Air Force Officials Disciplined Over Handling of Human Remains

Washington – Three senior officials at Dover Air Force Base in Delaware, sacred ground for the military and the main entry point for the nation’s war dead, knew they had lost body parts of two service members killed in Afghanistan but did nothing to correct sloppy practices at the base mortuary, the Air Force said Tuesday.

An 18-month Air Force investigation said the officials had displayed “gross mismanagement” at the mortuary, the largest in the nation and an increasingly hectic place as the wars in Iraq and Afghanistan sent the remains of thousands of American men and women to Dover.

In its own report on Tuesday, the Office of Special Counsel, the agency that handles whistle-blower complaints within the federal government, offered scathing criticism of the Air Force’s handling of the affair and raised questions about the thoroughness of its investigation. Both inquiries were the result of complaints last year from three civilian employees of the Dover Port Mortuary, either embalmers or technicians, who alleged that there had been 14 sometimes gruesome failures at the facility, including one instance when mortuary employees sawed off a dead Marine’s arm without consulting his family.

The three senior officials were disciplined but not fired. Col. Robert H. Edmondson, the former commander of the Air Force Mortuary Affairs Operations Center, who left his position as part of a regular rotation last year, received a letter of reprimand, effectively ending any further promotions. Trevor Dean, Colonel Edmondson’s former deputy, and Quinton R. Keel, the former mortuary director, both civilians, were demoted within the last two months and moved to lesser jobs at Dover, although not in the mortuary.

The chief of staff of the Air Force, Gen. Norton A. Schwartz, called the lapses “systemic issues.” He said that they had since been corrected but that he could not say for sure that other mistakes had not been made. He acknowledged one notable statement in the Air Force investigation from an unnamed mortuary employee — that the mortuary lost body parts “every two years” — and said the Pentagon had named a panel to further review procedures at Dover.

“We and every employee of the Dover Port Mortuary understand the obligations of this work, the sanctity of this work, the necessity, the need for reverence, the need for dignity and respect for our fallen, just as if these were our sons and our daughters,” General Schwartz said Monday, a day before the investigation’s findings were released.

In a cover letter accompanying the special counsel’s report, Carolyn N. Lerner, the head of the office, said that although the Air Force had taken many important steps to correct problems, Mr. Keel and Mr. Dean should have been fired. “I am concerned that the retention of these individuals sends an inappropriate message to the work force,” Ms. Lerner wrote.

In particular, the special counsel’s report asserts that Mr. Keel repeatedly tried to cover up mistakes in the handling of remains and misrepresented his role in several important decisions. He also tried to fire two of the whistle-blowers after becoming aware of the investigation, but superiors overruled him, officials in the Office of Special Counsel said.

The disposition of war dead is a deeply emotional issue for the American military, which has sought in recent years to handle the remains of those killed on the battlefield with painstaking care. Dover in particular has projected an image of a hallowed place as presidents, hundreds of government officials and thousands of grieving families have met the flag-covered cases of loved ones that come out of the bellies of transport planes for solemn ceremonies on the tarmac. Since 2009 the Pentagon has allowed those ceremonies to be photographed for the nation to see.

But the Air Force investigation offers a graphic and disturbing account of what can occur when the cases move out of public view to the mortuary, at least in the instances of the lost body parts — a fragmented ankle from a soldier killed by a bomb in Afghanistan in April 2009, and a 1 ½-by-3 ½-inch piece of flesh from an airman who died in a fighter jet crash in Afghanistan in July 2009.

Although the investigation said the loss of the two body parts “equates to an aggregate success rate slightly greater than 99.9 percent” when based on the thousands of remains and body parts received at the mortuary, “the success rate for families of the deceased in the two individual cases is zero percent.” The investigation termed the lost body parts “mission failure.”

The investigation did not uncover what happened to the body parts, but held out the possibility that they fell out of plastic Ziploc bags while stored in a large refrigerator in the mortuary and ended up in tubs with the remains of another service member or perhaps cremated. A number of mortuary employees were quoted in the investigation as saying that medical examiners frequently sliced into the bags to conduct DNA analysis on the body parts. However, three medical examiners interviewed in the investigation said they did not slice into the bags.

Whatever occurred, the investigation describes a mortuary that had to manage the devastating effects of homemade bomb attacks, the No. 1 cause of military deaths in Iraq and Afghanistan, as well as frequent calls to handle mass casualties. One unnamed mortuary employee told investigators about a particularly busy day in July 2009 when the remains arrived of two airmen killed in a fighter jet crash in Afghanistan.

The employee described the medical examiners as taking body parts out of the Ziploc bags for DNA analysis and said, “It was kind of hard to keep track of everything.” The employee said the examiners “were kind of messing with the bags a lot, and then they would walk to the back, and then they’d come back and — it was — it was a really hectic day.”

The Office of Special Counsel report also took issue with the Air Force on the mortuary’s handling of the remains of a Marine killed by a roadside bomb in Afghanistan in January 2010.

The Marine’s family had asked that they see their son one last time in uniform, but the heat from the bomb had apparently fused a 12- to 15-inch portion of his left arm bone to his body and it was sticking out, unmovable, perpendicular to his torso.

Mortuary employees could not fit the Marine in either his uniform or his coffin, and so without consulting the family Mr. Keen ordered the employees to saw off the bone. They did so, and put it in the uniform’s pants. Although the Air Force said that mortuary officials should have told senior Air Force leadership what had happened, they did not have to get permission from the family. The special counsel found that conclusion “not reasonable.”