The Dover military mortuary entrusted with the solemn duty of receiving and caring for America's war dead twice lost body parts of remains shipped home from Afghanistan, the Air Force revealed Tuesday.
Three mortuary supervisors have been punished, 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 at Dover, Del., 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 whistleblower 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 whistleblowers that the Air Force retaliated against them in several ways, including an attempt to fire one of them.
The three whistleblowers 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.
Defense Secretary Leon Panetta issued a statement saying he was "deeply disturbed" by the matter. Panetta said he supports the Air Force's findings but has asked a separate panel of the Defense Health Board, a Pentagon advisory group, to conduct its own review of how the Dover mortuary is run. That review, to be led by former surgeon general Dr. Richard Carmona, is due within 60 days.
As gruesome as the revelations appear, Schwartz acknowledged that it's possible that mistakes also were made prior to 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. He said there were no plans to investigate any prior cases.
"We believe that we have uncovered the systemic issues," Schwartz said. "We have identified the dysfunction, have dealt with that over a period of many months."
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. Teams of morticians and embalmers then prepare the remains for disposition. Investigators found a disconnect between the work of the medical examiners and the morticians, each of which reports to a different military chain 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 pieces.
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.
The three supervisors at Dover who were disciplined are Col. Robert H. Edmondson, who was in overall command of the Air Force Mortuary Affairs Operations at Dover at the time; Trevor Dean, who was Edmondson's top civilian deputy; and Quinton "Randy" Keel, director of the mortuary division at Dover.
All three declined Tuesday, through the Air Force's office of public affairs, to comment for this story.
Edmondson, who had already rotated out of the Dover job by the time the Air Force probe was over, has been given a letter of reprimand, which makes it unlikely he will get a future promotion. Schwartz said the colonel was deliberately put in a staff, rather than command, job in the Pentagon.
Dean and Keel, who are licensed morticians, were dropped a notch in their civilian pay grade and reassigned at Dover. NBC News reported that Keel was moved to a new position that was created specifically for him.
NBC News' Courtney Kube contributed to this report.