WASHINGTON — Federal investigators said Tuesday they found "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 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 investigation there.
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 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 Edmondson, mortuary commander from January 2009 to October 2010, was issued a letter of reprimand. He has been reassigned to an Air Force personnel division.
• Quinton "Randy" Keel, a licensed funeral director and mortician who served as division director at the mortuary, was demoted in August.
• Trevor Dean, a mortician and funeral director who served as Edmondson's top civilian deputy, voluntarily accepted a transfer to a lesser, nonsupervisory position, Air Force officials said.
At the Air Force's request, a panel of public health experts headed by former Surgeon General Richard Carmona will 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.
Another problem surfaced in January 2010 when a Marine killed by a roadside bomb in Afghanistan arrived at the mortuary. 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 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. 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 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, said that the handling of the Marine's body was inconsistent with "the highest standards in the funeral service profession."