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DOVER AIR FORCE BASE — The U.S. troops killed in action were returning home at an alarming pace. The Iraq war was at its raging worst. On one particularly awful day in 2007, 42 bodies arrived at the mortuary at Dover Air Force Base.
The roadside bombs that were causing nearly three-quarters of the combat deaths were wreaking havoc on the remains. Some came home in medical pouches – literally, in bits and pieces.
The influx overwhelmed the visiting autopsy specialists from the Armed Forces Medical Examiner, who would not have a permanent presence at Dover until 2012. Personnel from the Dover Port Mortuary — the only U.S.-based funeral home for the nation’s combat fallen — often pitched in to help.
Unbeknownst to the public, control and tracking of soldiers’ remains was already a problem at Dover — a concern first raised internally in 2002, documents show.
Having so many people involved at the very point where the bodies were received, even prior to autopsy, was adding to the problem. Some remains were going missing.
“When you have a process with many hands in the process, and no centralized command, that will lead to chaos,” said the current Armed Forces Medical Examiner System director, Army Col. Ladd Tremaine.
The Port Mortuary had other issues: improper preparation of remains for burial; the disposal, in a Virginia landfill, of unclaimed or unwanted portions of at least 274 service personnel between 2003 and 2008; and retaliation by management — an Air Force colonel and two civilians — against those who protested and then blew the whistle on the lax and questionable practices.
In the end, the whistleblowers won out. Investigators confirmed what had taken place, the three top mortuary officials were disciplined and new policies and processes were put in place to handle the nation’s war dead with greater accountability.
The firestorm of anger that the shocking 2011 revelations lit, however, continues to this day.
“I get some pretty nasty ...‘nastygrams’ from people,” said Air Force Col. John Devillier, commander of what became known in 2008 as Air Force Mortuary Affairs Operations. “Not addressed to me, but addressed about, you know, the things that happened here at Dover.”
He says he doesn’t mind, noting that “I’d be more concerned if people didn’t care.”
But Devillier says it’s a new day at the Port Mortuary.
“We’re moving forward,” Devillier said during a recent interview inside the Mortuary Affairs complex at Dover Air Force Base. “And we’re taking corrective action and we’re doing things internally to allow people to have a voice to say, ‘This is wrong.’
“Anybody can tell me this is wrong. And they’ve done so. And that is good. And that just wasn’t the environment,” he said.
The man who runs the Port Mortuary Branch of AFMAO agrees. And his opinion carries a special weight.
Although William Zwicharowski was removed as mortuary branch chief in 2009 when a new command group came on board, he had a front row seat to the scandal and was the first employee to blow the whistle on the misconduct.
“Our mission was sort of disrupted by what I consider egos at the time,” said Zwicharowski, whose long experience with mass casualties at Dover includes handling of those killed when a jetliner was crashed into the Pentagon on 9/11. “There was a lapse where someone thought they could do it better. And that wasn’t the case.”
Problems are history
Now, Zwicharowski said, the Port Mortuary’s problems are history.
“I want to guarantee the families of our fallen, in the past and in the future, that they’re treated with honor, dignity and respect here at Dover,” said Zwicharowski, a former Marine. “And the colonel will support me 100 percent. We guarantee it. As long as I’m here, they’ll be treated that way.
“We have never been in a posture better than we have right now,” he added.
That some remain resentful over what happened is hardly surprising. What happened at Dover stunned Delawareans and tore at the psyche of a nation that had lost more than 5,000 uniformed Americans in Iraq and Afghanistan. Even those opposed to the wars were stunned to learn that the remains of loved ones had not been properly accounted for and handled.
Devillier, however, pointed to perhaps the bigger problem: leadership’s failure to heed its workers’ concerns about what was happening.
Remains had gone missing on at least two occasions, and the families weren’t being notified. In 2010, an embalmer was ordered to saw off a protruding arm bone fragment of a dead Marine — without the family’s permission — so it would fit into the burial dress uniform.
Four civilian workers raised concerns. Unheeded, they eventually blew the whistle to higher authorities. Management fired one of the workers and, while an Air Force Inspector General investigation was underway, a mortuary inspector who assisted investigators was also terminated. Suspensions, transfers and denied promotions followed.
The whistleblower complaints were validated by subsequent Air Force, Department of Defense and Office of Special Counsel investigations — although the Air Force denied legal culpability for all matters — save for two instances of missing remains.
The three supervisors who retaliated against the four workers were reprimanded, and the Air Force adopted several changes suggested by an independent Pentagon review, chaired by retired Army Gen. John Abizaid. Among the changes were:
■ A streamlining of the command and control.
■ Improving training and standardizing of procedures.
■ Creating lines of authority for AFMAO and the now-neighboring Armed Forces Medical Examiner System.
Investigators didn’t ping AFMES nearly as hard as AFMAO. But the problems with missing remains pouches did stem at least in part, AFMES director Tremaine said, from the policy that gave AFMAO responsibility for the receipt and cataloging of remains and the subsequent sharing of personnel during that initial processing.
A Pentagon-sponsored independent review found the policy created problems with accountability.
The Abizaid panel said the two groups needed to be completely separate. AFMES moved from Rockville, Md., in 2011, into a new building adjacent to AFMAO.
A physical barrier to the rear passages between the two buildings is now secured, and only a select few have the codes needed to open it, Tremaine said. The number of times the two organizations exchange a set of remains has been reduced from seven to two: when AFMES receives the remains following a dignified transfer and when AFMES passes them to AFMAO once the autopsy has been completed.
Additional measures include labeling each pouch with a bar code and establishing a chain of custody.
None of what happened in the past at Dover is defensible, Devillier said. But he takes issue with the media coverage of the disposal regarding incinerated remains in a Virginia landfill, a story first reported by The Washington Post after the scandal broke.
The Port Mortuary’s practice was that remains that were either unidentified or were subsequently discovered but families said they didn’t want to know about were cremated, then incinerated and disposed of as medical waste. The contractor taking them to a Virginia landfill wasn’t informed about the content, investigators found.
The press, Devillier said, conflated the landfill story with that of the mishandled remains.
“The press is often factually accurate but contextually inaccurate,” Devillier said. “And that landfill thing is contextually inaccurate. But it was tied together with the things that happened here at the Port Mortuary because of the whistleblowers.
“They’re two separate issues. They are two separate issues. They are not related at all. But they came out at the same time,” he said.
The remains that ended up in a landfill weren’t body parts, Devillier contends.
“We would cremate those remains, those remains would then be incinerated, and the incineration would leave a little bit of dust,” Devillier said. “And that little bit of dust would go into a biowaste bag. And that’s what went into a landfill.”
Devillier, echoing the Air Force’s 2011 stance, said such disposal of incinerated remains was “standard medical practice” in the civilian world.
The International Cemetery, Cremation and Funeral Association took issue with that line of thinking in a 2011 statement to the Post, saying the “disposition of the remains at a landfill violates every formal and informal professional standard.”
Lt. Col. John Dorrian, an Air Force spokesman at the Pentagon, questioned whether such a standard exists. “I’m not sure there are many equivalents in the civilian world,” he said, referring to the incineration of cremated remains.
Devillier argues that the Air Force has done a poor job of addressing the issue.
“Public relations-wise, we probably just didn’t explain it very well,” Devillier said. “We did not do a very good job of explaining the process.”
The Abizaid panel concluded that the policy “caused many people to lose faith in our ability to care for the Fallen.”
The Air Force says it now understands this.
“We’re very sorry for the pain that that prior policy caused for the families,” Dorrian said recently.
The policy was changed in 2008. Now, families of fallen troops must fill out and sign a form that asks, “If additional remains are found, what do you want us to do?” The options are being told and determining whether the family wants them processed and returned for re-interment or not being told and allowing the service to dispose of the remains.
When the remains are unidentified or families have told AFMAO they don’t want them, the remains are cremated on site at Dover and buried at sea, with a chaplain and honor guard complement on board a Coast Guard cutter. The Army is currently building a Vault of Remembrance at Arlington National Cemetery that will contain such remains.
Post-scandal changes go to the issues raised by the whistleblowers.
“Anybody, regardless of rank, can stop a process they think is illegal, immoral or unsafe,” said Devillier, who oversees a staff of 54 civilian and military workers and 44 service members, drawn largely from Dover’s 512th Airlift Wing, who “deploy” here for six-month tours.
He meets quarterly with union workers and maintains an open-door policy. AFMAO also has an anonymous feedback line.
Operating instructions have been narrowed to a checklist of 33. “We cannot make mistakes,” Devillier said. “This is a no-mistake environment.”
In addition to the reduced number of “touches” shared by AFMES and AFMAO, Devillier said he and Tremaine communicate regularly to tackle any issues that might arise.
While some may have lingering animosity toward the facility or simply harbor doubts about the facility’s treatment of America’s war dead, Devillier said those feelings should be put to rest.
“I can tell America that the men and women who work at the Charles C. Carson Center for Mortuary Affairs take great pride in what we do here, in providing dignity, honor and respect for our nation’s fallen,” Devillier said. “They’ve earned it.”
The nasty letters still come, “but they’re fading,” Devillier said.
Still, he realizes that all the assurances in the world won’t by themselves ease the pain some suffered or assuage angry feelings.
“Trust is built through action. And that’s the only way we’re going to get it back,” Devillier said. “It’s gonna take time.”