C. Michael Bowers DDS, JD

Diplomate, American Board of Forensic Odontology

See variously;

This will be a short visual and detailed post-incident report which will take you on an excursion into the general details surrounding the Alaska Air 261 crash. This event occurred about 14 miles from my dental office in Ventura, California. On January 31, 2000 this event permanently changed many lives when 88 passengers and crew were killed in the crash of a MD 80.

Mass Disaster preparedness and operations manuals are found in numerous local, state, and federal agencies.

I strongly suggest that interested forensic professionals review the information I have placed in this page. Your local jurisdiction may have a plan that addresses some, but probably not all, of the issues  raised in the later sections.

The forensic details of any Mass Disaster are numerous and in this case, may not end for months after the event. We are still managing the DNA specimens that were obtained during the event. The DNA profiling is being done through the Armed Forces DNA Lab in Rockville , Maryland.

The postmortem examination process is best described by a local dentist who worked during the rather intense first three weeks of the incident.

The tragic crash of Alaska Airlines Flight 261 off our coast in late January brought together Ventura County’s forensic dental ID team to help identify some of the 88 passengers.

Deputy Medical Examiner Michael Bowers, D.D.S. of Ventura contacted Ray Johansen, D.M.D. of Santa Barbara, Paul Gabriel, DDS of Camarillo and myself within hours of the crash to enlist our volunteer help. Several days following the tragedy, we all met at a dock in Port Hueneme where federal officials from the Navy, NTSB, FEMA, and DMORT had set up a portable morgue. This is where we began our work. We all received FBI clearance to gain admittance.

The differences between a routine John Doe dental ID and this incident was, of course, the number of victims and the fact that there were very few intact sets of jaws (let alone bodies) being recovered from the ocean. Therefore, only partial post-mortem records could be recorded and then compared to complete ante-mortem dental charts that were slowly sent to us for every person listed on the passenger manifest. Unfortunately there are 20 of the 88 who had no available dental records. Every jaw fragment with dental significance was numbered. The high degree of fragmentation occasionally produced two different specimens, recovered at different times, which were later associated to the same crash victim.

The force from impact to create the amount of human destruction we observed had to be incredible. We recorded over 100 post-mortem dental remains and compared them to 68 ante-mortem dental charts. At last count, 62 people had been identified of which 22 were dental. The case is still ongoing as the potential for more remains being found is always a slight possibility. The Feds are long gone. Future work will be done at the County Medical Examiner’s Office. Many non-dental specimens have been sent to Washington, D.C. for DNA testing to hopefully identify more of the victims.

It was very gratifying to aid the investigation by helping to identify some of the passengers and bring closure to their families. Our Ventura-based team of Paul Gabriel, Ray Johansen, Mike Bowers and myself worked very well together.

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In the United States, the federal government offers local jurisdictions help when a major disaster strikes. Aid comes in many forms and a principal one is the delivery of a portable morgue and able bodied workers who are already trained in forensic identification. The acronym DMORT will be seen in the following statement. This is the federal group that showed up within a day with equipment and staffing to augment the ME's normal staff of two pathologists, six investigators, and one consulting dentist.

In a perfect world, things work well. But, although this mix of locals and visitors so far have identified 61 out of the 88 (note: these numbers have increased by July 12, 2000) there were some rocky steps in the process. In part, it was caused by the limited experience of certain critical members of the DMORT management team. Anyway, the following is only my perspective. I hear there may be some changes in the works to prevent a repeat performance of what is described below. Time will tell.

The following critique does not reflect on the hard work and efforts of everyone involved in this event. None of the problems outlined below appear to have affected any of the final outcome as of this date. The first article was written to a forensic dentistry newsletter. The second went to the NTSB and the federal government. The later sections have been added July 11 and 12, 2000.

I would like to especially thank my forensic colleagues,

Their immediate response and ongoing assistance (via the Internet and telephone) in many important matters indicates how dedicated the forensic community is in time of emergency. Numerous others provided professional courtesy, knowledge and moral support.

C. Michael Bowers DDS, JD

These comments are the personal opinion of the author and do not represent any official governmental organizational report. The purpose of this report is to target specific areas that need improvements and which would benefit local agencies in their interfacing with governmental entities tasked to assist in the recovery of human remains (HR) This report is not meant to discount the hard work and dedication provided by any of the participants in the search, recovery and identification efforts during the Alaska Air 261 incident. I want to further emphasize that none of the issues that appear below resulted in fewer conventional identifications or irreversible errors. The final forensic results of this accident were successful and the all individuals involved were helpful and positively contributed. Conventional identifications ended on Saturday March 18 with three additional dental identifications making the total identified as 62 out of 88 crew and passengers. The DNA results are pending.

Included in these communications should be an agreement on how to number, categorize, and process ALL information derived from recovery efforts. Conventional identification methods in a large MFI can be challenging because of victim fragmentation. This fact underlies the following proposed pre-arrangement agreement with DMORT and other federal agencies.

DNA Protocols:

A numbering system of the human remains to include the following:

If the management of DMORT promises to assist the local MEC in performing the usual duties of identification, "autopsy" and death notification, this series of delegated duties should be performed to the level requested by the local MEC.

The DMORT management and scientific professional staff should understand the many valid ways postmortem human identification can be made. This includes the use of unique jewelry, clothing and wallets, and tattoos. The MEC should establish an acceptable ratio of experienced DMORT identification members to DMORT trainees. Comment: The team that "first-responds" should have extensive experience. A MFI should not be a training experience for individuals who are then given responsibility for any DMORT identification services

DMORT data processing:

A step by step description of what information the local MEC needs to monitor the identification process. Comment: The benefit of the existing computer data services provided by DMORT is not apparent, as it provided little assistance to identifications. The cataloging of internal DMORT forms and reports appears to be the main function of this aspect of the DMORT response. The use of WINID2 by the DMORT dental section demands functional knowledge of the full program from the very beginning.

March 29, 2000

Post-Incident Report to the NTSB and GAO regarding Alaska Airlines 261 Recovery Efforts

Premise: The ability to maintain an organized mortuary and identification response to a MFI event is dependent on preplanning and adherence to nominal standards used in forensic and criminal investigation. The blend of "forensic science" and investigatory logic must be established prior to arriving on the crash scene.

Rationale: The totality of the circumstances and the availability of ALL evidence contained in a MFI must be the paramount view. The fatalities’ personal information available AT THE SCENE must be considered just as important as the airline manifest report and other sources of circumstantial evidence.

Debrief: DMORT lacked a defined agenda and written SOP’s on how to identify the crash fatalities by conventional means. It appeared to me that if categories of evidence couldn’t be fingerprinted, measured, weighed, or x-rayed, the DMORT team leader and his supporters thought the information was somehow tainted. Why this evidence was held in such low esteem was never explained to me. I determined there were two levels of mis-direction working in this event. One, the management had never been taught how to develop identification evidence from a death scene, and two, the academic people supporting him were equally untrained or had some professional conceit and self-fulfilling hope that what they knew "forensically" would be sufficient and less "risky."

The totality of any MFI utilizes substantial amounts of circumstantial evidence. This is defined as facts that do directly relate to the question at hand, are relevant and tend to prove or disprove questions related to the ultimate truth of the matter. You know that many areas of hypothesis exist in determining physical parameters from fragmented human remains such as height, weight, and sex. There are NUMEROUS assumptions made in the so-called "scientific-based" identification concept. Associative personal effects information and physical evidence are just as important. Ignoring PE information that tends to support or deny the potential for linking MFI victims to fragmentary human remains is short-sighted and unfairly decreases the scope of the total investigation.

DNA evidence is commonly misconceived by people outside the DNA community. The common misconception unrealistically considers it infallible. It is certainly a step beyond most other disciplines in reliability but it has serious limitations. The number of Unknown specimen samples and the required family reference samples created by a MFI would tax ANY of the commercial, high-throughput biotechnical laboratories. Now the chance of multiple events that are nearly contemporaneous has occurred with the Rhode Island and Alaska Air incidents. The overweighing of "genetic identification" perpetuates the delusion that DNA profiling is "100% certain" and is a substitute for exhausting all avenues of traditional investigation.

Debrief: DMORT was given the opportunity to thoroughly investigate all the physical evidence present during their tenure at Port Hueneme. The final opinion I have is that they perform the easy identification procedures and generate a plethora of internal record keeping but make excuses why they can’t continue the on-site investigation to its logical conclusion.

It is admirable that the NTSB entered the mass disaster identification business after the TWA incident. The lack of consistent mortuary and family assistance prior to the NTSB mandate demanded a more centralized and professional approach.

Debrief: DMORT arrived at Port Hueneme with excellent equipment and physical support staffing. The mortuary management and identification services were severely hindered by their myopic opinion on human identification and an organizational culture that tends to resent input from locals who are better qualified but outside the DMORT hierarchy of control.

I was not impressed by the initial DMORT promises to "work with" and "assist" the Ventura Medical Examiner Office. I was pessimistic that their upper management would support the whims and opinions of their onsite counterparts when serious disagreements arose.

This was affirmed by my personal experience throughout DMORT’s tenure at Port Hueneme and their later "liaise" at the Ventura Medical Examiners Office on Foothill Road. The issues that were incorrectly managed by DMORT are categorized below:

"Do not let two inexperienced individuals function together unsupervised as a team in any section. Forensic trained people should be in charge of forensic operations regardless of their position in an organization rank, or perceived station.

Local personnel must be adequately prepared, through experience or training, to properly handle such forensic situations. If not, for humanitarian reasons they should voluntarily bow out of locally appointed positions of responsibility. Problems of egoism, based upon preconceived notions of self glorification, have no place in mass disasters. Vainglorious reiterations of self-proclaimed "successful" identification efforts are overabundant in the forensic literature, and on the forensic lecture circuit. Self-abnegation for humanitarian principals is claimed more often than it is practiced. To needlessly prolong the agonizing wait of families who know their loved ones have perished in a terrible disaster, because of the inconceivable practice of training forensic dentists on-the-job, borders on the unethical.

If the forensic dental section of an identification operation is properly staffed and managed by experienced dentists, it is possible to offer inexperienced personnel, adequately versed in forensic dental techniques and capabilities, the opportunity to learn from their peers in the field.

The infusion of experienced forensic dentists into this operation prevented numerous errors from becoming anything more than time consuming nuisances, thus, allowing the effort to conclude successfully.

While the errors encountered during this effort did not result in any nonidentifications or misidentifications, in all probability, this was due to the nature of the remains and the timely arrival of experienced forensic odontologists who quickly rectified the problems they encountered. However, the implications of this post-incident analysis are quite serious. Had more of the dental remains been severely fragmented and of lesser quantity, some of the errors previously discussed could have, in the worst case scenario, resulted in misidentifications. One cannot manage an identification effort using exclusively inexperienced personnel and expect to make no mistakes.

The numbers of dental remains discussed in this paper were of an easily manageable size, and the condition of the remains such that the needless and frustrating duplication of efforts eventually yielded correct results. In a large disaster involving great numbers of remains that are severely fragmented and incomplete, data automation of inaccurate records, such as the type observed in this operation, could well result in possible dental identifications going undetected. In a scenario involving several hundred sets of

severely fragmented remains, such as the recent JAL airline disaster, utilization of data automation and a software sorting program such as CAPMI, moderate errors such as those discussed previously will result in "matches" being turned into only "possible matches". Worse yet, critical errors can turn "matches" or "possible matches" into "mismatches". One can easily imagine a scenario where these same inexperienced personnel who improperly prepared the antemortem composite records, could unwittingly place too much faith in the results obtained from such a technological tool, overstep the bounds of forensic science, and misidentify remains.

It is apparent from the magnitude of the errors discovered by the author, that the on-the-job training in forensic dentistry that had initially taken place, is a lesson in managerial misjudgment."

The DMORT VIP program that inventories the other information from the autopsies does not interface with WINID2 in the current DMORT data center. It can be patched in, but the time wasn’t appropriate to problem solve this. This necessitated the dental team to recreate the passenger list and input the physical characteristics of antemortem and postmortem records. In this event, the DMORT dentist was insensitive to the possibility of sorting information by these criteria. I backed up the information on CAPMI IV at home to provide this cross-referencing capability.

The management style and ponderous structure of DMORT will never result in a consistent, cohesive forensic and investigatory response team. I have doubts that their previous activities have been thoroughly debriefed and improvements initiated to rectify past insufficiencies. There are too many Regions and too many people involved to bring this organization of apparently HUNDREDS of people from varying strata of forensic training, mortuary service and amateur volunteers. I urge you to establish a relationship with AFIP and consider hiring select civilians to augment the staffing requirements.

Respectfully submitted.,

Mike Bowers DDS, JD

Diplomate, American Board of Forensic Odontology

Fellow, American Academy of Forensic Sciences

Senior Crime Scene Analyst, International Association for Identification