Senator KEMPTHORNE. Without objection.

[The information referred to follows:]

Area One: Crime scene protection, evidence collection and retention, photographs and investigative procedures:

A. Often the crime scene is not secured, particularly if the victim is still alive when found and the primary focus is directed toward life saving efforts. In these situations, often hours go by before the attention of investigators goes to the scene and individuals present at the time of the incident.

B. Collection and handling of evidence is incomplete and often sloppy. There is no clear mandatory period for retention of physical evidence after the investigation is concluded. The decision to close an investigation rests with the Command and physical evidence can then be destroyed.

Č. Photographs taken by civilian jurisdictions when the victim is found off base are often of very poor quality (i.e. snapshots) or are incomplete.

D. Photographs taken by civilian jurisdiction officials may or may not be made available to the family and even if they are provided to the Department of Defense, the civilian jurisdiction controls the release (even to family or Congressional offices) of the photographs.

E. Fingerprints are not mandatory nor often requested of witnesses or those in area with the victim at the time of the incident or those having had problems with victim. Neither is there immediate nitrate/power testing on those individuals. Frequently hours pass before such testing. Fingerprinting of crime scene is incomplete and at times non-existent.

F. There is a failure to use common investigative techniques and procedures currently utilized throughout the country's police departments, even when training has been comparable to that of civilian equivalent authorities.

G. Investigators appear to make a suicide/self-inflicted or accidental determination prior to initiating an investigation and that predisposition controls the conduct of the investigation. This attitude was clearly stated by a Commander from Camp Pendleton who was quoted in the Bergen Record 9/26/93 as saying "Normally, it's very obvious what happened. Most of these are witnessed and the circumstances are such that it's pretty clear what took place”. This attitude is common throughout the military and pervades each case from Command level down.

Area Two: Notification process, assignment and participation of casualty officer: A. There are extreme variations in relating to family members the facts of what happened as well as errors in relating when and where the death occurred. Some families receive as many as four variations in the circumstances. Casualty officers assigned to families lack detailed information, lack procedural information and are frequently changed throughout the course of the investigation.

Area Three: Autopsy authorization, autopsy photographs, treatment of remains and notification of procedural information:

A. There is an evident lack of explanation concerning military autopsy and treatment of remains, and in many cases the absence of any description of other markings, injuries and lacerations in the report.

B. Deaths occurring in civilian jurisdiction may or may not have a full autopsy, which may or may not be photographed and those photographs may or may not be made available to families. As a result of the lack of mandatory conformity in the deaths of active duty military personnel, autopsies may solely state the cause of death and never note defensive or other injuries, bruising, lacerations, etc. The inju. ries are often not known until the family receives the photographs, has a second autopsy or receives the crime scene photographs.

C. There is a complete failure to inform families concerning the remains of the victim and serious violations of existing military regulations governing the treatment of remains frequently occurs.

Area Four: Theft of personal belongings of deceased servicemen and women:

A. There is widespread random looting of the personal belongings of victims, before and after it has been inventoried. Almost without exception, families find that numerous articles are missing, ranging in size and value, even after they have been inventoried.

B. Often the military makes a determination as to whether certain personal belongings are suitable to be returned and will remove those items they deem unsuitable. Journals are read and pages removed or entirely confiscated.

Area Five: Psychological autopsy as determining factor in manner of death:

A. There is widespread use of rumor and unverified information contained in current psychological autopsies, and they frequently appear to be an attempt to explain why a criminal investigation was not thoroughly conducted.

B. The use of unverified and erroneous information, aside from being profoundly hurtful to the families, provides investigators with an opportunity to conform evidence, with which intent is established. In order for there to be a suicide, there must be intent. Without proof of intent, and in the face of flawed investigations, the manner of these deaths should be recategorized as 'undetermined'.

Area Six: Deaths within civilian jurisdictions:

A. Servicemen who die off base are usually not well-served by either local or military investigators.

B. There are widespread problems presented by the fact that localities do not want to expend their resources on "military personnel" and the military does not have jurisdiction to become the lead investigative agency. In effect, the death has occurred in 'no-man's-land', further compounded by Command desires to stay on non-critical and friendly terms with hosting community officials.

Area Seven: Release of information, photos and response to questions during the investigations and after:

A. Despite regulations to the contrary, over and over again families must write, often appeal and wait an inordinate amount of time for records, reports and photos. B. Responses to questions are incomplete or not ever forthcoming and never is there a 'session' wherein the entire case is reviewed with the family.

C. Without exception, an arrogance of attitude by the military is reported by the families in most of their contacts with base officials. Families feel that they are viewed with contempt and that their children are dishonored.

Overview:

1. Aside from numerous inadequacies existing in these investigations that conclude with a finding of self-inflicted, there is substantial reason to believe that many investigations concluding with a finding of accidental death are similarly flawed and initially should also have been fully investigated. This is particularly true when the deaths or disappearances are unnatural and are not crash related or attributed to training.

The essential point is that while there are many causes of death there are only four manners of death: suicide, accidental, natural or homicide. Despite the fact that some deaths appear to be suicide or accidental, when any investigating agency make such decision on the spot, there is incomplete documentation and incomplete collection of evidence exactly what is found in the cases reviewed.

2. There is substantial need to resolve the jurisdiction problems of investigation when a serviceman or woman dies off base, to assure that there is a full autopsy, that there is a complete and professional investigation and that no reports, photos and information can be withheld from the families. There may be some need to discuss the possibility of investigative lead being taken by a federal investigating agency, such as the FBI, thereby taking it out of the hands of both the civilian and military jurisdictions.

3. There is a compelling need for a suicide prevention action program that utilizes the expertise of professionals and that encompasses an “immediate safety net" approach to troubled and fearful servicemen and women-one which allows them to remove themselves from a threatening situation. Many of the cases reviewed contained information that the deceased serviceman or woman had been physically threatened or intimidated for a variety of reasons.

4. The establishment of a board of investigative review should be seriously considered within the Department of Defense, to assure that conflicting medical, technical and investigative opinions are heard and weighed in those cases where conflicts exist and families make the request. Such a board should be able to recommend and implement a change in the official records concerning the manner of death, when the evidence or lack thereof supports it.

Mr. PALLONE. It essentially summarizes our recommendations, our findings, in the best manner, I think, that we could. But I still wanted to talk about some other specifics, if I could today, briefly. First, I have to say that I am repeatedly asked if I believe that the problems I have identified in the study of unattended deaths are systematic throughout the military, and my answer is emphatically yes. With few exceptions, the deficits in investigation that I

have reviewed have occurred everywhere, and exist in each branch of the military.

I have been asked to explain why there are not more families questioning or challenging determinations of self-inflicted death if the problems are so systematic, and I have to say that that question assumes that each family was somehow notified that they could request a review by the DOD Inspector General's Office, which was not and is not the case. My understanding from families interviewed is that they usually spend considerable time in the first 2 years after the death in pursuing answers and documentation. In too many cases over a year will pass before the final report is issued, and many families have never received specific information that has been requested. After the emotional exhaustion of months or years of being patronized or ignored, countless citations of regulations barring information, delays in receiving reports, and the finality of these reports, none of which provide recourse, many families have resigned themselves to their grief and come away with a sense of helplessness and a loss of faith in their Government. That is particularly unfortunate because so many of them, obviously all of them, have a great faith in Government.

There are others such as those here today that have been meeting with each other at the crossroads of grief and anger as they understand the commonality of not only their loss but their experiences with the Department of Defense, and these families have chosen to seek accountability and answers. They have endured exhumations, second autopsies, brutal discussions of crime scene photos, and they have often sought out independent expert opinions. They now want the record of these deaths amended because the military has not proven through competent investigation the manner of death, only the cause. They look now to you for recourse, obviously, and for your collective commitment to families who may be similarly affected in the future.

Now, frequently I am asked whether or not I believe these families are in denial. This is sort of a catch-all phrase utilized by many military investigators to describe those families who refuse to accept official findings. This question appears to be based on failure to understand that a self-inflicted death, a suicide, is the only manner of death wherein the victim is also charged with a crime, essentially. But the victim cannot speak nor defend himself, and in a system where no provision exists to act in that capacity, the victim's families must. The motivating force-and I really want to stress this, Mr. Chairman-the motivating force behind these families is one of defense, not denial.

Overall, the military investigators have not proven their cases against these servicemen. In fact, there is, in my opinion, no mechanism within the military, no defense attorney, no investigative review board, that requires the military investigators to substantiate their allegations against these deceased servicemen and women, and even, and I respect the professional opinion, often contradicts these findings. If an attempt were made to support a homicide. charge with the types of investigations currently used to determine that an unintended death was accidental or self inflicted, no court in this land would entertain such a prosecution. There just would not be a conviction.

We have over 230 in 1995 and over 4000 since 1979 that have been subjected to flawed and incomplete investigations that have led to findings of suicide or accidental self-inflicted death. I just wanted to say briefly my 21-year-old constituent, Marine Lance Corporal Scott Jakovic, died of a contact bullet wound to the head. Another young Marine was court martialed for involuntary manslaughter based upon an admission to a friend. In the end, the other Marine was acquitted because he had never been read his rights, because critical paperwork disappeared, and because evidence had been mishandled. But Scott Jakovic remains a self-inflicted death on the records today despite all this.

In most of the recent cases the armed forces employment of psychological autopsies has compounded the injury done to these families. I just wanted to talk a little bit about that, and then I will finish.

The use of psychological autopsies, without checks and challenges, by underspecialized and possibly undereducated investigators in many cases has become a tool to conform or provide evidence where concrete evidence exists. In many of these cases, relationships between the victim and everyone that ever played a part in the victim's life is dissected in a vacuum. I just wanted to give some examples of that.

If a person bounced a check, he is considered to have financial problems. If he likes to hike, he is considered a loner. If his grandfather drank too much, he is probably an alcoholic. If he was found to have been a homosexual, he is considered unhappy. If he worked out, he was overly concerned with being strong. It is these kinds of conclusions, sort of general conclusions, that we often get; I am not trying to take away from this kind of profiling. I have a lot of respect for the criminal profiling efforts of the FBI experts at Quantico, and I appreciate that developments in this field of psychology have lent valuable assistance to police throughout the country.

But I believe that this psychological profiling as currently being utilized in military autopsies is only as good as the information provided to the profiler by criminal investigators who have performed a thorough criminal investigation. In fact, often this is a problem. A DOD investigator may be misusing information, misquoting witnesses, or unknowingly misdirecting the profiler, and when that happens these psychological autopsies are irretrievably corrupted.

If the physical evidence from the body and the crime scene is withheld or mishandled, the profiler preparing this psychological autopsy is missing key elements in making his report. Here again, once these reports are prepared and part of the record there exists no remedy to correct erroneous information alleged to be factual. In one case we had the mother of a young Air Force woman, who has to live with a report stating that she had little communication or contact with her daughter despite having enjoyed a 2-week touring vacation just before the daughter's death. Without exception among these families, the flawed investigations, the reports, the unsupported findings, and the absence of recourse inflict immense personal pain to these families.

I just wanted to conclude by saying that I believe, Mr. Chairman, it is obvious that there must be recourse to resolve differences of professional opinion; there must be recourse in correcting military records concerning the manner of death; there must be procedural changes in the procedures and practices of military criminal investigators; there must be a means by which there is a Federal investigatory involvement in those deaths which occur in civilian jurisdictions; there must be the entitlement to a full physical autopsy documenting each physical finding, no matter in which jurisdiction the death occurred; and finally, and I cannot stress enough, there must be a substantial change in the process of preparing psychological autopsies. As I said in the beginning, in this issue summary we basically go into each of these areas where we believe that there have been problems in the way the investigation is handled, and we do have suggestions about what we think should be changed. One of the areas, of course, is the psychological autopsy.

I cannot stress enough the fact that the group that is here today who asked that this hearing be held has really done a tremendous amount of work in looking at all these cases and preparing findings and preparing recommendations to you. It is not a case of where grieving parents are just talking about their grief. They have actually spent a lot of time with me and other members actually coming up with what changes they think would be helpful. I know that you are going to be looking a that, and I understand the nature of this hearing today, but as I leave, we would be remiss if we did not actually act on some if not all of these recommendations.

Thank you very much.

[The prepared statement of Mr. Pallone follows:]

PREPARED STATEMENT BY CONGRESSMAN FRANK PALLONE, JR.

More than 3 years ago, Congressman Dave Levy and I began a joint effort to have Congress and the Department of Defense recognize deficiencies and correct the findings of investigations that had been conducted into the deaths of certain servicemen-our constituents-who are alleged to have died by their own hand.

We were joined in this effort by many other Members of Congress and their own constituents, family members who had been devastated by similar losses. These families joined together in an informal organization that is represented here today. They provided the motivation that resulted in enactment of our Section 1185 amendment to the fiscal year 1994 DOD Authorization bill, which directed preparation of the report this committee addresses today.

While I am submitting for the record a brief summary of my findings from the study of approximately 80 cases of unattended, non-combat military deaths, there are several specific things I need to say.

First, I am repeatedly asked if I believe that the problems I have identified in the study of unattended deaths are systemic throughout the military.

My answer is yes. With few exceptions, the deficits in investigation that I have reviewed have occurred everywhere and exist in each branch of the military.

I have been asked to explain why there are not more families questioning or challenging determinations of self-inflicted death, if the problems are systemic?

That question assumes that each family was somehow notified that they could request a review by the DOD Inspector General's Office, which was not and is not the case.

My understanding from families interviewed is that they usually spent considerable time in the first 2 years after the death in pursuing answers and documentation.

In too many cases, over a year will pass before the final report is issued. Many families have never received specific information that has been requested.

After the emotional exhaustion of months or years of being patronized or ignored, countless_citations of regulations barring information, delays in receiving reports and the finality of those reports-none of which provide recourse-many families