Infighting, mishandled cases, questionable record keeping, alleged office romances and a lurid rumor mill led an Air Force Academy investigator to find that the school's Sexual Assault Prevention and Response Office was "derelict in the performance" of duties and bungled care for victims.
The scaldingly critical report called for the firing of the office's former boss, Teresa Beasley, and revealed an office atmosphere that witnesses compared to a toxic high school.
The 560-page report released to The Gazette under the federal Freedom of Information Act shows that some victims were ignored - this as the office's victim advocates filed claims and counterclaims of inappropriate conduct against each other.
"The amount of evidence demonstrating a lack of competency and ability in delivering professional victim care is overwhelming," the investigation found. "It wouldn't be feasible to try to rehash - or even summarize - all the issues and concerns borne out by witness testimony."
The office is the academy's first line of care for victims of sexual assault and also provides training to the school's staff and cadets in a bid to prevent sexual assaults.
The academy had 45 sexual assault reports in 2016, more than the Naval Academy and the U.S. Military Academy combined.
But the new report said record keeping by the sexual assault office was so shoddy that investigators now question whether the number of sexual assaults reported in the last 10 years is even accurate.
The report substantiated three claims against Beasley, who has since resigned:
- Failure to "effectively manage" the office.
- Spreading rumors about personnel.
- Lack of competency that jeopardized the "delivery of professional victim advocacy."
Beasley couldn't immediately be contacted for comment. A telephone number for Beasley was no longer in use.
Three other claims investigated in the report were redacted, with the academy citing privacy concerns.
The probe was ordered in May by former academy Superintendent Lt. Gen. Michelle Johnson, who told investigators to examine the "culture and climate" of the office. Johnson also ordered an investigation of "unprofessional relationships and inappropriate comments of a sexual nature" in the office.
The academy later suspended four of six office employees.
The school in recent months has appointed an interim director for the office and has hired new staffers to augment and airmen pulled in to fulfill its obligations.
The office's interim leader, Kimberly Dickman, said the pick-up team came together from bases around the Pikes Peak region and has focused on caring for victims while the tumult that followed the report and Beasley's departure subsides.
"The team that's in there now is highly qualified," Dickman said.
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"I admit that during my first seven years on the job, I wasn't a leader or a manager at all." - Statement of Teresa Beasley in the report
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The Sexual Assault Prevention and Response Office, referred to by cadets with an acronym pronounced "sapper," grew from the darkest chapter of the school's history. The academy was plunged into scandal in 2003 when dozens of women came forward with claims that their reports of sexual assault were mishandled or ignored.
Under Beasley, who came to Colorado Springs in 2007, the academy office was held up as an example of how the school wouldn't allow similar problems to reoccur.
Beasley was praised by Pentagon leaders including Nate Galbreath, deputy director of the Department of Defense Sexual Assault Prevention and Response Office.
"One of the things that the Air Force Academy does exceptionally well is they have a sexual assault response coordinator who is very well-known throughout the academy," Galbreath said of Beasley during a 2014 news conference. "Her - she and her team - work overtime in getting in front of the cadets."
Behind the scenes, though, Beasley led an office known for its chaos, the report found.
"I can't think of anything to call it other than toxic," one witness told investigators.
The names of witnesses were redacted from the report sent to The Gazette.
Another witness "compared the office to a high school with lots of back-and-forth infighting," the report said.
In May, when the report was commissioned, every member of the office had a pending formal human resources complaint against one or more co-workers, the report said.
Investigators say Beasley was at the center of much of the office's woes, which investigators found were fueled by office gossip.
"Ms. Beasley once shared with me that (name redacted) had an intimate relationship with a security forces major," one witness reported. "An additional example was when Ms. Beasley shared with me that she thought (name redacted) was gay even though (pronoun redacted) was married."
Investigators found that Beasley talked about office affairs and once alleged that one of the office's advocates was having sex with an alleged victim of sexual assault.
"No fewer than eight witnesses testified under oath that they had knowledge of Ms. Beasley spreading rumors," the report said.
On the management front, Beasley was often a no-show, investigators said.
"Ms. Beasley's organizational management skills are horrible," one witness told investigators. "She generally keeps to herself and fails to adequately address, let alone resolve personnel issues within the office."
In a statement to investigators, Beasley admitted management struggles.
"I admit that during my first seven years on the job, I wasn't a leader or a manager at all," she said.
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"We had a victim who went several months without (victim advocate) support. Unfortunately the victim ended up on suicide watch at Fort Carson, which might have been preventable." - Witness statement
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Repeated witnesses told investigators that the chaos in Beasley's office left victims of sexual assault without proper care.
The office is responsible for helping any academy victim of sexual assault and is on call 24 hours a day, 365 days a year.
One witness told investigators that a cadet who had reported a pair of sexual assaults in her hometown was caught in the mayhem. The cadet was given two victim advocates. Neither was particularly responsive, the witness said. When the cadet's commander called Beasley to ask who could help, she responded "I don't know," the witness said.
The cadet wound up leaving the academy.
"She was eventually sent back to her hometown where she had been assaulted and - to make matters worse - she was sent home with no support," the witness said. "The whole situation was absolutely unconscionable."
One cadet quoted in the report said the Sexual Assault Prevention and Response Office was best avoided.
"Nobody goes there," the cadet said. "It's too dysfunctional."
Cadets offered repeated complaints about the office, the investigation found, "three of which complained of Ms. Beasley being overly involved, confused about their case, and telling victims what to do rather than explore options."
Other witnesses complained that Beasley's office didn't return phone calls, respond to new reports, or head to the hospital to support a victim undergoing a forensic examination for sexual assault evidence.
"We were at the hospital for nearly five hours total," the witness said. "This kind of disorganization threatens victim care and prolongs an already emotional trauma."
Other victims were neglected, witnesses said.
"We had a victim who went several months without (victim advocate) support," a witness said. "Unfortunately the victim ended up on suicide watch at Fort Carson, which might have been preventable."
Investigators ruled that the workers "were derelict in the performance of their duties" from at least 2014 on.
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"I need accurate data to do my job, and yet I have no confidence in the data the . office produces. . I'm not sure I can trust USAFA data for the past decade." - Witness statement
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The problems in the office included paperwork issues that have leaders wondering whether the number of sexual assaults reported at the school has been accurate in the past 10 years.
The academy has documented sexual assaults in reports sent to the Pentagon and Congress. Those reports found that the academy had a higher number of reports than any of its sister schools.
But some of those reports may have been phantoms, with auditors finding an error rate as high as 44 percent in a Defense Department sexual assault database under Beasley's tenure, the report found.
Beasley was responsible for updating the database but "failed to maintain her credentials to conduct this duty," the report found.
"Ms. Beasley has missed critical sexual assault reporting timelines in three cases," a witness said.
In some cases, incomplete reports were filed to the database, creating reported sexual assaults in cases where victims weren't identified.
A high-stakes report to Congress was handled in a manner that witnesses found remarkably casual.
"On the day the draft report was due . Ms. Beasley provided 17 pages of hand-written notes that were poorly written and lacked verifiable data," a witness said.
The handwritten report came after the Pentagon had chastised the academy for its record keeping.
"The department found that record-keeping and data entry (at the Air Force Academy) was not meeting department standards," a 2015 Pentagon report on sexual assaults at service academies said.
According to regulation, Beasley had sole control of record keeping but filed reports that weren't backed up by paperwork documenting the alleged sexual assaults.
The academy and the Pentagon use sexual assault data to track cases and ensure victims get proper care. The information is also used to identify trends in an effort to combat sexual assault.
But at the academy, leaders said they can't say whether the information they have used for years reflects reality.
"I need accurate data to do my job and yet I have no confidence in the data the office produces," a witness said. "I'm not sure I can trust USAFA data for the past decade,"
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"Let's be clear, these aren't numbers - they're people and even one of them being assaulted is too much." - Lt. Gen. Jay Silveria, academy superintendent
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Leaders at the academy say they moved quickly to suspend problem employees in the office and pull sexual assault experts from other bases in the Pikes Peak region to help at the school.
Academy spokesman Lt. Col. Allen Herritage said there was no interruption in care for those in need.
The academy is also worried that paperwork issues in its Sexual Assault Prevention and Response Office will drive some to assume that the school was hiding its problems.
In an email to The Gazette, academy Superintendent Jay Silveria, who took command in August, said artificially reducing sexual assault numbers would run counter to what he stands for.
"Our goal is to increase the number of reports while decreasing the prevalence of assaults," he said.
Silveria also pointed to a report released by the Pentagon this month that showed the Air Force Academy, with 45, had the highest number of sexual assault reports among service academies.
"Honestly, I have to say that if we're trying to hide numbers, we're doing a horrible job of it," he said.
The restaffed sexual assault office is rebuilding trust among the academy's cadets. Leaders are adding new staffers and growing educational programs that encourage cadets to seek help if they've been assaulted.
More than a third of the reports at the academy last year involved events that happened before the victims entered the Air Force.
"I think that's a good news story, that these cadets felt enough confidence in the system and felt safe enough to trust us in helping them overcome this absolutely horrible part of their past," Silveria said.
The general, though, is not pleased with any reported sexual assault. He made headlines in September by telling cadets that those who would commit such a crime "need to get out."
"Let's be clear, these aren't numbers - they're people and even one of them being assaulted is too much," he said. "We need each and every one of them to perform at their peak to be a lethal force. That is what our nation expects of us."
Contact Tom Roeder: 636-0240