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AF leaders accept blame for mishandled remains

Nov. 8, 2011 - 09:51PM   |   Last Updated: Nov. 8, 2011 - 09:51PM  |  
An Army carry team moves a transfer case during a dignified transfer at Dover Air Force Base.
An Army carry team moves a transfer case during a dignified transfer at Dover Air Force Base. (Mark Wilson / Getty Images)
Air Force Col. Robert Edmondson salute as an Army carry team carries a transfer case at Dover Air Force Base, Del., in 2010. Edmondson received a letter of reprimand and was put in a staff job at the Pentagon in the wake of an investigation that found that human remains were lost twice at Dover in 2009. (Steve Ruark / The Associated Press)


The Air Force has set up a toll-free number for families of fallen service members with questions about the Office of Special Counsel investigation or Air Force mortuary operations. That number is 1-855-637-2583, and the service will also answer questions through

Air Force Chief of Staff Gen. Norton Schwartz choked back tears Tuesday as he publicly disclosed what he had known for more than a year: The service had mishandled the remains of fallen troops passing through Dover Air Force Base, Del.

A report">released Tuesday by the Office of Special Counsel blasted the service for what the agency said is "a pattern of the Air Force's failure to acknowledge culpability" for mishandled and lost remains.

Schwartz said the Air Force has taken steps to correct problems at the Dover Port Mortuary, which handles almost all U.S. military casualties returning from overseas.

"It's my conviction that the sanctity of this work is in the hearts and minds of every single employee at the Dover Port Mortuary," Schwartz said. "I cannot certify with certainty that prior performance met with our standard of perfection. ... We understand [our] obligation and we understand the sanctity of our work."

Three whistleblowers from Dover sparked the series of investigations when they noticed concerns, such as the improper preparation, handling and transport of remains.

The investigation confirmed that a fragment of remains of two F-15 crew members, killed when their plane went down in Afghanistan in 2009, disappeared from a small plastic bag at the mortuary. A Marine's left arm also was sawed off to fit into a military uniform without notification or consent from the family. In another case, a portion of a soldier's remains disappeared, the Office of Special Counsel investigation found.

In five separate cases, fetal remains from military families were shipped to Dover using plastic pails inside non-reinforced, used cardboard boxes, the investigation found. In another case, whistleblowers said mortuary management didn't properly notify staff that they were handling the remains of a contractor who had contagious tuberculosis.

Defense Secretary Leon Panetta">responded Tuesday by calling for a separate investigation.

Schwartz told reporters Tuesday during a Pentagon press conference that there should be no misunderstanding about who is responsible: "It's [Air Force Secretary] Mike Donley and me. There's no escaping it."

Donley said in a letter to airmen that the service has kept the Defense Secretary and members of Congress "apprised of the investigation and the corrective actions we have taken."

"I am working with our service counterparts to ensure that their equities are respected," Donley said. "In addition, an independent panel of the Defense Health Board has been tasked to review the adequacy and effectiveness of our corrective actions and to recommend any further improvements at Dover mortuary."

After a yearlong investigation covering events between 2008 and 2010, the Air Force Inspector General's Office substantiated several allegations made by the three whistleblowers James Parsons, Mary Ellen Spera and William Zwicharowski. But investigators also determined that the problems discovered at Air Force Mortuary Affairs Operations and the Port Mortuary Division did not violate any laws or regulations.

The Air Force first notified the families of the fallen service members over the weekend.

Carolyn Lerner, head of the Office of Special Counsel, slammed the service's timeline for notification in a letter to President Obama, saying that "even after these matters were referred by OSC and fully investigated by the Air Force, the Air Force chose to delay notifying the families of the involved service members until publication of the reports was imminent."

Schwartz told reporters that he and Donley received the Air Force IG report more than a year ago. The decision to wait to talk to families until both reports were completed was intended to give families a final answer on what had happened, he said.

"Our judgment was that it was in the better interest of the families to have the definitive position on this, not an interim call, not a ‘we'll get back to you with both,' " Schwartz said.

The release of the Office of Special Counsel investigation comes a little over a year after an">Army probe found critical problems at Arlington National Cemetery, including mislabeled remains and a lack of electronic system to manage data.

Schwartz said the Air Force has no indication that the problems at Dover stretch beyond the cases investigated by the Office of Special Counsel. He said the Air Force can account for all the remains that have passed through Dover, except for those of the F-15 crew and the soldier mentioned in the investigation.

"I have confidence, and I believe the secretary of the Air Force has confidence, that we have identified the dysfunction and dealt with it over a period of many months," Schwartz said. "This is what the defense health board independent panel [selected by Panetta to investigate] will help assure us that our corrective action is in fact on target."

In response to the investigation, the Air Force">said it has taken corrective actions that include:

Developing and implementing procedures in the event of a loss of accountability for portions of remains;

Issuing a new directive on notification of and written permission from the person authorized to direct disposition (PADD) that is now a part of the joint standard operating procedure;

A memorandum of understanding and a joint standard operating procedure between mortuary operations and the medical examiner to ensure continuous accountability of remains; and

Increased training for all areas.

The three whistleblowers are still employed at Dover and "are still making great contributions," Lt. Gen. Darrell Jones, the Air Force's deputy chief of staff for manpower, personnel and services, told reporters Tuesday. The Office of Special Counsel thwarted attempts by Dover officials to fire one of them, along with another employee who had cooperated with the Air Force investigation, according to the OSC report.

Three of the leaders who figure prominently in the investigation have been disciplined, but none of them was fired.

Col. Robert H. Edmondson, command of mortuary operations at the time of the incidents, received a letter of reprimand for gross mismanagement and failure of leadership, according to the Office of Special Counsel. He rotated out of the command before the Air Force finished its investigation.

Former mortuary director Quinton Keel was downgraded to a nonsupervisory GS-13 positions and is currently serving as the Air Force Survivor Assistance Program Manager, a position created specifically for him. Trevor Dean, Edmondson's top civilian deputy, was reassigned as the entitlements branch chief in the Mortuary Affairs Division, according to the Office of Special Counsel.

"You have to look at the good that people have done and the wrong that people have done, and you weigh those two and make the commander judgment on what is appropriate in those cases," Jones told reporters Tuesday. "I think that's what happened in those three cases.

"…This was difficult work, 24/7," he said, "and while their performances did not meet standards, this was not a deliberate act."

The mortuary center has received the remains of more than 6,300 remains since 2003.

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