standoff as far away and as quickly as possible, with no vehicle passage.

(U) Recommend a comprehensive review of TCP and blocking position procedures, to include risk assessment, required equipment, considerations for site selection, and the establishment of clearly visible warnings or indicators, both day and night, for Soldier and civilian recognition. The Soldiers and leaders must look at the position holistically, i.e., from the perspective of Iraqi drivers and what they might see. Units must enforce a quality control program to maintain established standards.
(U) As of this writing, MNC-I has already embarked on a comprehensive analysis of Entry Control Points (ECPs), TCPs, and BPs.
• (S//NF) This analysis will produce standard practices and guidelines for the selection and establishment of ECPs, TCPs, and BPs.
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(U) Recommend that permanent Coalition participation be included in the Force Protection Working Group to solicit lessons learned from other nations’ experiences in operating ECPs, TCPs, and BPs in an insurgency environment.
(U) Recommend the development and publication of a written SOP for Rhino Bus Runs.
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IV. THE INCIDENT AT BP 541
A. (U) Introduction
(U) This section examines the shooting incident at BP 541 on the night of 4 March 2005. The section begins with a description of the site and then a brief look at the individuals involved. The mission assigned to the 1-69 IN Soldiers is detailed. The incident itself is then described. The events immediately following the shooting are addressed next. Following this is a look at the forensic evidence. The section concludes with findings and recommendations.
B. (U) Site Description
(U) BP 541 was located on the on-ramp from southbound Route Vernon onto westbound Route Irish approximately six miles west of the International Zone in Baghdad. Specifically, BP 541 (Grid 38S MB3571 8371) was located at the intersection of Route Vernon and Route Irish, which is the second intersection on Route Irish east of Baghdad International Airport (BIAP). The road leading to the on-ramp begins where the westernmost lane of Route Vernon separates from the highway. The on-ramp itself begins near a side street that borders the edge of a housing area on the west side of the road. This point is approximately 640 meters south of the nearby underpass on Route Vernon, and approximately 380 meters from where the road to the on-ramp splits from Route Vernon. (Annexes 141K, 144K).
(U) At the interchange of the on-ramp and Route Vernon, the highway becomes an overpass extending over Route Irish. Three separate concrete Jersey barriers are located in the on-ramp to Route Irish. The barriers are arranged with the first two barriers on the right hand side of the on-ramp and the third one on the left hand side of the on-ramp, but not in a serpentine configuration, as one approaches from the north. The first barrier is approximately 75 meters from the concrete abutment of the Route Vernon overpass near the beginning of the on-ramp. The second barrier is approximately 37 meters beyond the first barrier (112 meters from the concrete abutment). The third barrier is approximately 31 meters beyond the second barrier (143 meters from the abutment). This third, or southernmost, barrier is approximately 80 meters from where the on-ramp merges with westbound Route Irish. The total length of the on-ramp is approximately 223 meters. (Annexes 142K, 144K).
(U) From the vantage point of the southernmost barrier, Route Irish is directly south of the position with a 50-meter median separating the eastbound and westbound lanes. To the north and northwest of the position, there is a large open area that is littered with garbage and debris. The field extends from the bottom of the on-ramp to the side street and west. Immediately beyond the side street, approximately 150 meters from the southernmost barrier, is a large housing community with windows and porches that overlook the on-ramp. There is a clear line of sight from the houses to the on-ramp. The
 23 UNCLASSIFIED UNCLASSIFIED
Route Vernon overpass stands several stories higher than the on-ramp and runs parallel to the on-ramp until the on-ramp curves to the southwest, approximately 50 meters from the beginning of the on-ramp. The overpass is supported by large cylinder concrete supports. The ground under the overpass is also littered with garbage and debris. (Annexes 16K, 143K).
(U) The road itself is concrete. There is a slight elevation gain between the beginning of the on-ramp and its merger with Route Irish. The curve is banked slightly. The on-ramp, but for the Jersey barriers, is wide enough to accommodate two vehicles abreast of each other, i.e., it is two-lanes wide. (Annexes 16K, 19K).
C. (U) Personnel Involved
1. (U) Captain Michael Drew, New York Army National Guard, a New York City Police Department Sergeant was the Commander, A Company, 1-69 IN, in charge of patrolling Route Irish and establishing blocking positions at four checkpoints on the night of 4 March 2005. (Annex 1J).
2. (U) First Lieutenant Robert Daniels, New York Army National Guard, was the Executive Officer for A Company, 1-69 IN on 4 March 2005 and was initially present at BP 541. (Annex 2J).
3. (U) Second Lieutenant Nicolas Acosta, Louisiana National Guard, was the platoon leader in charge of BP 541 on 4 March 2005. (Annex 6J).
4. (U) Sergeant Sean O’Hara, Louisiana National Guard, was in the overwatch vehicle at BP 541 on 4 March 2005. (Annex 8J).
5. (U) Sergeant Luis Domangue, Louisiana National Guard, was the secondary gunner in the overwatch vehicle at BP 541 on 4 March 2005. (Annex 5J).
6. (U) Specialist Kenneth Mejia, Louisiana National Guard, was the driver of the overwatch vehicle at BP 541 on 4 March 2005, and a trained combat life saver. (Annex 4J).
7. (U) Staff Sergeant Michael Brown, New York Army National Guard, a New York City Police Department officer was the acting Platoon Sergeant at BP 541 and the Truck Commander of the blocking vehicle on 4 March 2005. (Annex 7J).
8. (U) Specialist Mario Lozano, New York Army National Guard, was the gunner on the blocking vehicle at BP 541 on 4 March 2005. He had been an M240B and M249 gunner in previous assignments. (Annex 10J).
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9. (U) Specialist Brian Peck, New York Army National Guard, was the driver of the blocking vehicle at BP 541 on 4 March 2005. (Annex 9J).
10. (U) Sergeant First Class Edwin Feliciano, New York Army National Guard, was with the Company Commander’s vehicle on 4 March 2005. (Annex 3J).
11. (U) Mr. Nicola Calipari was an Italian military intelligence officer with the rank of Major General who was in charge of the recovery of Ms. Sgrena on 4 March 2005. (Annex 104C).
12. (U) Mr. Andrea Carpani is an Italian military intelligence officer with the rank of Major in the Carabinieri with years of experience working and driving in Baghdad. He was driving the car involved in the incident on 4 March 2005. (Annex 104C).
13. (U) Ms. Giuliana Sgrena is an Italian journalist for Il Manifesto. She had been kidnapped and held hostage in Baghdad for one month at the time of her release on the night of 4 March 2005. (Annex 103C).
D. (U) The Mission
1. (U) Receipt of the Mission
(U) The mission of A Company, 1-69 IN on 4 March 2005 was their standard mission, i.e., to provide security along Route Irish. The mission entailed looking for IEDs and VBIEDs and ensuring Coalition convoys could safely transit between the International Zone and BIAP. A Company, 1-69 IN had been performing this mission since 15 February 2005. Their normal patrol shift was 1500 to 2300 daily. (Annex 137C).
(U) While on patrol, Captain Drew received two VBIED BOLO reports via radio, one for a black car, another for a white car. (Annexes 74C, 13E, 14E). He passed that information via radio to his subordinate leaders, including Second Lieutenant Acosta, who passed it on to his troops. (Annexes 74C, 77C).
(U) At 1843 hours, the 1-69 IN Battle Captain received a call from the 1-76 FA Battle Captain asking how quickly they could establish blocking positions along Route Irish. (Annexes 60C, 61C, 3L).
(S//NF) Adverse weather had mandated that the VIP travel by ground rather than by helicopter, and the Embassy requested that access to Route Irish be blocked for the movement. (Annexes 60C, 61C, 3L).
(S//NF) At approximately 1900 hours, A Company, 1-69 IN received a mission from its Battalion TOC. A Company was directed to establish blocking positions on the four westbound on-ramps along Route Irish to support the movement of a VIP from the
 25 UNCLASSIFIED UNCLASSIFIED
International Zone as they would for a Rhino Bus Run mission. (Annexes 58C, 133C, 137C).
(U) At 1916 hours the 1-76 FA Battle Captain called the 1-69 IN Battle Captain to order all elements to report to their blocking positions for the VIP transit. (Annex 3L).
(S//NF) Captain Drew considered the current enemy situation, and decided to place an M2 Bradley Fighting Vehicle at both Checkpoint 542 and Checkpoint 543, and two HMMWVs each at Checkpoint 540 and Checkpoint 541. He assigned Checkpoint 541 to a team led by Second Lieutenant Acosta. (Annex 137C).
(U) At approximately 1930 hours, Second Lieutenant Acosta arrived at Checkpoint 541 with three HMMWVs. He found First Lieutenant Daniels in position at the on-ramp. Second Lieutenant Acosta relieved First Lieutenant Daniels. A short time later, Captain Drew pulled up in his HMMWV, took one of Second Lieutenant Acosta’s HMMWVs for placement at Checkpoint 540, and then left with First Lieutenant Daniels accompanying him. (Annex 133C).
(U) At 1938 hours, the 1-69 IN Battle Captain reported to the 2/10 MTN Battle Captain that all blocking positions had been established. The 1-76 FA Battle Captain reported to the 2/10 MTN Battle Captain that the VIP would depart in approximately five to ten minutes. (Annex 2L).
(U) At 1945 hours, the VIP security convoy NCOIC reported to the 1-76 FA Battle Captain that the convoy with the VIP departed the International Zone with a destination of Camp Victory. The 2/10 MTN Battle Captain requested the VIP’s convoy departure time and composition from the 3ID JOC Battle Captain, as they were not in direct contact with 1-76 FA. Meanwhile, the 1-76 FA Battle Captain directed 1-69 IN Battle Captain to initiate the Route Irish closure plan. (Annexes 59C, 64C, 2L).
2. (U) Establishing the Blocking Position
(U) The instructions given to Second Lieutenant Acosta by Captain Drew were to set up a blocking position to facilitate the movement of a VIP down Route Irish. (Annex 77C). Captain Drew also issued guidance on the importance of force protection. (Annex 74C). He expected to maintain the blocking position no more than 15 minutes. (Annexes 74C, 77C).
(U) Second Lieutenant Acosta emplaced his two vehicles to establish the blocking position. He positioned the blocking vehicle commanded by Staff Sergeant Brown on the road, near the outer curb, positioned in conjunction with the second barrier of three Jersey barriers already on-site on the on-ramp. Second Lieutenant Acosta placed the overwatch vehicle by the third Jersey barrier, closest to Route Irish. (Annexes 142K, 143K). In their final positions, both vehicles were facing toward Route Irish. (Annex 77C).
 26 UNCLASSIFIED UNCLASSIFIED
(U) Second Lieutenant Acosta, using the factors of METT-TC, positioned the vehicles to provide standoff from the overpass (a common hand grenade throwing location), a clear line of sight to on-coming traffic, overwatch field of view (to watch for threats from nearby buildings), and to allow adequate room for on-coming vehicles to stop and turn around. (Annexes 77C, 83C).
(U) Staff Sergeant Brown’s vehicle was positioned to block traffic from using the on-ramp to enter Route Irish. The other vehicle was positioned to provide overwatch of the area as well as to block traffic entering the on-ramp the wrong way from Route Irish. (Annexes 77C, 83C).
(U) After consulting with Staff Sergeant Brown, Second Lieutenant Acosta established the Alert Line at the concrete abutment of the Route Vernon overpass. The Warning Line was established as the second light pole on the overpass up the on-ramp from the Alert Line. (Annexes 77C, 83C, 16K).
(U) Second Lieutenant Acosta and Staff Sergeant Brown informed the gunners of the Alert Line and Warning Line locations, and reviewed when to shine the spotlight, and when to fire warning shots. (Annexes 77C, 83C).
3. (U) The duties of the Soldiers
(U) Specialist Peck was the driver of the blocking vehicle and was to remain in the driver’s seat, facing west down Route Irish. (Annexes 85C, 130C).
(U) Specialist Lozano was the gunner in the blocking vehicle. He was to remain in the turret, facing north up the on-ramp toward on-coming traffic. From there, he was to operate a three million candlepower hand-held spotlight that he was to shine on approaching vehicles as soon as possible, even before the Alert Line (he was able to see at least 20 meters beyond the Alert Line). (Annexes 77C, 79C, 83C, 134C).
(U) Staff Sergeant Brown, the Truck Commander of the blocking vehicle and acting Platoon Sergeant, was to be dismounted so he could execute local security around his vehicle. (Annexes 83C, 131C).
(U) Specialist Mejia was the driver of the overwatch vehicle and was to remain in the driver’s seat, facing west down Route Irish. (Annexes 89C, 128C).
(U) Sergeant Domangue was to be in the turret of the overwatch vehicle where he would operate a green laser pointer. He was to shine the laser pointer on a vehicle as soon as he saw it, but no later than at the Alert Line, focusing it on the driver’s side of the windshield. He was also to keep watch on the area between Route Irish and the on-ramp. (Annexes 87C, 129C).
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(U) Sergeant O’Hara was to be dismounted from the overwatch vehicle so as to provide local security for his vehicle. (Annexes 81C, 132C).
(U) Second Lieutenant Acosta was to be dismounted so he could supervise the operation of the BP. (Annexes 77C, 133C).
4. (U) Communications Regarding the Mission Duration
(U) Captain Drew, Second Lieutenant Acosta, and Staff Sergeant Brown were all concerned about the length of time that the Soldiers had been manning their blocking positions. (Annexes 74C, 77C, 83C). Captain Drew was concerned that leaving his Soldiers in a static position for more than 15 minutes left them open to attack. He was also concerned that he was not adequately performing his patrolling mission because his Soldiers were tied down to the blocking positions. (Annex 74C).
(U) Captain Drew checked with the 1-69 IN TOC at least two times seeking to collapse the blocking positions and return his Soldiers to their patrolling mission. The 1-69 IN TOC, after checking with 2/10 MTN TOC, informed him that the convoy had not passed and to stay in position. (Annexes 74C, 2L).
(U) At 2010 hours, the 2/10 MTN Battle Captain requested permission from the 3ID TOC to remove blocking positions until 15 minutes before VIP movement. (Annex 2L).
(U) At 2014 hours, the 3ID TOC Battle Captain informed the 2/10 MTN Battle Captain that A Company, 1-69 IN could reduce their blocking positions until 2018 hours. (Annex 2L).
(U) At 2015 hours, the 2/10 MTN Battle Captain reported to the 3ID TOC Battle Captain that A Company, 1-69 IN blocking positions would remain in place. (Annex 2L).
(U) At 2020 hours, the 2/10 MTN Battle Captain notified 1-69 IN to keep blocking positions in place. (Annex 2L).
(U) At 2030 hours, Captain Drew asked again about collapsing the blocking positions. He was told that the word from 3ID was not to move off the blocking positions, that the convoy would be coming down Route Irish in approximately 20 minutes, and that the convoy would consist of four HMMWVs and an up-armored Suburban. (Annexes 97C, 3L).
(S//NF) 1-76 FA was able to communicate the requirement for blocking positions along Route Irish for a VIP movement from the International Zone to BIAP. (Annexes 58C, 59C, 62C, 63C). The security escort platoon with the VIP was able to, and did, relay departure and arrival times to the 1-76 FA Battle Captain. (Annexes 59C, 64C).
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The VIP convoy departed the International Zone in four HMMWVs (and no Suburban) at approximately 1945 hours. It arrived at the Camp Victory gate at 2010 hours (Annex 59C). The convoy reached its destination on Camp Victory at 2020 hours (Annex 59C). The VIP returned to the International Zone by helicopter at approximately 2205 hours. The determination to fly by helicopter back to the International Zone was not made until shortly before the VIP departed as a result of clearing weather conditions. (Annexes 59C, 64C).
(S//NF) The 1-76 TOC had two means of communicating with 4th Brigade, its higher headquarters: Voice Over Internet Protocol (VOIP)2  and FM. The 1-76 FA Battle Captain was using only VOIP to communicate with 1-69 IN, but experienced problems with VOIP, therefore losing its only communication link with 1-69 IN, other than going through 4th Brigade. (Annex 97C). As a result, the Battle Captain was unable to pass updated information about the blocking mission either directly to 1-69 IN, or to 4th Brigade. He did not attempt to contact 4th Brigade via FM communications. (Annex 63C). Fourth Brigade, in turn, could not pass updated information to its major command, 3ID. (Annex 57C). Likewise, 3ID had no new information to pass to its subordinate command, 2/10 MTN. Finally, 2/10 MTN was thus unable to pass updated information to its subordinate command, 1-69 IN. (Annexes 51C, 52C).
(U) There is no evidence to indicate that 1-76 FA passed on the information about the VIP departure and arrival times to any unit. (Annexes 59C, 63C). As a result, A Company, 1-69 IN’s Soldiers were directed to remain in their blocking positions.
(U) Other than the duty logs, there are no other written records of communications or tape recordings among involved units relating to the coordination to block Route Irish on the evening of 4 March 2005. (Annex 6M).
E. (U) The Incident
(U) After arriving at BIAP from Italy in the late afternoon of 4 March 2005, and taking care of some administrative matters, Mr. Carpani and Mr. Calipari went to some undisclosed location in the Mansour District of Baghdad. (Annexes 104C, 105C). At approximately 2030 hours they recovered Ms. Sgrena and headed back toward BIAP. (Annexes 103C, 104C, 109C). Both agents made a number of phone calls to various officials during the drive. (Annex 104C). Mr. Carpani was mostly talking to his colleague, Mr. Castilletti, who was waiting for them outside of BIAP near Checkpoint 539. He updated Mr. Castilletti on his location and discussed arrangements at the airport. (Annex 105C). Mr. Carpani, who was driving, had to slow down at one point due to a flooded underpass on Route Vernon. (Annexes 103C, 104C). Mr. Carpani, who had experience driving in Baghdad, did not have an alternate route to the airport planned.
2  (S//NF) 2  VOIP is a technology that allows telephone calls to be made using a broadband internet connection instead of a regular (analog) phone line.
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(Annexes 104C, 105C). He was taking what he considered to be the most logical route to BIAP, but was not checking his speedometer. (Annex 105C). Neither he, nor Mr. Calipari, knew the on-ramp to Route Irish was blocked. (Annex 104C). Indeed, Mr. Carpani believed the road to the airport was open. (Annex 105C).
(U) At approximately 2045 hours the Soldiers at BP 541 were in the positions that they had been occupying since 1930 hours. They had successfully turned around 15-30 vehicles, with none getting more than a few meters beyond the Alert Line. (Annexes 77C, 79C, 81C, 83C, 87C, 132C). Specialist Lozano was in his turret, his M240B (on which he had last qualified just five days before (Annex 6G)) pointed down and to his left at a grassy area with Specialist Peck in the driver’s seat in the blocking vehicle. Specialist Mejia was in the driver’s seat of the overwatch vehicle with Sergeant Domangue in the turret. Sergeant O’Hara was sitting in the rear passenger’s seat of the overwatch vehicle, cleaning his protective glasses. Staff Sergeant Brown, the acting Platoon Sergeant, was seeking to determine how much longer they were to remain in position. As such, he was standing with Second Lieutenant Acosta near the overwatch vehicle, their backs to the on-ramp. (Annexes 79C, 83C, 128C, 129C, 130C, 131C, 132C, 133C, 134C). None of the Soldiers knew that the Italians were coming. (Annexes 116C, 117C, 118C, 119C, 120C, 121C, 122C).
(U) As the car approached the on-ramp to Route Irish, Mr. Carpani was on the cell phone updating Mr. Castilletti on their position and reporting that everything was going fine. (Annexes 104C, 105C). Though not in the habit of checking his speedometer, Mr. Carpani estimated his speed at 70-80 kph as he exited off of Route Vernon, heading toward the on-ramp to Route Irish. (Annex 105C). The courtesy light in the car was on and had been since picking up Ms. Sgrena in the Mansour District of Baghdad. (Annex 104C). Additionally, Mr. Carpani had his side window halfway open to listen for possible threats. (Annex 105C). Ms. Sgrena and Mr. Calipari were in the rear of the car talking to each other. (Annexes 103C, 105C). The atmosphere in the car was a mix of excitement over the recovery of Ms. Sgrena, and tension from the tasks yet to be completed. (Annex 140C).
(U) At approximately 2050 hours, Specialist Lozano saw a car approaching the on-ramp, approximately 140 meters from his position. (Annexes 79C, 134C, 144K). Specialist Lozano, holding the spotlight in his left hand, shined his spotlight onto the car before it arrived at the Alert Line. (Annexes 79C, 85C). At this time, Sergeant Domangue acquired the vehicle’s headlights and saw the spotlight shining on it. He then focused his green laser pointer onto the windshield of the car as it reached the Alert Line. (Annexes 87C, 129C). Both Specialist Lozano and Sergeant Domangue perceived the car to be traveling in excess of 50 mph (and faster than any other vehicles that evening). (Annexes 79C, 87C, 129C, 134C).
(U) The car crossed the Alert Line still heading towards the Soldiers’ position without slowing down. Specialist Lozano continued to shine the spotlight, and shouted at the vehicle to stop, a fruitless effort, but an instantaneous reaction based on his training.
 30 UNCLASSIFIED UNCLASSIFIED
(Annexes 85C, 130C). Without slowing down, the car continued toward the Warning Line with the spotlight and laser still on it. (Annexes 79C, 87C, 129C).
(U) The car continued to approach at a high rate of speed, coming closer to the Soldiers than any other vehicle that evening. (Annexes 79C, 87C, 129C). When the car got to the Warning Line, Specialist Lozano, while still holding the spotlight in his left hand, used his right hand to quickly fire a two to four round burst into a grassy area to the on-coming vehicle’s right (the pre-set aiming point) as a warning shot. (Annexes 79C, 87C, 125C, 129C, 134C).
(U) The vehicle maintained its speed as it went beyond the Warning Line. (Annexes 77C, 79C, 81C, 83C, 129C, 131C, 132C, 133C). Staff Sergeant Brown, a New York City Police Officer trained in vehicle speed estimation, estimated the car was traveling at 50 mph and believed that it would not be able to stay on the road around the curve at that speed. (Annex 83C). Specialist Lozano dropped the spotlight and immediately traversed his weapon from his left to his right, without having to move the turret, to orient on the front of the car. With both hands on the weapon, he fired another burst, walking the rounds from the ground on the passenger’s side of the vehicle and towards the car’s engine block in an attempt to disable it. (Annexes 77C, 79C, 81C, 83C, 87C, 129C, 131C, 132C, 133C). The rounds hit the right and front sides of the vehicle, deflated the left front tire, and blew out the side windows. (Annexes 104C, 105C, 132C, 1I).
(U) Mr. Carpani reacted by saying into the phone, “they are attacking us,” not knowing who was shooting at him. (Annexes 103C, 104C, 105C). He stepped on the brakes, curled up on the left side of the car, and dropped the phone. (Annexes 104C, 105C). Specialist Lozano stopped firing as he saw the car slow down and roll to a stop. Approximately four seconds had elapsed between the firing of the first round and the last round, and no more than seven seconds from the time the car crossed the Alert Line until it came to a stop. (Annexes 77C, 79C, 81C, 83C, 87C, 129C, 131C, 132C, 133C, 134C). The car came to a stop near the middle of the on-ramp, such that the first Jersey barrier was aligned with the vehicle between the front and back doors. (Annexes 79C, 83C, 105C).
F. (U) Post-Incident Events
(U) Once the car came to a stop, Mr. Carpani got out of the car with his hands raised, cell phone in one hand, and told the Soldiers that he was from the Italian Embassy. (Annexes 77C, 79C, 81C, 83C, 85C, 104C, 130C, 131C, 132C, 133C, 134C). Second Lieutenant Acosta, Staff Sergeant Brown, Sergeant O’Hara, and Specialist Peck approached the car with weapons raised and secured the driver. (Annexes 130C, 131C, 132C, 133C). Staff Sergeant Brown patted him down and asked him if there were others in the car. Mr. Carpani said there were two others and that there was one weapon on the front seat and another on the male passenger in the back seat. He warned Staff Sergeant Brown that both weapons had a round in the chamber. Staff Sergeant Brown then moved
 31 UNCLASSIFIED UNCLASSIFIED
Mr. Carpani about 10 meters away from the car and off to the side of the road to question him and examine him. After initially taking control of the cell phones as well as Mr. Carpani’s and Mr. Calipari’s identification and badges, Staff Sergeant Brown returned those items to Mr. Carpani. At some point, Staff Sergeant Brown directed the car be placed in park since the car continued to roll. (Annexes 83C, 105C).
(U) Sergeant O’Hara and Second Lieutenant Acosta searched the vehicle. (Annexes 77C, 81C). Second Lieutenant Acosta ordered Sergeant Domangue to inform Captain Drew and to send Specialist Mejia over with his medical kit. Specialist Mejia arrived at the car and found Mr. Calipari gravely injured. Specialist Mejia was able to bandage Mr. Calipari’s wound, but Mr. Calipari died a few minutes later. Specialist Peck also tried to assist with Mr. Calipari. He then returned to the blocking vehicle and relieved Specialist Lozano in the turret to allow him to collect himself. (Annex 85C, 130C). Specialist Mejia then turned his attention to Ms. Sgrena’s wounds. (Annex 89C, 128C). He tried to administer an IV, but his needles were too large. Meanwhile, Sergeant O’Hara bandaged Ms. Sgrena’s shoulder wound. (Annexes 128C, 132C).
(U) Captain Drew then arrived on the scene along with Specialist Silberstein, who was a qualified medic. (Annexes 127C, 128C, 133C, 134C). Specialist Silberstein assessed Ms. Sgrena and treated her for shock. He then confirmed that Mr. Calipari was dead. (Annex 127C). Captain Drew assessed the situation, passed all available information to his command, and ordered the casualties to be evacuated to the Combat Support Hospital (CSH) in the International Zone for treatment of their wounds. He also requested an ambulance for Mr. Calipari’s body. (Annexes 74C, 133C, 137C). Ms. Sgrena was loaded into the blocking vehicle and proceeded to the CSH with the overwatch vehicle following as U.S. military vehicles do not travel alone. (Annexes 127C, 128C, 129C, 130C, 132C, 133C). Mr. Carpani was transported later by a separate vehicle from another element of Captain Drew’s patrol. (Annex 136C). All equipment in the vehicle before the shooting was later returned to Mr. Carpani. (Annex 4M).
(U) Before Mr. Carpani was transported to the CSH, he made at least seven phone calls on his cell phone. He tried asking how his companions were but was unable to get an answer. (Annexes 104C, 105C). Sergeant First Class Feliciano arrived with Captain Drew and found that Mr. Carpani spoke Spanish, as did Sergeant First Class Feliciano. He was able to tell Mr. Carpani about the condition of his companions. (Annex 91C)
(U) Mr. Carpani told Sergeant First Class Feliciano who Ms. Sgrena was and that he was trying to get to the airport. He told Sergeant First Class Feliciano that he heard shots from somewhere, and that he panicked and started speeding, trying to get to the airport as quickly as possible. Mr. Carpani further told Sergeant First Class Feliciano that he continued to speed down the ramp, and that he was in a hurry to get to the airport. (Annexes 91C, 136C).
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(U) Mr. Carpani became a little dizzy, so Sergeant First Class Feliciano got some water for him. Mr. Carpani kept making phone calls. He contacted Mr. Castilletti who put Captain Green on the phone. Mr. Carpani then had Captain Drew talk to Captain Green. Mr. Carpani kept on insisting that he wanted to go to the airport. After one of the phone calls, though, he said he needed to go to the hospital where Ms. Sgrena had been taken. (Annex 91C).
(U) The incident was reported through command channels, and the Commanding General, 3ID ordered an immediate commander’s inquiry/preliminary investigation into the incident. Before the investigator had arrived on the scene, the HMMWVs involved in the incident had departed to the CSH and the car had been moved in an effort to clean up the site so that the on-ramp could be re-opened. The Commander, 2/10 MTN arrived about two hours after the incident and ordered the car be put back in its stopped position to support the commander’s inquiry as much as possible. (Annex 65C).
G. (U) Forensic Evidence
1. (U) 5 March 2005 Report
(U) Photographs of the incident scene were taken in the hours after the incident by Combat Camera personnel, as advised by CID personnel. (Annexes 32K – 69K). The exact locations of the three incident vehicles could not be determined since the two HMMWVs had been moved upon transporting Ms. Sgrena to the Combat Support Hospital, and the car had been moved during cleanup efforts at the site. (Annex 5I).
2. (U) 11 March 2005 Report
(U) The forensic investigation of the incident scene conducted on the morning of 11 March 2005 provided the following distances between relevant points based on GPS measurements3 :
• (U) Blocking vehicle to Alert Line – 389 feet, 7 inches (118.8 meters)
• (U) Blocking vehicle to Warning Line – 272 feet (82.9 meters)
• (U) Blocking vehicle to disabled vehicle stop point – 125 feet (38.1 meters)
• (U) Disabled vehicle stop point to Warning Line – 147 feet (44.8 meters)
33
(U) 3  The position of the Toyota was determined from photographs taken before it was moved during cleanup efforts. The blocking vehicle location comes from GPS readings provided by the Preliminary Investigating Officer based on witness statements regarding its position at the time of the incident.
 UNCLASSIFIED UNCLASSIFIED
• (U) Disabled vehicle stop point to Alert Line – 264 feet, 7 inches (80.7 meters)
• (U) Alert Line to Warning Line – 117 feet, 7 inches (35.9 meters)

(Annexes 5I, 143K).
3. (U) 14 March 2005 Report
(U) A forensic examination of the car was performed after its removal from the scene. This analysis disclosed 11 entrance bullet holes. They are consistent with 7.62 mm bullets. Three bullets perforated the front section of the car at the bumper, right head light, and right fender. Two bullets perforated the windshield. Six bullets perforated the right side, right door, right front and rear passenger windows. No bullet holes or ricochet damage was noted on the car’s undercarriage. (Annex 1I).
(U) The trajectory analysis demonstrated that all 11 bullets came from one point of origin. The actual distance from the car to the machine gun could not be conclusively determined because of several variables: the grade of the curve and curvature of the roadway; depressions or elevations of the terrain; the lateral movement of the car; human reaction time, modulation of speed and braking by the driver; a flat tire; and lateral and vertical movement of the machine gun. The security situation at the incident site prevented examiners from visiting the scene. (Annex 1I).
4. (U) BP 541 Traffic Samples
(U) On Friday, 25 March 2005, a certified radar operator conducted two traffic samples at BP 541. From 1809 hours to 1824 hours, 27 vehicles were clocked. The average speed at the Alert Line was 44 mph. The average speed at the beginning of the on-ramp’s curve was 24 mph. From 1956 hours to 2015 hours, 30 vehicles were clocked. The average speed at the Alert Line was 46 mph. The average speed at the beginning of the curve was 26 mph. Unlike the night of the incident, which was also a Friday, the road was dry during these samples. (Annex 1M).
5. (U) Number of Rounds
(U) The ammunition box in the blocking vehicle originally contained 200 rounds. There were 142 rounds remaining in the M240B ammunition box. No casings were collected. Eleven rounds hit the vehicle. The weapon had been fired on seven previous occasions using the same ammunition box. As such, there were no more than 40 additional rounds that could have been fired. (Annexes 85C, 99C).
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H. (U) Findings
(U) Second Lieutenant Acosta was under a time constraint to establish the BP quickly and expected to be in position for a very limited time, i.e., no more than 15-20 minutes. Further, the position was on a tight curve that caused Second Lieutenant Acosta to make less than optimal choices in positioning his vehicles. Still, Second Lieutenant Acosta properly considered and employed the factors of METT-TC in deciding where to emplace his two vehicles so as to provide vehicle stand-off, force protection, overwatch field of view, and clear line of sight for the spotlight operator. From 15-30 vehicles were turned around without incident based upon how the position was established. (Annexes 77C, 79C, 81C, 83C, 87C, 1F, 2F, 3F).
(U) At the time of the incident, there were only two HMMWVs, and seven U.S. military personnel, at BP 541. Both the blocking vehicle and the overwatch vehicle were positioned on the on-ramp, facing Route Irish. There were no other vehicles, or Soldiers in the immediate vicinity of BP 541, and the BP could not be seen by any other BPs on Route Irish. (Annexes 77C, 79C, 81C, 83C, 85C, 87C, 89C, 117C, 118C, 119C, 120C, 121C, 122C, 123C, 124C).
(U) The Soldiers had a heightened sense of awareness because of the two VBIED BOLOs, one for a black car, another for a white car. (Annexes 74C, 77C, 13E, 14E). Given the number of vehicles that had been stopped and turned around, and this awareness of VBIEDs, it is highly unlikely that Specialist Lozano was not paying attention. Further, Specialist Lozano had recently rotated into the position, replacing Specialist Peck, to ensure that there was a fresh set of eyes in the turret. (Annexes 79C, 85C). Rotating qualified personnel in and out of the turret to maintain alertness was a wise decision by the BP 541 leadership.
(U) Ineffective battle tracking procedures (communications, log posting, and information sharing) at the 1-76 FA TOC caused A Company, 1-69 IN to be left in their blocking positions longer than expected. The night of 4 March 2005 was the last night of the Left Seat Ride for 1-76 FA, and 4-5 March 2005 was the first full duty day for the unit. (Annexes 59C, 63C, 97C).
(U) The spotlight and green laser pointer had proven effective in stopping and turning around vehicles before the car with the Italians arrived at the on-ramp. Many of the vehicles, though, screeched their tires when stopping. While effective for accomplishing the mission, the spotlight and laser pointer may not be the best system from a civilian point of view. (Annexes 77C, 79C, 81C, 83C, 87C, 132C)
(U) Specialist Lozano did not drop the spotlight until after he fired the warning shots, then immediately transitioned to two hands on his weapon as he fired the disabling shots. (Annexes 79C, 83C, 85C, 87C).
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(U) Specialist Lozano spotlighted the car before it reached the Alert Line, fired warning shots as it reached the Warning Line, and fired on the vehicle in an attempt to disable it immediately after it crossed the Warning Line. (Annexes 79C, 87C, 129C, 134C).
(U) Specialist Lozano was the only one to fire his weapon. (Annexes 77C, 79C, 81C, 83C, 85C, 87C, 89C).
(U) The car was traveling at approximately 50 mph as it crossed the Warning Line. (Annex 83C).
(U) Mr. Carpani did not apply his brakes until after the rounds began striking the car. (Annexes 104C, 105C).
(U) Given the cyclic rate of fire of the M240B, Specialist Lozano’s expertise with the weapon, and that only 11 rounds struck the vehicle with only five of those impacting the front of the car, it is highly unlikely that any shots were fired after the car came to a stop. (Annexes 79C, 6G, 1I, 3M).
(U) Both the blocking and overwatch vehicles were moved after the incident as directed by Captain Drew to transport Ms. Sgrena to the Combat Support Hospital. Both vehicles were needed to provide security for the move to the hospital. (Annexes 74C, 77C).
(U) The gunner complied with the Rules of Engagement. After operating the spotlight, and perceiving the on-coming vehicle as a threat, he fired to disable it and did not intend to harm anyone in the vehicle. (Annexes 79C, 83C).
(U) There were a number of unrelated events that had a role in the incident. These were: (1) bad weather forcing a VIP to convoy on Route Irish that evening vice the preferred method of traveling by helicopter; (2) communications problems involving a unit new to the AOR that caused the Soldiers to be left in position longer than expected; (3) the recovery of Ms. Sgrena being pushed back daily, for several days, to 4 March 2005; (4) the Italians did not know the Soldiers were at the on-ramp, and were not expecting any such roadblocks; and (5) the Soldiers did not know the Italians were traveling to BIAP. (Annexes 51C, 52C, 57C, 59C, 60C, 61C, 63C, 97C, 104C, 105C, 107C, 109C, 116C, 117C, 118C, 119C, 120C, 121C, 122C).
(U) Mr. Carpani was driving faster than any other vehicle observed by the Soldiers that evening. He failed to stop for the spotlight since he was not expecting a roadblock. Additionally, he was dealing with multiple distractions including talking on the phone while driving, the conversation in the back seat, trying to listen for threats, driving on a wet road, focusing on tasks to be accomplished, the need to get to the airport, and the excited and tense atmosphere in the car. (Annexes 104C, 105C, 125C, 140C). Any one of these would have affected his reaction time.
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I. (U) Recommendations
(S//NF) Recommend the Force Protection Working Group consider the use of additional non-lethal measures (e.g., spike strips, temporary speed bumps, and wire) be emplaced to slow down or stop vehicles before the use of disabling shots. The intent is to provide as many non-lethal options as possible before asking a Soldier to focus on firing the weapon.
(U) Recommend that the Force Protection Working Group, in conjunction with MNC-I Information Operations, propagate a Public Awareness/Public Service Campaign to inform all drivers of their responsibilities for behavior when approaching and while at Coalition Checkpoints. This information could be posted on panels or boards at airports and other major transportation centers, as well as in pamphlets to be distributed from various locations, to include rental car agencies and border control points. This public awareness campaign should enhance safe operations by promoting mutual trust, cooperation, and confidence for Coalition Forces and Iraqi citizens as well as formally outlining expected driver behavior throughout the AOR.
(U) Recommend the Force Protection Working Group consider the following points as they develop the MNC-I SOP for TCP operations:
• (S//NF) Different signs for ECPs, TCPs, and BPs. For example:
 o (S//NF) Road Closed – Do Not Enter (for BPs).
 o (S//NF) Coalition Checkpoint Ahead – Proceed Slowly and Follow Directions (for TCPs).

(U) Signs written in Arabic and English should, where possible, also incorporate international symbols to accommodate foreign nationals as they begin operating in Iraq.
• (S//NF) Highly visible and quickly deployable checkpoint and roadblock warning signs for Soldiers on patrol.
• (S//NF) Standards for when and how to use spotlights and lasers.
• (S//NF) The use of hand-held signs as an alternative to hand-and-arm signals.

(U) Recommend a review of frequently established TCP locations to consider the use of existing permanent highway overpass signs that warn drivers that checkpoints may be upcoming (e.g., “Possible Checkpoint Ahead – Next Exit”).
(S//NF) Recommend an assessment of the current technique of requiring the gunner to operate both the spotlight and the weapon in the turret of the vehicle. This will allow more reaction time and simplify duties and responsibilities of the gunner.
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(U) Further recommend a transition to a more driver friendly alert signal by substituting devices such as rotating warning lights and sirens to replace spotlights as early warning tools.
(U) Recommend periodic reviews of Right Seat/Left Seat Ride Relief in Place procedures based on:
• (S//NF) Transfer of Authority between units (before and after).
• (S//NF) Changes in MTOE equipment.
• (S//NF) Significant changes in the operational environment.

(S//NF) These reviews will ensure there is rigor in enforcing standards and essential tasks in accordance with existing SOPs. Further recommend MSC enforcement of “Right Seat/Left Seat Ride” certification programs where outgoing commanders certify incoming units’ ability to perform required tasks before TOA. This will ensure Soldiers and leaders can properly execute tasks to standard and understand the reasons for tasks that deviate from established procedures as a result of any recent changes.
(S//NF) Recommend the MSC Commanders review MNF FRAGO 1269/5 2005 Dec 04 with subordinate commands to ensure thorough fratricide reporting and investigation of fratricide incidents. The use of Rapid Response Teams (SJA, PAO, PMO, CID, Safety, etc.) to provide support to the on-site commander is highly recommended.
(U) Recommend development of a casualty post-incident procedure reference guide to assist junior leaders in accurately preserving incident scenes as much as time and the tactical situation allow.
(S//NF) Some key pieces of information could include:
• (S//NF) Diagram of the scene to include exact grid of locations of personnel/equipment included.
• (S//NF) Amount of ammunition expended.
• (S//NF) Digital photos.
• (S//NF) Chronology of events.
• (S//NF) Personnel involved with the incident.
38 • (S//NF) Personnel on-site at the time of the incident.
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• (S//NF) Permission to stand down or remove any equipment.

(U) Recommend that no disciplinary action be taken against any Soldier involved in the incident.
(U) Recommend that this report be circulated to all MNC-I Major Subordinate Commanders for use as an After Action Review tool.
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V. COORDINATION
A. (U) Introduction
(U) This section addresses the status of coordination with MNF-I, MNC-I, and their subordinate units regarding the recovery and transport of Ms. Sgrena on 4 March 2005. Further, it examines the role that Captain Green played in this incident.
B. (U) MNF-I/MNC-I Involvement
(U) When moving through another unit’s battlespace in a combat zone, coordination with forces in the area is required for situational awareness, and, more importantly, for deconfliction of unit movements, positioning, and operations. For example, 2/10 MTN has successfully coordinated and executed previous movements and operations of units and forces not assigned to their AOR. The unit had coordinated, sometimes on relatively short notice, with numerous Joint Special Operations Units, Special Missions Units, and Special Tactics Units before 4 March 2005, with no incidents. (Annex 65C).
(U) To determine who or what organizations were aware of the Sgrena recovery and transport operation, sworn statements were taken from key military officials within MNF-I, MNC-I, and their subordinate units that, by their function, would have had access to information about such an operation. A statement was also provided by the Political Military Counselor, U.S. Embassy Baghdad. The results are listed below:
• (U) No one at the U.S. Embassy, including the Political Military Counselor, knew about the Sgrena operation until after the shooting incident had occurred. (Annex 114C).
• (U) No one within the MNF-I leadership knew about the Sgrena operation until after the shooting incident had occurred. (Annexes 1C to 27C).
• (U) No one, with one exception to be addressed below, within the MNC-I leadership knew about the Sgrena operation until after the shooting incident had occurred. (Annexes 28C to 43C).
• (U) No one within the 3ID leadership knew about the Sgrena operation until after the shooting incident had occurred. (Annexes 44C to 56C).
• (U) No one within 4 BCT knew about the Sgrena operation until after the shooting incident had occurred. (Annex 5M).
• (U) No one within the 1-76 FA leadership knew about the Sgrena operation until after the shooting incident had occurred. (Annexes 58C to 63C).
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• (U) No one within the 2/10 MTN leadership knew about the Sgrena operation until after the shooting incident had occurred. (Annexes 65C to 71C).
• (U) No one within the 1-69 IN leadership knew about the Sgrena operation until after the shooting incident had occurred. (Annexes 72C, 96C to 99C).
• (U) No one at the BIAP Command Post knew about the Sgrena operation until after the shooting incident had occurred. (Annex 110C).
• (U) No one at the Hostage Working Group knew about the Sgrena operation until after the shooting incident had occurred. (Annex 126C).
• (U) No one with A Company, 1-69 IN knew about the Sgrena operation until after the shooting incident had occurred. (Annexes 76C, 78C, 80C, 82C, 84C, 86C, 88C, 90C, 92C).

(U) Thus, it can be positively stated that the U.S. military was totally unaware of the recovery and transport of Ms. Sgrena on 4 March 2005 until after the shooting incident had occurred.
C. (U) Captain Green
(U) Captain Green (USA) is the Aide-de-Camp to Major General Mario Marioli (ITAR), DCG, MNC-I. (Annex 107C). As early as 28 February 2005, Captain Green was aware that a number of Italian VIPs would be coming into BIAP. The date for their arrival kept getting pushed back. He was aware that the VIPs would be involved in working the Sgrena hostage situation. Captain Green knew no specifics beyond that. (Annexes 107C, 109C).
(U) At approximately 1330 hours on 4 March 2005, Captain Green, Lieutenant Colonel Zarcone (ITAR), and one PSD departed for BIAP, arriving at about 1350 hours. Major General Marioli and another PSD arrived shortly thereafter. (Annex 107C). The plane finally arrived at 1626. (Annex 1H). Eleven passengers deplaned and were immediately taken to the Al Faw Palace at Camp Victory. There, security badges were obtained for five of the VIPs. (Annexes 106C, 107C).
(U) Captain Green accompanied three Italian VIPs, Major General Marioli, and two PSDs in three cars to a location about one kilometer beyond Checkpoint 539 on Route Irish. Two Italians left, heading into Baghdad. The rest of the group waited at the site for a short while, returned to Camp Victory, then went back to the spot past Checkpoint 539. Major General Marioli did not want Captain Green to go back out to Checkpoint 539, but Captain Green, as his aide, insisted since his presence would be necessary to interface with the U.S. security forces in the area. (Annexes 100C, 106C, 107C).
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(U) At approximately 2030 hours, Major General Marioli approached Captain Green and asked him how he was doing and if Lieutenant Colonel Zarcone had told him what was going on. Captain Green said no, but that he suspected it had something to do with the Italian journalist. Major General Marioli said “Yes, but it is best if no one knows.” Captain Green took this as an order from a General Officer not to pass that information on to anyone. (Annex 109C). Moreover, Major General Marioli did not intend for Captain Green to take any action whatsoever on that information. He only told Captain Green so that he would not be surprised when Ms. Sgrena arrived. (Annex 100C).
(U) Approximately 20 minutes later, a phone call came in to the third Italian VIP at the site near Checkpoint 539. The call brought news of the shooting. Captain Green made contact with U.S. personnel in a nearby Bradley Fighting Vehicle and confirmed the shooting. Captain Green subsequently was able to speak with Captain Drew at BP 541. Captain Green discussed the matter with Captain Drew and relayed to Major General Marioli that it was best for them to return to Camp Victory as the wounded were being transported to the Combat Support Hospital in the International Zone. (Annex 107C). Major General Marioli was very appreciative of Captain Green’s coordination efforts following the shooting. (Annex 100C).
(U) Captain Green was not informed of the recovery and transport of Ms. Sgrena until a short time before the incident at BP 541 occurred. (Annex 109C). He was not expected to take any action in the matter as it was an Italian national issue, nor was he in a position of any authority to do so. (Annex 100C). He was obeying an order from Major General Marioli. (Annex 109C).
D. (U) Findings
(U) No U.S. military personnel within MNF-I, MNC-I (to include Captain Green), or subordinate units were informed by the Government of Italy of the hostage rescue mission that occurred on 4 March 2005. (Annexes 1C to 56C, 58C to 63C, 65C to 72C, 76C, 78C, 80C, 82C, 84C, 86C, 88C, 90C, 92C, 96C to 99C, 110C, 114C, 126C, 7M).
(U) Not coordinating with U.S. personnel was a conscious decision on the part of the Italians as they considered the hostage recovery an Intelligence mission and a national issue. (Annex 100C).
(U) Based upon previous successful coordination efforts by 3ID and 2/10 MTN working with organizations from various agencies outside their chain of command, it is clear that, while the hostage recovery operation may have otherwise been a success, prior coordination might have prevented this tragedy. Iraq is still a hostile environment, i.e, a combat zone, and the more coordination that can be done to increase situational awareness of those operating within the battlespace, the better it is for all involved. (Annex 65C).
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