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Forensic pathology and mass casualties
9Perspectives in Pathology
FORENSIC P A T H O L O G Y A N D MASS CASUALTIES H/illiam J. Reals, M.D., Brig. Gen. M.C., U.S.A.F.R.* and WiUiam R. Cowan, Col. M.C., U.S.A.F.-M.C.?
Modern high speed jet aircraft have become the principal means of travel and commerce for much of the world. The development of the turbojet engine and pressurized high altitude aircraft has brought about changes in this era as significant as those resulting from the invention and development of the steam engine in the nineteenth century. The safety of nmdern air transportation is largely taken for granted by the traveling public. When one compares the carnage on the world's highways due to automobile accidents, flying is by far the safer mode of travel. The 50,000 or more highway deaths that occnr annually in the United States are largely ignored by the press and television, but an air disaster produces instant headline news throughout the world. The collision of two 747 jet aircraft on the runway at the ah'port at Santa Cruz de Tenerife in tim Canary Islands on Sunday, March 27, 1977, was such an event. The details of tim accident have been recounted in the press and will not be fully repeated, since tim intent in this article is to discuss the role of forensic pathology in mass disasters of this type. The probable cause of the collision has been annotmced by the Spanish authorities in
whose territory the accident occurred. The KLM 747, for unexplained reasons, began its takeoff roll along a fog shrouded rumvay where a Pan American World Airways aircraft was, on instructions from the control tower, taxiing. Realizing the situation, the pilot of the American aircraft desperately tried to turn off tim runway to avoid the oncoming plane, but his aircraft was struck as the KLM jet lifted off premature/ly in an effort to avoid the other air~'aft. The resulting explosion and rii-e instantly killed 577 passengers and crew from the two aircraft with only 69 Americans surviving, some to die subsequently of injuries and burns. The Dutch plane crashed and burned down the runway from tim American airplane. No one survived tlm crash of tim KLM aircraft. The cockpit crew and some passengers and flight attendants escaped from the Pan American aircraft as it repeatedly exploded and hurned. With dense fog, fire fighting and rescue units at the airport were delayed in reaching the sites of the accident, and by this time they could do little other than extinguish the fires and remove the bodies of the victims from the burned out fuselages. The Spanish identified the
*Assistant Dean and Professor of Pathology, Universityof Kansas School of Medicine-Wichita. Director of Laboratories,St.Joseph MedicalCenter, Wichita,Kansas. tClinical Professor of Pathology, Uniformed Services University of the ltealth Care Sciences. Deout,~ Director,Armed Forces Inmtute of Patholo~, ~ ashmgton,D.C. 9
.
.
B
,
r
9
133
HUMAN PATHOLOGY--VOLUME 10, NUMBER 2 March 1979
134
dead by individual n u m b e r and moved the bodies to a hangar where the Dutch and American bodies were placed in separate areas. Following an invitation from the Spanish government, a group of military and civilian forensic pathologists, forensic dentists, and other scientists was assembled by the National Transportation Safety Board in Washington, D. C., and sent to the Canary Islands the day following tile tragedy to assist the board in its investigation. T h e remote location of the Canary Islands, off the coast of Africa, delayed the arrival of the group at Santa Cruz de Tenerife until Tuesday evening, more than 48 hours following tile acizident. T h e Canary Islands are semitropical, with principal .industries of tourism and agriculture. Although Santa Cruz is a large modern city, facilities for dealing with the remains of 577 badly burned hu man bodies were nonexistent, as they are in most cities of the world except large metropolitan areas such as New York, Los Angeles, and European centers. Spanish law, moreover, requires embalming or burial within 48 hours after death. Owing to the lack of refrigerated holding facilities for such a large n u mb er of bodies, the dead were embalmed within the two day period by Spanish morticians and placed in individual numbered wooden coffins, the numbers corresponding to the body number. Personal effects were identified by the same n um be r and were kept intact. It was impossible to perform forensic activities of any type in a hangar, and because of the lack of other adequate facilities, the decision was made to move the bodies to their respective countries. Spanish authorities issued death certificates and the bodies of the victims were released to tile two involved airlines. T h e American bodies were flown out approximately one week after the accident, following removal of the remaining aircraft wreckage and repair of the badly damaged runway at Santa Cruz. T h e United States Government responded to a request for assistance in identification from Pan American World Airways and directed that the Department of Defense carry out the mission. T h e 326 American dead w e r e t h e n flown
directly to Dover Air Force Base in Delaware where a large military mortuary facility is located. T h e Department of Defense mobilized a task force of military medical and dental forensic experts, a graves registration unit, and an FBI fingerprint t e a m - 120 individuals in a l l to carry out the identification for the airline. This group arrived on the same day as the bodies. Working u n d e r ideal circumstances, the forensic scientists-pathologists, dentists, serologists, fingerprint experts, and other identification experts-within a three week period established positive identification of 212 of the dead, using total body postmortem x-ray films, fingerprints, dental examination, personal effect analysis, and gross body inspection. Table 1 presents details of the num ber of bodies .identified and the method used. T h e airline assisted by using its staff to seek out dental and medical records from the families of the victims so that comparisons could be made at the mortuary. T h e large num ber of victims identified by dental means alone was a direct result of this search for dental records. Most o f ; t h e " victims were from California, a state that requires a fingerprint on autd'inobile drivers' licenses. Those identified by FBI fingerprint experts had prints on file with the FBI or State of California that could be compared to postmortem fingerprints. After all extensive 21 day effort at identification, the remaining unidentified numbered bodies were flown to California and buried in a common site, but in individually num bered graves. Since that time several have been identified as new medical or dental information has been found and they have been reburied elsewhere. Most of the bodies not identified were incinerated or fragmented to such a degree that little remained other than a torso or a vertebral column. T h a t 212 badly burned victims were positively identified is evidence of the skill of modern forensic pathology and the forensic sciences. T h e accident has evoked much discussion from those who survived, from those who were at Tenerife, and from those who, like these writers, are concerned about the future, t-3 Forensic experts for years have pre-
FORENSIC PATHOLOGY AND MASS CASUALTIES--REALS, Cownx TABLE 1.
STATISTICAL FINDINGS IN" 212 AMERICANS IDENTIFIED IN" TIlE CANARY ISLAND CRASII*
Positive identification by: Dental only Fingerprint only Medical x-rays Personal effects
156 5 15 3
Positive identification by: Dental and fingerprint Dental and medical x-ray Dental and personal effects Dental and medical findings Medical x-ray and medical findings Medical x-ray and personal effects
19 8 3 1 1 1
212
Total Supportive data elements aiding in identification: Dental Medical x-ray Personal effects Dental information in personal effects Medical finding
7 12 38 27 9
*Four Dutch among these 326 bodies.
dieted that the aviation attthorities of the world would be unprepared for the massive medical and forensic pathology investigation that would result from the crash o f two wide-bodied jet aircraft. This prediction came true in an unlikely place. The Spanish aviation authorities invited the National Transportation Safety Board to the accident site, but the human factor investigation could not be carried out because of elapsed time, distances, and working facilities. Spain is a friendly sovereign nation, and its officials carried out, to the best of their ability, their tasks according to S p a n i s h - - n o t United States laws. The first concern of the Spanish was for the badly injured 69 survivors, who received excellent care in the hospital in Santa C r u z - a proper priority? The forensic science task torce was asscmbled on an ad hoc basis after hours of long distance telephone calls on a weekend. Active duty military staff members from the Armed For~:es Institute of Pathology, Washington, D. C., provided most of the experts who made the long trip to Santa Cruz de Tenerife, and this group later formed the nuclens for the team performing identifications at the Dover Air Force Base.
Forensic pathology has made m a j o r contributions to air safety throughout tile history of aviation? Ill the Tenerife accident, forensic expertise ,was utilized in the identification effort 6ialy, but that hnmanitarian activity has bronght comfort to tile victims' families and will assist in the legal activities that will surely follow. The only readily available mobile group of forensic scientists are those in the aviation accident pathology, forensic pathology, and oral pathology sections of the Armed Forces Institute of Pathology. Pathologists from these sections have assisted tile National Transportftion Safety Board in a number of major air disasters in the United States and its possessions overseas in the past. Officials of Pan American, being aware of this resource developed to support the Department of Defense's intensive flying safety program, through the Department of State requested aid from this source for the identification process. If modern society continues to insist that victims of natural or manmade disasters be completely identified, advance planning and selection of experts must be carried out for the task. The alternative is mass burial within hours after the accident, and that seems unacceptable in
i35
HUMAN PATHOLOGY--VOLU*IE 10, NUMBER 2 March 1979 o u r cultnre for m a n y r e a s o n s - - h u m a n i tarian, legal, a n d scientific. O t h e r t h a n the A r m e d Forces forensic experts, the United States has no g r o u p s that can be quickly called t o g e t h e r for either the investigative and forensic aspects of mass disasters or the h u m a n i t a r i a n work o f identifying the dead. Similar g r o u p s o f military experts have b e e n used in the United K i n g d o m a n d in West German), in the past, but most nations have no g r o u p o f experts available. Both Eckert 2 a n d C a r r o n 3 have called f o r f o r m a t i o n o f an international g r o u p o f forensic experts u n d e r private or g o v e r n m e n t a l s p o n s o r s h i p who could be called to the scene o f a disaster a n y w h e r e in the world, such as the crash in T e n e r i f e . We heartily concur. Such a g r o u p to augm e n t the A r m e d Forces Institute o f Pathology experts is ttrgently n e e d e d in the United States as well as in overseas accidents im'olving United States airlines. It is obvious f r o m the accident at T e n e r i f e that a l t h o u g h the forensic expertise is available in the United States and elsewhere, m o r e than one y e a r a f t e r the accid e n t little or no e f f o r t is b e i n g m a d e to assemble or identify such a g r o u p in o r d e r to assist both g o v e r n m e n t a l aviation agencies a n d tbe airline industry in f u t u r e accidents. Since there may be l m m a n failnres as well as mechanical failure in aircraft accidents, p o s t m o r t e m exanfinations o f air
136
crew m e m b e r s are an essential p a r t o f the h u m a n factor investigation. I n addition, analysis o f p o s t m o r t e m blood a n d u r i n e samples can reveal the p r e s e n c e o f toxic substances that m i g h t have incapacitated the pilot or o t h e r crew m e m b e r s a n d c o n t r i b u t e d directly to the accident. As m o r e wide-bodied j e t aircraft are i n t r o d u c e d onto the world's airways, we can anticipate that f u t u r e accidents will result in mass casualties o f 500 to 600 deaths each. T h u s the p r o b l e m o f mass casualties will grow in the f u t u r e r a t h e r than diminish. T i l e most obvious lesson to be learned f r o m the T e n e r i f e accident is that there is no worldwide organized forensic pathology system for h u m a n factor investigation a n d identification o f the dead. Such a system m u s t be created in the n e a r f u t u r e either by g o v e r n m e n t s or by industry, or we will have to r e l e a r n the lesson o f the C a n a r y Islands accident. REFERENCES 1. Otis, G.: Terror at Teneri.fe. Van'Nuys, California, Bible Voice, Inc., 1977. 2. Eckert, W. G.: Major airizrash investigation; lessons of Tenerife. Info]:in.t9:3-5, 1977. 3. Curran, W. J.: The medico-legal lessons of the Tenerife disaster. New Eng. J. Med., 297:986987, 1977. 4. Mason, J. K., and Reals, W. J., Aerospace Pathology. Chicago, College of American Pathologists, 1973.
FORENSIC P A T H O L O G Y A N D MASS CASUALTIES H/illiam J. Reals, M.D., Brig. Gen. M.C., U.S.A.F.R.* and WiUiam R. Cowan, Col. M.C., U.S.A.F.-M.C.?
Modern high speed jet aircraft have become the principal means of travel and commerce for much of the world. The development of the turbojet engine and pressurized high altitude aircraft has brought about changes in this era as significant as those resulting from the invention and development of the steam engine in the nineteenth century. The safety of nmdern air transportation is largely taken for granted by the traveling public. When one compares the carnage on the world's highways due to automobile accidents, flying is by far the safer mode of travel. The 50,000 or more highway deaths that occnr annually in the United States are largely ignored by the press and television, but an air disaster produces instant headline news throughout the world. The collision of two 747 jet aircraft on the runway at the ah'port at Santa Cruz de Tenerife in tim Canary Islands on Sunday, March 27, 1977, was such an event. The details of tim accident have been recounted in the press and will not be fully repeated, since tim intent in this article is to discuss the role of forensic pathology in mass disasters of this type. The probable cause of the collision has been annotmced by the Spanish authorities in
whose territory the accident occurred. The KLM 747, for unexplained reasons, began its takeoff roll along a fog shrouded rumvay where a Pan American World Airways aircraft was, on instructions from the control tower, taxiing. Realizing the situation, the pilot of the American aircraft desperately tried to turn off tim runway to avoid the oncoming plane, but his aircraft was struck as the KLM jet lifted off premature/ly in an effort to avoid the other air~'aft. The resulting explosion and rii-e instantly killed 577 passengers and crew from the two aircraft with only 69 Americans surviving, some to die subsequently of injuries and burns. The Dutch plane crashed and burned down the runway from tim American airplane. No one survived tlm crash of tim KLM aircraft. The cockpit crew and some passengers and flight attendants escaped from the Pan American aircraft as it repeatedly exploded and hurned. With dense fog, fire fighting and rescue units at the airport were delayed in reaching the sites of the accident, and by this time they could do little other than extinguish the fires and remove the bodies of the victims from the burned out fuselages. The Spanish identified the
*Assistant Dean and Professor of Pathology, Universityof Kansas School of Medicine-Wichita. Director of Laboratories,St.Joseph MedicalCenter, Wichita,Kansas. tClinical Professor of Pathology, Uniformed Services University of the ltealth Care Sciences. Deout,~ Director,Armed Forces Inmtute of Patholo~, ~ ashmgton,D.C. 9
.
.
B
,
r
9
133
HUMAN PATHOLOGY--VOLUME 10, NUMBER 2 March 1979
134
dead by individual n u m b e r and moved the bodies to a hangar where the Dutch and American bodies were placed in separate areas. Following an invitation from the Spanish government, a group of military and civilian forensic pathologists, forensic dentists, and other scientists was assembled by the National Transportation Safety Board in Washington, D. C., and sent to the Canary Islands the day following tile tragedy to assist the board in its investigation. T h e remote location of the Canary Islands, off the coast of Africa, delayed the arrival of the group at Santa Cruz de Tenerife until Tuesday evening, more than 48 hours following tile acizident. T h e Canary Islands are semitropical, with principal .industries of tourism and agriculture. Although Santa Cruz is a large modern city, facilities for dealing with the remains of 577 badly burned hu man bodies were nonexistent, as they are in most cities of the world except large metropolitan areas such as New York, Los Angeles, and European centers. Spanish law, moreover, requires embalming or burial within 48 hours after death. Owing to the lack of refrigerated holding facilities for such a large n u mb er of bodies, the dead were embalmed within the two day period by Spanish morticians and placed in individual numbered wooden coffins, the numbers corresponding to the body number. Personal effects were identified by the same n um be r and were kept intact. It was impossible to perform forensic activities of any type in a hangar, and because of the lack of other adequate facilities, the decision was made to move the bodies to their respective countries. Spanish authorities issued death certificates and the bodies of the victims were released to tile two involved airlines. T h e American bodies were flown out approximately one week after the accident, following removal of the remaining aircraft wreckage and repair of the badly damaged runway at Santa Cruz. T h e United States Government responded to a request for assistance in identification from Pan American World Airways and directed that the Department of Defense carry out the mission. T h e 326 American dead w e r e t h e n flown
directly to Dover Air Force Base in Delaware where a large military mortuary facility is located. T h e Department of Defense mobilized a task force of military medical and dental forensic experts, a graves registration unit, and an FBI fingerprint t e a m - 120 individuals in a l l to carry out the identification for the airline. This group arrived on the same day as the bodies. Working u n d e r ideal circumstances, the forensic scientists-pathologists, dentists, serologists, fingerprint experts, and other identification experts-within a three week period established positive identification of 212 of the dead, using total body postmortem x-ray films, fingerprints, dental examination, personal effect analysis, and gross body inspection. Table 1 presents details of the num ber of bodies .identified and the method used. T h e airline assisted by using its staff to seek out dental and medical records from the families of the victims so that comparisons could be made at the mortuary. T h e large num ber of victims identified by dental means alone was a direct result of this search for dental records. Most o f ; t h e " victims were from California, a state that requires a fingerprint on autd'inobile drivers' licenses. Those identified by FBI fingerprint experts had prints on file with the FBI or State of California that could be compared to postmortem fingerprints. After all extensive 21 day effort at identification, the remaining unidentified numbered bodies were flown to California and buried in a common site, but in individually num bered graves. Since that time several have been identified as new medical or dental information has been found and they have been reburied elsewhere. Most of the bodies not identified were incinerated or fragmented to such a degree that little remained other than a torso or a vertebral column. T h a t 212 badly burned victims were positively identified is evidence of the skill of modern forensic pathology and the forensic sciences. T h e accident has evoked much discussion from those who survived, from those who were at Tenerife, and from those who, like these writers, are concerned about the future, t-3 Forensic experts for years have pre-
FORENSIC PATHOLOGY AND MASS CASUALTIES--REALS, Cownx TABLE 1.
STATISTICAL FINDINGS IN" 212 AMERICANS IDENTIFIED IN" TIlE CANARY ISLAND CRASII*
Positive identification by: Dental only Fingerprint only Medical x-rays Personal effects
156 5 15 3
Positive identification by: Dental and fingerprint Dental and medical x-ray Dental and personal effects Dental and medical findings Medical x-ray and medical findings Medical x-ray and personal effects
19 8 3 1 1 1
212
Total Supportive data elements aiding in identification: Dental Medical x-ray Personal effects Dental information in personal effects Medical finding
7 12 38 27 9
*Four Dutch among these 326 bodies.
dieted that the aviation attthorities of the world would be unprepared for the massive medical and forensic pathology investigation that would result from the crash o f two wide-bodied jet aircraft. This prediction came true in an unlikely place. The Spanish aviation authorities invited the National Transportation Safety Board to the accident site, but the human factor investigation could not be carried out because of elapsed time, distances, and working facilities. Spain is a friendly sovereign nation, and its officials carried out, to the best of their ability, their tasks according to S p a n i s h - - n o t United States laws. The first concern of the Spanish was for the badly injured 69 survivors, who received excellent care in the hospital in Santa C r u z - a proper priority? The forensic science task torce was asscmbled on an ad hoc basis after hours of long distance telephone calls on a weekend. Active duty military staff members from the Armed For~:es Institute of Pathology, Washington, D. C., provided most of the experts who made the long trip to Santa Cruz de Tenerife, and this group later formed the nuclens for the team performing identifications at the Dover Air Force Base.
Forensic pathology has made m a j o r contributions to air safety throughout tile history of aviation? Ill the Tenerife accident, forensic expertise ,was utilized in the identification effort 6ialy, but that hnmanitarian activity has bronght comfort to tile victims' families and will assist in the legal activities that will surely follow. The only readily available mobile group of forensic scientists are those in the aviation accident pathology, forensic pathology, and oral pathology sections of the Armed Forces Institute of Pathology. Pathologists from these sections have assisted tile National Transportftion Safety Board in a number of major air disasters in the United States and its possessions overseas in the past. Officials of Pan American, being aware of this resource developed to support the Department of Defense's intensive flying safety program, through the Department of State requested aid from this source for the identification process. If modern society continues to insist that victims of natural or manmade disasters be completely identified, advance planning and selection of experts must be carried out for the task. The alternative is mass burial within hours after the accident, and that seems unacceptable in
i35
HUMAN PATHOLOGY--VOLU*IE 10, NUMBER 2 March 1979 o u r cultnre for m a n y r e a s o n s - - h u m a n i tarian, legal, a n d scientific. O t h e r t h a n the A r m e d Forces forensic experts, the United States has no g r o u p s that can be quickly called t o g e t h e r for either the investigative and forensic aspects of mass disasters or the h u m a n i t a r i a n work o f identifying the dead. Similar g r o u p s o f military experts have b e e n used in the United K i n g d o m a n d in West German), in the past, but most nations have no g r o u p o f experts available. Both Eckert 2 a n d C a r r o n 3 have called f o r f o r m a t i o n o f an international g r o u p o f forensic experts u n d e r private or g o v e r n m e n t a l s p o n s o r s h i p who could be called to the scene o f a disaster a n y w h e r e in the world, such as the crash in T e n e r i f e . We heartily concur. Such a g r o u p to augm e n t the A r m e d Forces Institute o f Pathology experts is ttrgently n e e d e d in the United States as well as in overseas accidents im'olving United States airlines. It is obvious f r o m the accident at T e n e r i f e that a l t h o u g h the forensic expertise is available in the United States and elsewhere, m o r e than one y e a r a f t e r the accid e n t little or no e f f o r t is b e i n g m a d e to assemble or identify such a g r o u p in o r d e r to assist both g o v e r n m e n t a l aviation agencies a n d tbe airline industry in f u t u r e accidents. Since there may be l m m a n failnres as well as mechanical failure in aircraft accidents, p o s t m o r t e m exanfinations o f air
136
crew m e m b e r s are an essential p a r t o f the h u m a n factor investigation. I n addition, analysis o f p o s t m o r t e m blood a n d u r i n e samples can reveal the p r e s e n c e o f toxic substances that m i g h t have incapacitated the pilot or o t h e r crew m e m b e r s a n d c o n t r i b u t e d directly to the accident. As m o r e wide-bodied j e t aircraft are i n t r o d u c e d onto the world's airways, we can anticipate that f u t u r e accidents will result in mass casualties o f 500 to 600 deaths each. T h u s the p r o b l e m o f mass casualties will grow in the f u t u r e r a t h e r than diminish. T i l e most obvious lesson to be learned f r o m the T e n e r i f e accident is that there is no worldwide organized forensic pathology system for h u m a n factor investigation a n d identification o f the dead. Such a system m u s t be created in the n e a r f u t u r e either by g o v e r n m e n t s or by industry, or we will have to r e l e a r n the lesson o f the C a n a r y Islands accident. REFERENCES 1. Otis, G.: Terror at Teneri.fe. Van'Nuys, California, Bible Voice, Inc., 1977. 2. Eckert, W. G.: Major airizrash investigation; lessons of Tenerife. Info]:in.t9:3-5, 1977. 3. Curran, W. J.: The medico-legal lessons of the Tenerife disaster. New Eng. J. Med., 297:986987, 1977. 4. Mason, J. K., and Reals, W. J., Aerospace Pathology. Chicago, College of American Pathologists, 1973.