Federal investigators said today they uncovered “gross mismanagement” at the Dover Air Force Base mortuary that cares for America’s war dead after whistleblowers reported horror stories of lost body parts, shoddy inventory controls and lax supervision.
The former mortuary commander and two other senior officials have been disciplined – but not fired — in response to separate investigations conducted by the Air Force Inspector General, the Secretary of the Air Force and the Office of Special Counsel, an independent federal agency that also received the whistleblower complaints.
The grisly findings at Dover echo a similar scandal at another hallowed repository for the military’s dead, Arlington National Cemetery. An Army investigation last year documented cases of misidentified remains at Arlington, dug-up urns that had been dumped in a dirt pile and botched contracts worth millions of dollars. The Army Criminal Investigation Command and the FBI are now conducting a criminal probe there.
The sloppy handling of troops’ remains at Dover and Arlington painfully undercuts what the military has long borne as a sacred obligation: to treat its fallen members and their families with utmost levels of dignity and honor.
“The ultimate requirement here is to fulfill our professional and moral obligation to ensure that our fallen are treated with the reverence and respect they deserve,” said Gen. Norton Schwartz, the Air Force Chief of staff.
Three civilian whistleblowers who work in the mortuary filed complaints last year alleging 14 specific instances of wrongdoing by their supervisors, from endangering public health to losing a dead soldier’s ankle to sawing off a deceased Marine’s arm bone without informing his family.
The whistleblowers also complained that the Dover mortuary permitted an Army hospital in Germany to ship fetal remains in re-used cardboard boxes back to the United States for burial instead of in more-dignified aluminum transfer cases.
The Air Force Inspector General confirmed many of the basic facts in the complaints and documented a pattern of troubles at Dover. But the inspector general did not uphold the 14 accusations filed against three senior mortuary officials, concluding that there was not enough evidence to show that they had personally broken rules or regulations. The Air Force also found no evidence of criminal wrongdoing.
Nevertheless, citing an overall finding of “gross mismanagement” at the mortuary, the Air Force said it recently disciplined the three senior officials.
Col. Robert H. Edmondson, who served as mortuary commander from January 2009 to October 2010, was issued a letter of reprimand for “failure in leadership” – usually a career-ending punishment for a military officer. He is still on active duty but has been reassigned to an Air Force personnel division.
Quinton R. “Randy” Keel, a licensed funeral director and mortician who served as division director at the mortuary, was demoted in August. He no longer works at the mortuary but has been assigned to another position at Dover Air Force Base, where he works as a survivor-assistance program manager, officials said.
Trevor Dean, a mortician and funeral director who served as Edmondson’s top civilian deputy, also still works at Dover. The Air Force had sought to suspend him for 14 days, but instead he voluntarily accepted a transfer to a lesser, non-supervisory position in September, Air Force officials said.
Keel and Dean were both sanctioned by the Air Force for displaying a “lack of candor” with investigators. Keel, Dean and Edmondson all declined a request for comment through an Air Force spokesman.
Air Force officials said they have ordered record-keeping changes, extra security and other reforms because of the whistleblower complaints, which stemmed from several incidents between 2008 and 2010.
At the Air Force’s request, a panel of public health experts headed by former Surgeon General Richard Carmona will also conduct an independent review of Dover’s mortuary operations in the next 60 days.
The Air Force also has established a 24-hour toll-free hotline – 1-855-637-2583 – to answer possible questions from relatives of service members killed in action. The Dover mortuary processed over 4,000 sets of human remains from 2008 to 2010, the bulk of them from troops killed in Afghanistan and Iraq.
Troubles at the Dover mortuary became apparent in April 2009 when technicians noticed something amiss while conducting an inventory of body parts stored in a walk-in refrigerator.
A Ziploc bag that was supposed to contain a shattered ankle from a soldier killed in Afghanistan was empty, according to the Air Force investigative reports. The ankle had been stored in the refrigerator seven months earlier, but the plastic bag was slit at the bottom and a frantic search of the mortuary turned up no sign of it.
The mortuary is supposed to keep a strict inventory of the thousands of corpses and body parts that are processed at Dover. It is a critical mission given that violent roadside bombs are the leading cause of death in Afghanistan and Iraq. In catastrophic cases, troops’ remains can be intermingled; it is up to medical examiners and technicians at the mortuary to sort them out with DNA testing and other means so that each person’s remains can be properly identified.
As mortuary officials tried in vain to find the missing ankle, they learned that a similar problem had occurred three months earlier, when two plastic bags containing body parts were also found empty. In that case, technicians found what they believed were the missing remains in trays directly underneath the refrigerated storage racks where the plastic bags were located.
Although mortuary officials told investigators that they thought they had taken care of the problem, another empty plastic bag was found in the refrigerator in July 2009.
Missing was a four-inch long piece of flesh recovered from an F-15 fighter jet crash in Afghanistan; two airmen had died and medical examiners weren’t certain to whom the missing body part belonged. It was never located.
Another problem surfaced in January 2010 when a Marine killed by a roadside bomb in Afghanistan arrived at the mortuary. Although his body was shattered from the waist down, his family requested that he be buried in his dress uniform.
Morticians tried to honor the request but couldn’t fit the Marine into his uniform or a coffin because a section of his left arm was sticking out at a 90-degree angle; the arm bone had been fused in the heat of the explosion and could not be moved.
Keel ordered a mortician to saw off the bone and place it in a bag in the casket along with the rest of the Marine’s remains. Some technicians at Dover vigorously objected, saying it amounted to “mutilation” of the body and that the family should have been consulted. Keel overruled them.
The Air Force Inspector General and other Air Force officials found that Keel did the right thing because he was attempting to honor the family’s wishes for an open-casket funeral.
Investigators from the Office of Special Counsel, however, disagreed, saying that the handling of the Marine’s body was inconsistent with “the highest standards in the funeral service profession.”
The three whistleblowers remain employed at the Dover mortuary. Federal investigators said they agreed to make their names public. Air Force investigative reports identified them as Mary Ellen Spera, a mortuary inspector; James G. Parsons, Sr., an autopsy and embalming technician; and William D. Zwicharowski, the mortuary branch chief at Dover.
Air Force officials said there was no evidence that they were subjected to reprisals as a result of their complaints. “We definitely both respect and appreciate the fact that they raised these issues because we’re going to be better for it,” said Schwartz, the Air Force chief of staff.
{The Washington Post/Matzav.com Newscenter}
