International reference organization in forensic medicine and sciences

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INTERNATIONAL IN FORENSIC

REFERENCE MEDICINE

ORGANIZATION AND

SCIENCES

It is always important that there be travel by Forensic Scientists to other countries whether it be on the occasion of a formal lecture invitation, a visit and presentation to a National or International Meeting, or a visit for an informal reason to colleagues in another country. The value of such a visit is in the exchange of thoughts, ideas and informat,ion which is of grea.t benefit to both parties. During this year we have had the pleasure of welcoming and hearing presentations from Dr Julius Grant, Dr Ann Robinson and Dr Keith Mant of London to the United States and the American Academy of Forensic Medicine meeting in San Diego, followed by short visits in America. Dr H. Gujer of the Institute of Forensic Medicine in Zurich is currently spending a year with Dr Thomas T. Noguchi at the Office of the Chief Medical Examiner-Coroner of Los Angeles County, California. Visiting Wichita has been Dr Peter Herdson, Chairman of the Department of Pathology of the Auckland University Medical School, who has successfully developed a forensic pathology program in his Department under the direction of Dr Frank Cairns of Auckland. He is on his way to Duke Universi.ty in Durham, North Carolina, for a sabbatical year in the Medical School’s Department of Pathology. Dr R. Klaus Mueller of the Toxicology Department of the Institute of Forensic Medicine at the University of Leipzig recently visited Wichita where he went to the Helpern Center and discussed retrieval of information in forensic toxicology with Dr Eckert and members of the Data Processing Center at St Francis Hospital. He also took part in a discussion on resources at the Law Enforcement Training Center of the State of Kansas at Hutchinson. Dr Thomas Marshall of Belfast will be a speaker at the May 1%19th 1977 meeting of the Western Conference on Criminal and Civil Problems, a meeting sponsored by INFORM and held in Wichita every six months. These meetings are held in May and October and are geared for law enforcement, medicolegal and legal audiences; the average attendence is 300. The programs are developed around a theme; the theme for the May 4977 meeting is Forensic Aspects of Explosions and Explosives and Firearm Injury and Examination; for the October 19-20th meeting the theme is the Forensic Aspects of Alcohol and Drugs. These are developed so as to present the law enforcement, medicolegal and legal aspects in such a way as to illustrate the relationship between these areas. The program is documented by videotape, audiotape and as written proceedings” This provides an excellent source of material for the audiovisual program of the ‘Milton Helpern International Center for the Forensic Sciences which now includes more than 75 hours of videotape presentations in forensic medicine and sciences and more than 250 hours of audiotape material, including talks and presentations given at the annual meetings of the American Academy of Forensic Sciences,

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Just as it is important for direct contacts to be made between Forensic Centers and Practitioners it is also important to collect information about activities and problems and to disseminate it through newsletters and through a response to inquiry from the Reference service. The Registry of Cases of Unusual, Uncommon, Unique, and Notable Nature has been launched to serve this purpose at the Helpern Center. We would thus ask you to send in a short outline describing such a case which you may have had exposure to in the past or currently, together with a comment on the opinion as to the main lesson derived from this case and its qualities which may have made it unique. We are now developing a retrieval file and have a crossreference system for rapid access to cases. Information as to the contributor and locale of the case will be a help to stimulate communication between forensic practitioners throughout the world. The following report on the Tenerife crash in the Canaries is my personal opinion as to the facts which I, together with other forensic colleagues, was confronted with during the trip and visit to the crash scene; it is my hope that an international agreement can be reached for the establishment of a group of forensic experts who can be located in different parts of the world and be called upon for support in future air disasters. The Forensic Accident

Disaster

at Tenerife:

the

World’s

Greatest

Fatal

Aircraft

Early in the afternoon of March 27th, 1977, at the Los Rodeos Airport in Tenerife, Canary Islands, a KLM 747 took off in zero visibility and collided with a Pan Am 747 which was taxiing down the single runway for a take-off position and was still on the runway after the KLM had taken off. The zero visibility was due to a dense layer of clouds which rolled in before the planes could take off from the 11000 foot runway, which is at an altitude of 4000 feet above sea level on this volcanic island. It is almost impossible to imagine why the giant airships were allowed to move under these general conditions. The Pan Am 747 was attempting to leave the runway at right angles when it was struck in the aft cabin and tail section by the landing gear, the wing and the 3rd and 4th engine of the KLM 747. These remained with the wreckage of the Pan Am 747 and the Dutch plane continued sideways for another 1000 feet down the runway. Both planes erupted into flames and burned fiercely for minutes before the control tower personnel and the airport fire brigade were even aware of the fact that a crash had occurred. The notice of the crash to American authorities was followed by mobilization of accident investigators on all levels of the spectra of experts required to adequately do the investigation. Thus 17 men, including Pan Am officials, two pathologists from the AFIP in Washington, D.C., and members of the National Transportation Safety Board (NTSB) investigating team departed on a special plane from New York within hours of the notice of the crash. They arrived the next day after being shuttled 65 miles from Los Palmas airport on the Grant Canary Island to Tenerife by helicopter. The Spanish authorities in the meantime had begun the investigation, led by a Spanish Air Force General, with

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t,ight security on the wreckage and victims’ bodies. The local public health organization with forensic experts started processing the burned bodies by removing them to a hangar, with no indication that they had marked their focation. The bodies in the KLM plane were 1000 feet from those in the Pan Am wreckage, and the Spanish thus gave the Pan Am bodies designation A. for American and consecutive numbers, while the Dutch plane’s bodies were given consecutive numbers. The second wave of American investigators dispatched to the scene were sent on the request of the NTSB and consisted of AFIP pathologists, dentists, and photographers, as well as the Deputy Director. Civilian experts included pathologists, dentists and ID experts. They arrived 48 hours after the crash and found that the bodies were being embalmed and placed in wooden coffins, lead-lined and sealed. This was apparently the decision of the Spanish Government who have a 1a.w requiring embalming and burial within 48 hours. A week later, Pan Am officials claimed that it was their request. The Spanish did not apparently plan to make identification and there was a question whether they would release the bodies at all. The Dutch investigation team arrived the morning after the crash and were successful in receiving permission to have the KLM bodies examined by them for dental evidence. They opened and exposed the mouth, and dental charting was done on every body. The Dutch people aboard the plane were from a small city and many were expected to be identified as dental records were readily available. This group left after a day as they realized that the Spanish authorities would be slow in making their de&ion as to the disposition of the bodies. The AFIP pathologists who arrived the day after the crash did not have any opportunity to start examining the bodies and one helped with the evacuation of the badly burned survivoas. This was the state of affairs when the second wave of American investigators arrived on Tuesday. They were briefed by one of the American pathologists who had arrived the day before and by a member of the accident investigating team of tne NTSB. It was not until Wednesday, the third day after the accident, that the second wave of experts could go to the airport and, after a meeting with Pan Am, NTSB, and finally the Spanish public health. officials, they were given permission to view the body disposal in the hangar and the wreckage, which was by then partially removed from its original location to a fieid by the hangar. The American identification team had several briefings after this site visit and it was returned to America on a special Pan Am plane along with some survivors on Thursday. The removal of the remains of the crash victims was delayed till Sunday, seven days after the crash, when the runway would be repaired, Pan Am had apparently made arrangements with the U.S. Air Force to fly the victims to Dover Air Force Base in Delaware for the final identifi’cation, to the exclusion of more experienced and capable civilian experts,, including the Chief Medical Examiner of Delaware, the widely recognized forensic pathologist, Dr. Ali Hameli, whose permission was never obtained by the USAF to bring these transient bodies from a non-military source to Delaware and for which proper certification of death may never come without this cooperation. The utilization of primarily inexperienced military personnel for this massive task

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of identification is a travesty of justice and a major insult to the field of forensic sciences in the United States and certainly will leave more questions than answers in a very sensitive situation, to say the least. With the chances that this disaster will probably bring on one of the greatest legal cases in the history of transportation accidents, and certainly the most costly responsibilities for the defendent in the case, I would like to comment on the classic mistakes which were found in this case from the forensic aspects. (1) The bodies were removed from the places where they were found in the wreckage with no apparent efforts being made to note or mark their location. (This eliminates possible general identification if the seat location assignments were recorded by Pan Am or survivors and by KLM. It also negates any chance to study impact injuries and possible understanding of safety factors in the future.) (2) The bodies were embalmed and placed in coffins before identification was completed. (This obviated any opportunities of toxicologic study of the victims among the passengers and crew, including carbon monoxide, cyanides and other products of the combustion of plastics and fabrics which are especially noxious. It also negates the possibility of determining levels of carbon monoxide and other incompletely combusted material which might indicate possible survival potential in some of the victims and might emphasize possible advantages of flame hoods currently under development by the FAA. After embalming, the presence of alcohol and other intoxicants cannot be determined in the command pilot or key crew members.) (3) The examination of bodies in the hangar was carried out by Iocal public health and forensic authorities with little or no knowledge of the procedure to be followed in the investigation of such cases. No experts from Madrid were flown in and no dentists were available. (The dental examination as done by an inexperienced physician is worthless and must be done by a dental expert with records available for comparison of possible persons in the crash.) (4) The removal of the victims from the scene of the crash without a positive identification to another country is gross negligence on the part of a responsible party as the potential loss of the remains in transit always exists and the survivors have no positive proof of a claim if this loss takes place. (5) Removal of the bodies for identification to a strictly military base and utilization of non-civilian experts exclusively brings one into the same hassle which existed in the investigation of the death of President J. F. Kennedy. (6) Bringing the bodies into a jurisdiction of a regular formal Medical Examiner, without permission or prewarning, and especially when this is not a basic mission of the armed forces concerned, introduces many quest,ions, least of which is who will sign the death certification. (7) When other than the best available forensic experts are used in the investigation of such a massive problem, questions of a medicolegal nature may never be ascertained, including the accuracy of the identification and the survivor of a husband and wife. Bill Eckert