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Pentagon Taking Closer Look at Dover Morgue Where Body Parts Were Lost

The Pentagon is launching a drive to reassure members of the military and their families that flaws in the handling of human remains at the Dover military mortuary - including two instances of lost body parts - have been fixed.

That effort faces obstacles, including assertions by an independent federal investigative agency that the Air Force, which runs the mortuary, has not yet faced up to all the faults in Dover's operations.

After the Air Force on Tuesday revealed the results of its investigation into mishandling of remains at the Dover, Del., facility, Defense Secretary Leon Panetta directed a special review at the mortuary, to be completed within 60 days.

"Let me make very clear to the families of our fallen heroes that every step will be taken to protect the honor and dignity that their loved ones richly deserve," Panetta said in a written statement.

Three mortuary supervisors have been punished for what the Air Force called "gross mismanagement," but no one was fired in a grisly case reminiscent of the scandalous mishandling and misidentifying of remains at Arlington National Cemetery.

The Air Force, which runs the mortuary, acknowledged failures while insisting it made the right decision in not informing families linked to the missing body parts until last weekend - months after it completed a probe of 14 sets of allegations lodged by three members of the mortuary staff.

Gen. Norton Schwartz, the Air Force chief of staff, told a Pentagon news conference he and the service's top civilian, Michael Donley, are ultimately responsible for what happens at Dover and for its mistakes.

"There's no escaping it," Schwartz said.

However, an independent federal investigative agency, the Office of Special Counsel, said the Air Force had fallen short on accountability. That office, which forwarded the original whistle-blower allegations to the Pentagon in May and July 2010 and reviewed the subsequent Air Force investigative report, faulted it for taking an overly narrow view of what went wrong at Dover between 2008 and 2010.

"Several of the Air Force's findings are not supported by the evidence presented and thus do not appear reasonable," the special counsel's office said. "In these instances the report demonstrates a pattern of the Air Force's failure to acknowledge culpability for wrongdoing relating to the treatment of remains."

Special Counsel Carolyn Lerner said her office is investigating allegations by the three whistle-blowers that the Air Force retaliated against them in several ways, including an attempt to fire one of them.

The three whistle-blowers still work at Dover. They are James Parsons, an embalming/autopsy technician; Mary Ellen Spera, a mortuary inspector; and William Zwicharowski, a senior mortuary inspector.

There is no suggestion of criminal wrongdoing at Dover, and the Air Force said it found no evidence that those faulted at Dover had deliberately mishandled any remains. They attributed the mistakes largely to a breakdown in procedures and a failure to fix problems that had been building over time.

As gruesome as the revelations appear, Schwartz acknowledged that it's possible that mistakes also were made before 2008, during a period when U.S. troops were killed at even higher rates in Iraq. Other Air Force officials said on Monday they knew of no prior cases of mishandled remains at Dover.

"I cannot certify with certainty that prior performance met our standard of perfection," Schwartz told reporters.

At Dover all U.S. war dead are received in well-practiced procedures that place a premium on a dignified and respectful handling of remains. Medical examiners then carry out procedures to positively identify remains and determine the cause of death. After that, teams of morticians and embalmers prepare the remains for disposition. Investigators found a disconnect between the work of the medical examiners and the morticians. The two groups report to different military chains of command.

One of the two cases of missing parts was in April 2009. It involved fragments of ankle bone embedded in human tissue associated with two crew members recovered from an Air Force F-15 fighter that crashed in Afghanistan. The labeled plastic bag containing this portion of remains was found empty during normal processing, with a slit in the side of the bag. Staff members were unable to account for the missing piece.

The other instance was in July 2009 and involved a piece of human tissue an inch or two in length associated with a soldier killed in Afghanistan. As in the April case, the bag containing the piece was found empty, with a slit in its side. The piece of missing tissue was never located.

Officials said that in no cases do they suspect foul play, criminal acts or deliberate mishandling of the missing remains.

Two of the three officials who were punished still work at Dover but not in supervisory jobs. None was fired.

In reviewing the Air Force's probe, the Office of Special Counsel disputed the conclusion that none of the allegations of mishandling of remains amounted to violations of law or regulation. The special counsel submitted its own report Tuesday to the White House and to the House and Senate armed services committees.

The special counsel's office contradicted the Air Force's claim that it was taking full responsibility.

"While the report reflects a willingness to find paperwork violations and errors, with the exception of the cases of missing portions (of remains), the findings stop short of accepting accountability for failing to handle remains with the requisite `reverence, care and dignity befitting them and the circumstances,'" it said.

In addition to the two cases of lost body pieces, the Air Force reviewed allegations that mortuary officials acted improperly in sawing off an arm bone that protruded from the body of a Marine in a way that prevented his body from being placed in his uniform for viewing before burial. The Marine's family had requested seeing him in his uniform but was not consulted about - or told of - the decision to remove the bone.

The Marine, whose identity was not released by the Air Force, was killed by a roadside bomb in Afghanistan in January 2010.

The Air Force inspector general began his investigation in June 2010 and finished it in May 2011. It concluded that the mortuary had not violated any rule or regulation by removing the Marine's bone as it did. But the Air Force has since changed procedures to ensure that a representative of the deceased's service - in this case the Marine Corps - has a formal say in whether the family should be contacted before altering the body so significantly.

A total of four families affected directly by the investigation were told of it last weekend by Air Force officials.