San Diego Education Report
July 2013
Sept 2013
Sequenom Fires Top Brass After Investigation
David Washburn
Voice of San Diego  
September 28, 2009

San Diego-based Sequenom Inc. today forced out its CEO and three other executives,
including its research and development chief executive, after an in-house investigation
into the mishandling of test results for its potentially breakthrough blood test for Down
syndrome, the Associated Press is reporting.

The company, according to the AP story, fired CEO Harry Stylli, and Elizabeth Dragon,
senior vice president for research and development. Sequenom's chief financial officer
Paul Hawran and an unnamed executive resigned on Friday. Three lower-level employees
were also fired.

The news caused shares of the company to plunge 44 percent — from $5.69 to $3.21 —
in after hours trading Monday. Shares have been as high as $29.14 during the past year.

From the AP story:

"While each of these officers and employees has denied wrongdoing, the special
committee's investigation has raised serious concerns, resulting in a loss of confidence by
the independent members of the company's board of directors in the personnel involved,"
the company said in a statement.

The company did not say that any deliberate wrongdoing was discovered, but in a filing
with the Securities and Exchange Commission, it said it did not put adequate protocols and
controls in place. Some employees were not adequately supervised, it said.

Sequenom acknowledged on April 29 that employees had mishandled trial data on the
test, which, because it is far less invasive than amniocentesis, could revolutionize how
pregnant women are tested for the presence of Down syndrome in their babies.

As we chronicled in May, stock analysts and other industry watchers were shocked not
only with the news that data had been mishandled, but also with the way the company
managed the fallout. Since Sequenom's April admission, several class action lawsuits have
been filed against the company on behalf of shareholders.
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Report: 2001 Anthrax Attacks Were Preventable
Scientist With Psychiatric Problems Given Access to Deadly Pathogen
March 23, 2011

The Army scientist believed to have caused the 2001 anthrax attacks that left five dead
and paralyzed Capitol Hill and media organizations had severe psychological problems,
was obsessed with a sorority and should never have been given security clearance or
access to deadly pathogens, according to a newly released report.

An independent review of the psychiatric records of the alleged anthrax killer Dr. Bruce
Ivins has revealed that the Army scientist, who committed suicide in 2008, should never
have been given a security clearance or access to anthrax based on his psychological
profile and diagnosable mental illness.

The report also found that Ivins allegedly carried out the attacks for revenge and
redemption for questions about his work with the anthrax vaccine. The findings also
delve further into his troubled relationships with women and an obsession he developed
for a sorority that had a profound impact on his life.

"Information regarding his disqualifying behaviors was readily available in the medical
record and accessible to personnel had it been pursued," the report concluded in its
key findings.

The records were obtained by the Justice Department when they sought a court order
to obtain Ivins' sealed psychiatric records. The findings were made by the Expert
Behavioral Analysis Panel, ordered by a federal judge to review Ivins' sealed
psychological records to determine if future acts of bioterrorism could be prevented.

Read the full report here.

Ivins worked at the U.S Army's Medical Research Institute of Infectious Diseases
(USAMRIID) and committed suicide as FBI investigators, in 2008, zeroed in on him as
the main suspect in the Fall 2001 anthrax attacks. The anthrax attacks left five people
dead and sickened 17 others after mail containing the toxin arrived on Capitol Hill and
at news organizations in Florida and New York.

"Dr. Ivins had a significant and lengthy history of psychological disturbance and
diagnosable mental illness at the time he began working for USAMRIID in 1980 that
would have disqualified him from a Secret level security clearance had this been
known." said panel chairman Dr. Gregory Saathoff at a Tuesday press conference in
Washington to announce the panel's findings. Dr. Saathoff is the executive director of
the University of Virginia Critical Incident Analysis Group and associate professor of
Research Psychiatry at the UVA medical school. He also worked as an FBI consultant
during the investigation...

Medical records point to doctor in anthrax attacks,
report says
Psychiatric panel says there's support for FBI's accusation against Army employee
NBC News NBC News

Medical records of Dr. Bruce Ivins, blamed by the FBI for the deadly 2001 anthrax mail
attacks, "support the Justice Department's determination that he was responsible," a
panel of behavioral experts and psychiatrists contended in a newly released report.

"Dr. Ivins was psychologically disposed to undertake the mailings, his behavioral history
demonstrated his potential for carrying them out, and he had the motivation and the
means," they said in a report made public Wednesday.

Letters containing powdered anthrax were sent to news organizations and two US
senators in late 2001, infecting 22 people who received or handled them, five of whom
died. Ivins, a civilian researcher at the US Army's Medical Research Institute of
Infectious Diseases in Maryland, committed suicide in July 2008 as the FBI was
preparing to accuse him of preparing and mailing the letters. He was never charged.

Dr. Ivins displayed behavioral problems that should have led his Army employers to
look closer at his medical history, the report contended. Such an examination should
have prevented him from obtaining the security clearances needed to work with such a
dangerous material as anthrax, the panel members said.

Their report was requested in secret by a federal judge, Royce Lamberth of
Washington DC, who asked for an examination detailing "the mental health issues of
Dr. Bruce Ivins and what lessons can be learned from that analysis that may be useful
in preventing future bioterrorism attacks." The findings were filed last fall under seal.

Though many of his co-workers at the bioweapons lab in Maryland have disputed the
FBI's findings, the panel found that Ivins "cultivated a persona of benign eccentricity
that masked his obsessions and criminal thoughts."

Dr. Gregory Saathoff of the University of Virginia School of Medicine, the panel's
chairman, said the medical records "document behavior he claimed he undertook and
provide an indication of a strong component of revenge, including graphic plans to
engage in violent behavior."

But even though Ivins repeatedly waived confidentiality and gave Army background
investigators permission to obtain his medical records, such a step was never taken,
panel members said. "Had these records been obtained, they would have shown a
longstanding pattern of disturbed thinking in response to stress," the report said.

In one example, in 1987, Ivins placed question marks next to a check list of items on a
medical history report that included "memory change, trouble with decisions,
hallucinations, improbable beliefs, and anxiety."

A spokesman at the Army lab in Maryland declined to comment, citing privacy laws.

As for his motives, the report says he acted out of a desire for revenge against his
critics, "a desperate need for personal validation," and a hope that the response to the
attacks would revive the government's efforts to develop an anthrax vaccine — a
program on which he was a key researcher.

The scientists and doctors who studied the records emphasized what they said was an
obsession Ivins had with the Kappa Kappa Gamma sorority, which began when a
member of the sorority turned him down for a date while he was a graduate student.
Shortly after the first anthrax letters were mailed, but before they were discovered, he
wrote an e-mail to another KKG sister he had known as a student. In the e-mail, he
referred to bio-warfare and anxiety.

"The e-mail would soon cast him in her eyes, he appears to have hoped, as a prophet
and as a defender of the nation," the report said.

Briefing reporters on their findings, panel members also said they found no reason to
question the FBI's findings that Dr. Ivins acted alone in carrying out the anthrax attacks.

The FBI's findings, blaming Ivins for the attack, have been criticized by one of the US
senators who was sent an anthrax letter, Patrick Leahy of Vermont, and by the lawyer
who represented Ivins before his death.

In a written statement, the FBI said Wednesday that the panel's conclusions "provide
important insight that will further contribute to the public's understanding of the
investigation into the deadly anthrax mailings. The report also provides valuable
perspectives that may be useful in preventing future attacks."
High performers and
Incompetence? Negligence? Sabotage?
All three are found in schools--and other places.
Corruption in schools

Corruption in courts

Public Entity Attorneys
Incompetence or
"...[I]f 14,000 votes can
just disappear because
someone forgot to push
a button, how many
times has that happened
in the past when we
didn't learn about it?"
--Eugene Kane

Skeptical voters
raise collective
brows after
election surprises
Eugene Kane
Milwaukee Wisconsin
Journal Sentinel
April 9, 2011

"What's most disconcerting
about the Waukesha
County election foul-up is
the sense that if 14,000
votes can just disappear
because someone forgot to
push a button, how many
times has that happened in
the past when we didn't
learn about it?"

Wisconsin court race
won't be certified
without probe
By James B. Kelleher
Apr 8, 2011

The agency overseeing
Wisconsin elections will not
certify results of Tuesday's
state Supreme Court race
until it concludes a probe
into how a county clerk
misplaced and then found
some 14,000 votes that
upended the contest.

Michael Haas, Government
Accountability Board staff
attorney, told Reuters on
Friday the watchdog
agency was looking into
vote tabulation errors in
Waukesha County which
gave the conservative
incumbent a net gain of
more than 7,000 votes -- a
lead his union-backed
challenger seems unlikely
to surmount.

"We're going to do a review
of the procedures and the
records in Waukesha
before we certify the
statewide results," Haas

"It's not that we necessarily
expect to find anything
criminal. But we want to
make sure the public has
confidence in the results,"

Unofficial returns in the
statewide race had given
the challenger, JoAnne
Kloppenburg, a narrow 204
vote statewide lead over
David Prosser, a former
Republican legislator.

But late Thursday, the top
vote counter in Waukesha
County said votes she had
failed to report in earlier
totals resulted in a net gain
of 7,582 votes for Prosser
in the county.

Wisconsin Leaves Out
14,000 Votes After Clerk
Forgets to Click 'Save'
By: Nick Carbone
April 8, 2011

Computers are tricky
beasts. We've all had our
share of simple, avoidable
mishaps: accidentally
clicking “reply all” or saving
an essential file where you'll
never find it again. But a
Wisconsin clerk takes top
honors on avoidable errors.

While tallying votes,
Waukesha County Clerk
Kathy Nickolaus forgot to
click “save” – a mistake that
almost gave the state
Supreme Court election
away to the wrong
candidate. A windfall of
votes flowed into the camp
of David Prosser on
Thursday, after she finally
saved them in the tally

A visibly-shaken Nickolaus
appeared at a press
conference Thursday to
claim responsibility. “This is
human error which I
apologize for," she said.
Once she correctly input
the data and clicked that
elusive “save” button,
14,315 votes from the
Milwaukee suburb of
Brookfield suddenly
became valid. And what
was a meager 204-vote
lead for Democrat JoAnne
Kloppenburg turned, in a
matter of minutes, into a
huge runaway for Prosser,
putting him ahead by more
than 7,500 votes. Looks
like Kloppenburg was a little
rash in declaring victory.

Tuesday's Wisconsin
Supreme Court election
was a hotly-contested race
between incumbent
Republican Justice Prosser
and current Wisconsin
Attorney General
Kloppenburg, a Democrat.
In what would typically be a
bland election,
Wisconsinites voters turned
out to the tune of 1.5 million
on Tuesday, because the
state's Supreme Court may
have final say on Governor
Scott Walker's controversial
anti-union law.

The original 200-vote
difference would most likely
have prompted a recount.
And now, given this issue of
user error, it's practically
inevitable. This race isn't
over, folks.
FAA head of air traffic resigns
By Ashley Halsey III
Washington Post

The head of the Air Traffic Organization at the Federal Aviation Administration
resigned Thursday morning amid recent reports of several controllers sleeping
on the job.

Hank Krakowski submitted his resignation Thursday morning to FAA
Administrator Randy Babbitt, who said he accepted it, federal officials said.

Krawkoski joined the FAA in 2007. Prior to that he spent about 30 years at
United Air Lines in senior management positions, including as vice president of
flight operations.

“Hank is a dedicated aviation professional and I thank him for his service,”
Babbitt said in a statement. “Starting today, I have asked David Grizzle, FAA's
chief counsel, to assume the role of acting ATO chief operating officer while we
conduct a nationwide search to permanently fill the position.”

Babbitt said recent reports of “unprofessional conduct on the part of a few
individuals have rightly caused the traveling public to question our ability to
ensure their safety.”

On Wednesday federal officials ended the practice of leaving one controller on
duty in airport towers during overnight shifts.

The FAA also revealed that a Nevada air traffic controller allegedly fell asleep
Wednesday morning as a medical flight carrying a patient tried to land.The
plane landed safely at Reno-Tahoe International Airport with the help of a radar
controller based in California, the FAA said.  The controller was suspended and
the incident is under investigation.

However, the incident Wednesday was the fifth time this year that a controller
apparently slept while on duty, including at Reagan National Airport, where a
controller supervisor was suspended last month after he admitted to napping in
the tower .

The FAA plans to conduct a “top to bottom review” of the nation’s air traffic
control system, Babbitt said.
Norway police
slammed for slow
response to rampage

Associated Press
July 26, 2011

OSLO, Norway (AP) — When
Anders Behring Breivik
launched his assault on the
youth campers of Utoya
Island, he expected Norway's
special forces to swoop down
and stop him at any minute.

Instead, Delta Force police
officers made the 25-mile
journey by car — they have
no helicopter — then had to
be rescued by a civilian craft
when their boat broke down
as it tried to navigate a one-
minute hop to the island.

It took police more than 90
minutes to reach the
gunman, who by then had
mortally wounded 68 people.
Breivik immediately dropped
his guns and surrendered,
having exceeded his wildest
murderous expectations.

As Oslo's police force sounds
an increasingly defensive
note, international experts
said Tuesday that Norway's
government and security
forces must learn stark
lessons from a massacre
made worse by a
lackadaisical approach to
planning for terror.

"Children were being
slaughtered for an hour and
a half and the police should
have stopped it much
sooner," said Mads Andenas,
a law professor at the
University of Oslo whose
niece was on the island and
survived by hiding in the
bushes. One of his students
was killed.

"Even taking all the
extenuating circumstances
into account, it is
unforgivable," he said.

These include the fact that
Breivik preceded his one-
man assault on the island
with a car bomb in the heart
of Oslo's government center.
Authorities were focused on
helping survivors from that
blast as the first frantic calls
came in from campers hiding
from the gunman on Utoya,
northwest of Oslo.

Survivors said they struggled
to get their panicked pleas
heard because operators on
emergency lines were
rejecting calls not connected
to the Oslo bomb. When
police finally realized a
gunman was shooting teens
and 20-somethings attending
a youth retreat on the island,
Breivik had already been
hunting them down for half an

Police spokesman Johan
Fredriksen rebuffed criticism
Tuesday of the planning and
equipment failures, calling
such comments "unworthy."

"We can take a lot, we're
professional, but we are also
human beings," he said...

[Maura Larkins comment:  
Wait a minute.  Did you just
say you were a human
being?  Everybody involved
is, or was, a human being.  
The question is, "Is your
police force incompetent?"  
We don't need to discuss
whether or not you're human
Second chances underscore flaws in death
January 31, 2011
Ryan Gabrielson
Pro Publica

Chris Reynolds vividly remembers his first encounter with the work of forensic pathologist Dr.
Thomas Gill.

It was 2001. Reynolds, a Santa Rosa private investigator, was hired by a Sonoma County man
accused of killing his wife. Gill, who conducted the wife’s autopsy, was the prosecution’s key witness,
having determined the death was a “textbook” case of suffocation.

Reynolds’ client’s prospects looked grim. But when Reynolds dug into Gill’s background, he
unspooled a history in which Gill landed post after post despite a lengthening trail of errors and, in
one instance, drinking on the job.

Gill had been forced out of a teaching position at an Oregon university, and then fired for inaccurate
findings and alcohol abuse by the coroner in Indianapolis, Reynolds discovered. Demoted for poor
performance as a fellow for the Los Angeles County Coroner, he resurfaced at a private autopsy
company in Northern California.

Reynolds learned that Gill had missed key evidence in the Sonoma County case and that he had
been coached by prosecutors to downplay his past, prompting the dismissal of the murder charge.

Yet, in the decade since, Gill has continued to do thousands of autopsies and to serve as an expert
witness in criminal cases. He landed a job as the No. 2 forensic pathologist in Kansas City, Mo.,
where his work again drew fire, and then returned to Forensic Medical Group Inc., the Fairfield firm
that handled the case investigated by Reynolds.    

The private forensics firm has held contracts with 16 Northern California counties to perform
autopsies for local agencies. Besides Sonoma County, Gill has conducted death investigations or
testified in court cases in Contra Costa, Solano, Marin, Napa, Sutter, Lake and Humboldt counties as
a doctor for Forensic Medical Group. He had done more than 800 autopsies during a three-year
period in Yolo, Napa and Solano counties alone.

Forensic Medical Group cut its ties with Gill in December after Yolo County Sheriff-Coroner’s officials
learned of the doctor’s history from reporters and barred him from performing its autopsies. In a
written response to questions, Forensic Medical Group said that after Yolo County’s decision, it no
longer had enough cases to justify employing Gill.

Gill’s ability to resurrect his career time and again reflects a profound weakness at the center of the U.
S. system of death investigation.

A chronic shortage of qualified forensic pathologists allows even questionably competent
practitioners to remain employable. The absence of trained practitioners is so acute that many
jurisdictions don't look closely at the doctors they employ. Some of the officials who hired Gill
acknowledged they knew about his problems but said they had no other viable options.

With no national oversight of forensic pathologists or standards that dictate who can do autopsy work,
there is nothing to prevent Gill from resuming his career.

In some cases, officials in charge of death investigation are more concerned with costs than with
competent autopsies, said Dr. John Pless, a director of the National Association of Medical
Examiners and retired forensic pathology professor at Indiana University.

“What the problem is all over and why Tom Gill is accepted is there are people running the system
who don’t understand the complexity of the medical determinations,” Pless said.

Although the California State Bar deemed him incompetent in a 2006 report on the Sonoma case, Gill
ruled on more than 1,000 death investigations in eight California counties from 2007 to 2010.

Gill, 67, initially declined requests for interviews for this story. Approached by a reporter at his Fairfield
home in December, he would not address specific cases or criticism of his work.

“I am a qualified forensic pathologist, and I have testified on numerous occasions,” Gill said.

Later, in a written statement, Gill acknowledged that when he joined the Indianapolis coroner’s office,
“I had no formal training in forensic pathology and therefore made mistakes, particularly in pediatric
cases where findings tend to be more subtle and complex.”

Gill pointed out that his autopsy findings have not been contested or reversed since 2007.

Dr. Arnold Josselson, Forensic Medical Group’s vice president, said he had seen Gill’s work
firsthand and trusted him. “I've observed him doing autopsies, and I think he's competent,” Josselson

A troubling history

When Gill started work at the Marion County Coroner’s Office in Indiana on New Year’s Day in 1993,
he had performed only about 20 forensic autopsies since graduating from medical school 24 years

Certified specialists in forensic pathology, the science of unexplained deaths, have completed
medical school and a four-year residency in pathology, plus an additional year of intensive training
and autopsy work. According to the National Academy of Sciences, there are roughly 500 such
practitioners nationwide, less than half the number needed to properly investigate suspicious or
unattended deaths.     

Gill, a neuropathologist by specialty, had spent the first two decades of his career teaching medical
students at the Oregon Health & Science University and analyzing brain tissue for a nearby Veterans
Affairs hospital.

But Gill has acknowledged during preparation for court testimony that he was stripped of his teaching
duties in 1992, possibly due to a drinking problem that dated back to the mid-‘80s. Gill gave written
answers to nearly 200 questions that prosecutors anticipated defense attorneys would ask during a
2001 homicide trial. One inquired whether his drinking had affected his work in Oregon. “Probably,”
Gill wrote in response, “but no documentation.”

Gill was willing to shift from brain study to death investigation if that meant better job prospects.

At the time, the Marion County coroner, who serves the Indianapolis metropolitan area was desperate
for help. Left without autopsy services after a contract dispute, the office had bodies stacked up in its
refrigeration units.

Gill worked seven days a week during his first several months in Indianapolis, examining four to eight
bodies per shift, court and county records show. Signed to a four-year contract that paid $100,000
annually, he performed about 650 autopsies in 1993 alone, more than twice the maximum workload
recommended by the National Association of Medical Examiners.

It didn’t take long for problems to surface with the accuracy and precision of his work.

In early 1993, Gill ruled that Dylan Petroff, a 17-month-old boy, had died from a blood infection. A
second autopsy conducted by a leading specialist hired by Petroff’s parents, however, came to a
different conclusion.

Petroff had strangled, the specialist determined, caught in the slats of a defective crib at the
uncertified day care center run by his babysitter.

Pam Faught, Dylan’s grandmother, said she was shocked that Gill continued to be entrusted with
death investigations.

“They don’t tell the next person that’s going to hire him how unqualified this individual really is,” she
said. “And he’s got ‘doctor’ in front of his name.”

A year later, 6-month-old Julian Dorsey ended up on Gill’s table. The doctor ruled the infant was a
homicide victim, shaken to death by his father. But Gill’s finding was reversed by his boss. There was
no physical evidence that the child had sustained a brain injury.

Gill’s drinking also became an issue over the course of his tenure in Indianapolis.

Soon after he started in Marion County, another coroner’s office employee found him passed out
drunk in a loading dock after the end of a shift, Gill acknowledged in written answers during
preparation for a 2001 trial.

On March 31, 1994, Gill arrived at a law office for a deposition in a homicide case. The prosecutor and
court reporter later stated they smelled alcohol on his breath. Gill denied being drunk, but his sworn
testimony on the shooting death of Cheryl Angleton repeatedly contradicted his autopsy findings. At
one point, Gill speculated that his conclusion – that Angleton had been murdered – might have been
wrong and that Angleton could have committed suicide.

“Whatever credibility he may have had no longer exists,” the prosecutor wrote in a report afterward,
calling Gill’s testimony “inaccurate, contradictory and absurd.”

Although an internal investigation officially cleared him of testifying drunk, Gill was told in July 1994
that his contract would end after just 19 months.

“Your well documented inability to provide services at a reasonably necessary level has prevented
you from establishing and maintaining credibility with the law enforcement community,” Marion
County Coroner Karl Manders wrote in his termination letter.

Gill was given 30 days’ notice but was unable to complete his final month. He was arrested on the
charge of drunken driving on his way to the morgue one morning and barred from further work. He
was convicted of the charge and Indiana’s medical board suspended his license until he received
substance abuse treatment.

Fresh start in California

Gill moved to California and spent months undergoing treatment for alcohol abuse, records show.

Then, in early 1995, he landed a dream job: a one-year fellowship with the Los Angeles County
Coroner, an ideal place to hone his training in forensic autopsies and death investigation.

Gill did not disclose on his resume or application that he had been fired in Indianapolis. Los Angeles
officials first caught wind of his troubles when a reporter from The Indianapolis Star called.

“We were not knowledgeable, nor was this information voluntarily given to us,” a coroner’s office
personnel administrator told the newspaper regarding Gill’s mistakes in Marion County.

Gill kept his post, even after his omissions were exposed, but struggled to meet the program’s
requirements. Nine months into his training, personnel records show, the coroner’s office deemed
his work deficient, cut his pay in half and demoted him to the equivalent of a medical student.

In a written evaluation, Gill’s superiors wrote “there are significant technical problems in some of your
autopsies resulting in the need for continued supervision.”

Gill also was unable to complete the number of cases needed to finish the fellowship in a year, said
Dr. James Ribe, a Los Angeles County deputy coroner and one of Gill’s supervisors. The coroner’s
office gave Gill an additional six months to catch up.

In 1997, with his fellowship completed, Gill was eligible to take the American Board of Pathology’s
certification exam for forensic pathology, the field’s most universally recognized measure of

Gill failed the test on his first try. And his second. He passed the third time, in 1999.

Nevertheless, Gill was hired in April 1998 by Forensic Medical Group, the for-profit autopsy company
with contracts to handle cases for more than a dozen Northern California counties, including Sonoma
County in the heart of one of the state’s most renowned wine-producing regions.

It was there that Reynolds, the private investigator, began to unravel Gill’s past.

Private investigator Chris Reynolds outside the Sonoma County Coroner’s Office.Deanne
FitzmauricePrivate investigator Chris Reynolds outside the Sonoma County Coroner’s Office.

Errors surface in Sonoma case

Late on the evening of Nov. 7, 1999, a prominent local physician in Petaluma, Calif., called 911. His
wife was dead, Dr. Louis Pelfini told the emergency operator, adding that he feared she had
committed suicide.

The Sonoma County Sheriff’s Office investigators who responded to the call did not initially treat
Pelfini’s home as a crime scene, police records show, but they ultimately came to suspect Pelfini had
killed his wife, Janet.

Gill started his examination of her body two days later. After a month, he ruled that Janet Pelfini had
died from asphyxiation. His notes showed abrasions circling her mouth and a bruise on her
forehead. Based on his findings, the sheriff’s office classified her death as a homicide, and
prosecutors filed murder charges against Louis Pelfini.

Gill’s certainty about what caused Janet Pelfini to suffocate prompted her husband’s  defense team
to worry, said Reynolds, the private investigator hired by Louis Pelfini’s attorney.

But Gill’s work on the case had some holes.

Gill did not take pictures of Janet Pelfini’s injuries as he autopsied her. He made drawings, but
photographs from the scene taken by sheriff’s deputies showed they were inaccurate. He failed to
note a bruise on the back of her head on the drawings. In his written report, the injury was included,
but on the wrong side of her head.

Gill also overlooked mucus plugs in her lungs. Another pathologist, hired by the prosecution, later
argued the plugs were evidence that Janet Pelfini had suffered a severe asthma attack shortly before
her death, indicating she may have died from natural causes.

Another limitation: The body had been cremated after Gill's autopsy, leaving other experts to argue
over how to interpret his notes.

With Pelfini’s case resting primarily on Gill’s conclusions, Reynolds began running the doctor’s
name through news archives and calling his former colleagues.

When the defense team reported its findings about Gill to prosecutors, however, the state did not re-
examine the charges. Instead, they secretly began coaching Gill, arranging for him to meet with a
speech therapist to help craft his trial testimony.

In the videotaped sessions, Gill acknowledged he would have to sidestep flaws in his casework.
“There are deficiencies in the autopsy,” he acknowledged. “You know we have kind of alluded to that.”

The tapes also showed Gill and his coach, Jeffrey Harris, trying to downplay his past problems.

Practicing an answer to the question of why Marion County fired him, Gill said the termination was
due to “errors in autopsies and inability to testify in trials.”

“OK, timeout,” Harris interrupted. “Don’t say … I would not say, ‘My inability to testify in trials.’ I would
say, ‘My difficulty in testifying effectively,’ or ‘my inability to effectively communicate the results of my
autopsies.’ Something to that effect.”

Gill is shown on the tape taking down Harris’ instructions on a yellow notepad.

“We always want to be thinking about, how do we counter these allegations, these innuendos that
there’s something wrong with you,” Harris told Gill during one of the sessions.

The strategy failed when Pelfini’s attorney learned of the coaching sessions and the trial judge
ordered the tapes released to the defense. Days later, the district attorney’s office dropped all

The California State Bar investigated the handling of the Pelfini case and suspended the prosecutor
from practicing law for four years for his role in suppressing evidence about Gill’s coaching sessions.
The bar report devoted several pages to Gill’s errors.

“Unfortunately,” it concluded, “Dr. Gill was not a competent pathologist.”

Mistakes in Missouri

The Pelfini case left Gill’s reputation in Northern California tarnished. Sonoma County officials barred
him from conducting autopsies there. As he had before, Gill sought a new start in a new state.

In late 2002, the Jackson County Medical Examiner’s Office, which handles autopsies for Kansas
City, Mo., advertised for a deputy. The pickings were slim.

“There were two applicants,” said Dr. Thomas Young, then the office’s sole forensic pathologist. “And
the other one had already gotten into some ethical trouble back east, so he was just completely out.”

Young said he knew about the Pelfini case and about Gill’s drunken driving conviction. But Young
said he trusted what Gill told him: that the doctor had recovered from alcohol abuse and that the
Sonoma County murder case collapsed due to prosecutorial misconduct, not poor autopsy work.

Gill started work in Kansas City in November 2002, earning $140,000 a year. Young said he watched
his colleague closely.

“In terms of his conscientiousness, being thorough, he was good,” Young said. “He did make some
mistakes, but I caught them.”

Not all of them.

In September 2003, Gill autopsied 23-year-old Robert Patterson, who had died a day after being
injured in a car accident. Based on toxicology tests that showed painkillers in Patterson’s blood, Gill
ruled the death a suicide.

But a second autopsy commissioned by Patterson’s mother revealed an artery in Patterson’s neck
that showed signs of damage so severe it would have blocked blood flow to his brain. The injury
almost certainly occurred in the car accident, the second pathologist concluded.

Presented with the results, Gill reversed his finding, ruling the death an accident.

The following year, several Missouri prosecutors learned of Gill’s problems in California and
Indianapolis and threatened to boycott the Jackson County Medical Examiner’s Office unless it fired

Young refused. Asked why, he said the shortage of practitioners made the move impractical and that
even the field’s best sometimes misdiagnose causes of death.

Gill stayed another two years, quitting at the end of 2006 after one of the prosecutors became the
county’s chief executive and after Young retired.

Another new beginning

Again, it didn’t take long for him to find another job. In early 2007, Forensic Medical Group rehired Gill.

Click on the image to enlarge the graphic.Brian Cragin/California Watch

p>Dr. Brian Peterson, who was the firm’s president for 15 years before becoming Milwaukee’s chief
medical examiner, defended the decision.

“To my mind, he was always a victim,” Peterson said. “Gill’s a great guy, and he’s a fine pathologist.”

But the group didn’t advertise Gill’s background. On its website, it gave resumes and educational
histories for all its doctors – except Gill.

In his written statement, Gill said his work since returning to Forensic Medical Group in 2007 had
been above reproach. In addition, the doctor said that county officials in the jurisdictions he served
were aware of his background.

“In court and during application for jobs, since 2001 much of the background information has been
made available to prospective employers, defense lawyers and ultimately, if the latter deemed it
relevant to the jurors in court cases involving one of my postmortem examinations,” Gill wrote.

Several Forensic Medical Group clients say they did not receive this information, however.

Presented with records detailing Gill’s professional history in late November, officials with the Yolo
County Sheriff-Coroner’s Office expressed surprise.

“This is an eye-opener for us, to admit humbly,” said Yolo County Chief Deputy Coroner Robert

Yolo County subsequently joined Sonoma in demanding that Gill not be used on its cases.

Jana McClung*, a Sutter County prosecutor, said neither she nor the sheriff-coroner’s office were
aware of Gill’s background before being contacted by a reporter in December. Gill is scheduled to
testify in a death penalty case being prosecuted by the district attorney’s office. McClung said she had
alerted the sheriff and the defendant’s attorneys.

“Obviously, what we’re going to have to do is have another forensic pathologist look at our case as a
follow up to him,” she said.

Until December, when Forensic Medical Group says it stopped employing Gill, the doctor remained
active. Last summer he gave testimony in a homicide case, a stabbing.

Asked if he intended to continue working as a forensic pathologist and if he was seeking
employment, Gill e-mailed back.

“Yes and yes,” he said.
Negligently putting innocent people in prison
Serious problems among expert witnesses and doctors at
criminal trials
by Radley Balko
Leigh Stubbs,
Mississippi Woman,
Serving 44-Year
Sentence Despite

Leigh Stubbs, Mississippi
Dept. of Corrections photo.

Prosecutors in the U.S. often
decry what is sometimes
called the "CSI Effect." Movies
and TV crime dramas like the
popular "CSI" franchise on
CBS can fill jurors' heads with
unrealistic expectations about
forensic science. But there's
also a flip side to the CSI
Effect: Because jurors are
ready to believe the
fantastical feats preformed by
the wondrous forensics
computers they see on
screen, an unscrupulous
prosecutor armed with an
expert willing to offer
otherwise dubious forensics
on the witness stand can
cause a lot of damage.

Witness Michael West. In the
early 1990s, West, a dentist in
Hattiesburg, Miss., was one of
country's most prolific forensic
odontologists, or bite mark
specialists. West claimed to
have perfected a new method
of identifying bite marks on
human skin, saying he could
then match them to the teeth
of a criminal suspect.
Conveniently, West often
testified that only he could
perform this new analysis,
which he called the "West

Over the years, West
broadened his areas of
claimed expertise, testifying in
at least 10 states as a wound
pattern expert, a trace metals
expert, a gun shot residue
expert, a gunshot
reconstruction expert, a crime
scene investigator, a blood
spatter expert, a "tool mark"
expert, a fingernail scratch
expert and an expert in "liquid
splash patterns." He also got
himself elected coroner of
Forrest County, Miss. Though
West was discredited in a
number of national media
reports beginning in the
mid-1990s, he continued to
testify in Mississippi
courtrooms until just a few
years ago.

Mississippi prosecutors no
longer use West as a witness,
but state Attorney General Jim
Hood continues to defend
convictions won because of
his testimony. And
Mississippi's appeals courts
continue to uphold them.
There are still dozens of
people still in prison thanks
either to West's testimony or
his forensics reports, and
Mississippi officials don't seem
particularly concerned about
them. One of those people is
Leigh Stubbs, now 10 years
into a 44-year prison


Stubbs may not be the most
sympathetic of West's victims.
She's a former drug addict,
who on the night of her
alleged crimes wasn't in the
best of company. But witness
accounts say Stubbs
remained sober that night
(she passed a drug test), and
the evidence suggests she
was the group's caretaker.

Stubbs' story begins in March
2000, just after she
successfully completed
treatment at a rehab center in
Columbus, Miss. Stubbs
checked out with Tammy
Vance, a friend she met in
rehab, and Kim Williams, the
woman Vance and Stubbs
would later be accused of

After checking out, the three
women drove to the home of
Dickie Ervin, whom Williams
had been dating. Vance and
Stubbs then left Ervin's
house. They were joined later
by Williams, who had stolen
some of Ervin's Oxycontin.
Vance and Williams began
drinking and taking the
Oxycontin, while Stubbs drove
and remained sober. The
three eventually ended up at
a Comfort Inn in Brookhaven,
Miss. By that time, Vance and
Williams had passed out.
Stubbs checked the three of
them in to the hotel.
According to the clerk's
testimony, Stubbs didn't
appear drunk or high, only

By Stubbs' account, she then
helped the other two women
into the room, and the three
went to sleep. The next day,
Stubbs and Vance went to get
some food, leaving Williams in
the room, still sleeping. Later
the same afternoon, Stubbs
and Vance noticed that
Williams still hadn't woken up,
and was having trouble
breathing. They called an
ambulance, and Williams was
admitted and treated for a
drug overdose. She fell into a
coma. At the hospital, doctors
found a number of injuries on
Williams, including swollen
breasts, a swollen and
bruised vagina, and marks
across her buttocks. The
attending physician believed
the injuries appeared to be
two to four days old. A rape kit
was inconclusive. Another
doctor later also found an
injury to Williams' head. A few
days later, the office of
then-District Attorney Dunn
Lampton called in Michael
West to examine Williams'
injuries. (Williams, who has
since recovered, says she
doesn't remember who
attacked her.)

Lampton chose to bring in
Michael West as a witness
even though West's credibility
problems were already
well-known. West had
previously claimed to be able
to trace the bite marks in the
bread of a half-eaten bologna
sandwich to the prosecution's
chief suspect; he had
compared his own genius to
the musical genius of Itzhak
Perlman; and he once
testified in court that his own
error rate was merely
"something less than my
savior, Jesus Christ." West
had been exposed in articles
in both the American Bar
Association Law Journal and
the National Law Review, and
he was suspended and later
resigned from the American
Board of Forensic
Odontologists. But Lampton
ignored West's history and
called in his expertise in yet
another criminal case.

In a routine he had by then
repeated dozens of times with
law enforcement officials
across Mississippi and
Louisiana, West claimed to
find human bite marks on
Williams that other doctors
had overlooked. He then
ordered dental impressions
taken from Stubbs, Vance and
two other suspects. But by the
time the plaster impressions
arrived, Williams' alleged
wounds had faded. So West
performed his analysis based
on photographs he had taken
of his findings days earlier. He
would later testify that it was a
"probability" that a bite mark
he claimed to have found on
William's thigh was made by
Stubbs. (In a rare display of
humility, West did concede
that he wasn't "100 percent"
certain of the match -- only
that it was likely.)


From there, the case against
Leigh Stubbs only grew more
bizarre. On the night of the
alleged attack, the Comfort
Inn had a security camera
camera trained on its parking
lot. Lampton sent the grainy
VHS tape, which was taken
after nightfall, to the FBI for
analysis. The agency's report
found nothing incriminating in
the footage. It repeatedly
points out that the quality of
the recording is insufficient to
tell for certain how many
people are depicted in the
video, much less determine
their identities or what sort of
clothing they're wearing. The
report also makes no mention
of anyone moving a "body."

Though he was obligated by
law to do so, Lampton never
turned that FBI report over to
Stubbs' defense attorney. But
he sent the video to Michael
West, who, now donning his
"video enhancement expert"
cap, claimed he was able to
enhance the video and
capture still photos from those
enhancements incriminating
Stubbs and Vance for
Williams' injuries.

The ability to "enhance" security
camera footage beyond its
resolution is a
Hollywood-perpetuated myth so
common that mocking it has
become a running pop culture
meme. Yet West testified in
court that he could do exactly
that. West and Lampton both
knew that the FBI itself was
unable to glean anything useful
from the video, according to this
correspondence, in which West
references the FBI's
examination of the tape. They
kept that correspondence from
the defense and the jury.
What happened at NASA?  
How did such a successful
agency develop such a
Aug. 31, 2011
Panel: Widespread waste and fraud in war spending
Associated Press

WASHINGTON (AP) - An independent panel that concluded as much as $60 billion
in U.S. funds has been lost to waste and fraud in Iraq and Afghanistan over the
past decade will release results Wednesday of its three-year investigation into
wartime spending.

In its final report to Congress, the Commission on Wartime Contracting blamed the
losses on lax oversight of contractors, poor planning and widespread corruption,
especially during the early stages of the wars when few controls were in place to
monitor the heavy flow of money.

The Associated Press obtained a copy of the commission's 240-page report in
advance of its public release on Capitol Hill. The commission was created by
Congress in 2008 and ceases operating at the end of September.
Stranded JetBlue
pilot pleaded for help
from Conn. airport
By Rebecca Ruiz, Senior editor,

A recording of transmissions
between a JetBlue pilot and Bradley
International Airport near Hartford,
Conn., captured the pilot's
frustration at being stuck on the
runway during a snowstorm for
more than seven hours on Saturday.

Story: At least 4 jets strand Conn.
passengers for hours

The pilot continues to request
towing assistance so that
passengers can deplane at a gate.
"We can't seem to get any help from
our own company," says the
unidentified pilot. "I apologize for
this, but is there any way you can
get a tug and a towbar out here to
us and get us towed somewhere to
a gate or something? I don't care --
take us anywhere."

The seven-minute recording was
posted to the air traffic website

Flight 504, as it's identified in the
recording, was one of at least three
JetBlue planes that reportedly sat
on the tarmac for several hours
after being diverted from New York-
area airports during a snowstorm.
According to JetBlue's website,
flight 504 is a daily flight from Ft.
Lauderdale to Newark.

The Department of Transportation
is investigating the JetBlue tarmac
delay and others that lasted more
than three hours. Airlines that keep
passengers stranded for more than
three hours face fines of up to
$27,500 per flier.

A JetBlue spokeswoman, Victoria
Lucia, confirmed in an e-mailed
statement to the Associated Press
that six of its planes, carrying a total
of about 700 passengers, were
diverted to Hartford as a result of a
"confluence of events" including
equipment failures at Newark and
New York's John F. Kennedy
International Airport that prevented
planes from landing in low visibility.

Andrew Carter, a passenger on the
plane, told the AP that the crew ran
out of snacks and bottled water for
the last few hours of the delay. "The
toilets were backed up. When you
flushed, nothing would happen," he

The recording begins with the pilot
warning the airport not to let a
trooper board the plane. It is
unclear at what point during the
ordeal the airport considered
sending police to the plane.

"If you try to come on the jetway now
and flash a trooper's uniform on
this plane, it's not going to be good,
it's not going to be pretty," the pilot
said to the airport. "They've calmed
down a little bit. We've told them
we're waiting for the gate, we're just
waiting for a tug and a tow bar ... I
appreciate your efforts, but it'll be
worse if you try to put a trooper on
here right now."

The pilot later mentioned that a
diabetic and paraplegic were
among the passengers who
urgently needed to deplane. The
airport eventually towed the plane to
a gate.

"Thank you very much ... for helping
us out," said the pilot. "I think we got
more help from you guys than our
own people."

JetBlue spokesperson Sharon
Jones told that the
airline was looking into the incident.
"We don’t have any information
regarding that audiotape," she said.
"We’re conducting our own
investigation. Right now we don’t
have anything to share."

Information from the Associated
Press was included in this report.
San Diego Education Report
San Diego
Education Report
Incompetence: Thank
Heaven blog
Witness: Six Flags coaster victim concerned about seat
Natalie DiBlasio
July 20, 2013

Investigators were trying to determine Saturday how a woman fell to her death from the
tallest steel-hybrid coaster in the world Friday night at Six Flags Over Texas.

The accident happened just after 6:30 p.m. CT on Friday at Six Flags Over Texas in
Arlington. Park spokeswoman Sharon Parker confirmed that a woman died while riding the
Texas Giant roller coaster but did not specify how she was killed. However, witnesses told
local media outlets that the woman fell.

John Putman told the Star-Telegram in Fort Worth that he was in line awaiting his turn on
the ride when the car from which the woman fell returned to the ground. Putman said a
man and woman got out.

"They were screaming, 'My mom! My mom! Let us out, we need to go get her!' " Putman

Carmen Brown of Arlington was waiting in line as the victim was being secured in for the
ride. She told The Dallas Morning News the
woman had expressed concern to a park
employee that she was not secured correctly in her seat.

"He was basically nonchalant," Brown said. "He was, like, 'As long as you heard it
click, you're fine.' Hers was the only one that went down once, and she didn't
feel safe.
But they let her still get on the ride."...
Social workers involved in horrific child torture case fired
Boy's mother and her boyfriend have been charged with murder and torture.  
Los Angeles Times
By Abby Sewell
July 30, 2013

Two social workers and two supervisors in the county's troubled Department of Children
and Family Services have been fired over the death of an 8-year-old Palmdale boy after
the agency received several complaints of abuse, officials said.

Paramedics were summoned to the home of Gabriel Fernandez on the evening of May 22
and found the boy barely breathing with numerous injuries, including a fractured skull,
broken ribs and burns. He died in the hospital two days later. His mother and her
boyfriend were arrested and charged with murder and torture.

[Updated, 2:39 p.m. July 30: DCFS head Philip Browning said letters had gone out
Tuesday to the four employees most involved in the case notifying them of the
department’s intent to fire them. The employees have the right to appeal the decision.
Other employees who were “peripherally involved” received warning or reprimand letters.

Browning said the quick move to fire the employees marked a departure from past
processes. In the past, the department would have looked through the entire history of
Gabriel's involvement with DCFS before taking action. In this case, the initial investigation
focused on the last two years or so to come to a swifter resolution on the fate of the four
employees, who were put on desk duty soon after Fernandez's death.]

Los Angeles County Supervisor Michael D. Antonovich, whose district includes Palmdale,
announced the firing of the workers Tuesday during a board meeting in response to
public comments from child advocates, some of whom said they were related to Gabriel.

Advocates cheered at the announcement, but also called out, "What are their names?"

In the wake of Gabriel's death, the county also convened a blue-ribbon commission on
child protection, which is slated to begin meeting this week.
Failure to evaluate
security risks
Navy Yard shooter had
No need for Zachary
Turner to die: death
CBC News
Oct 04, 2006

The social services system
in Newfoundland and
Labrador failed a
13-month-old boy, who
drowned along with his
mother in a 2003
murder-suicide, a review
has found.

Zachary Turner died when
Shirley Turner, 42, clutched
him to her body and jumped
into Conception Bay, several
kilometres outside of St. John's.

"Nowhere did I find any ongoing
assessment of the safety needs
of the children," coroner Peter
Markesteyn, referring both to
Zachary and Turner's daughter
from another relationship, wrote
in a three-volume report
released Wednesday.

Shirley Turner with her son
Zachary: A child death
review has found that
officials gave more
consideration to her needs
than to his. ((CBC))

Turner, a general practitioner,
fled to Newfoundland after her
estranged lover Andrew Bagby,
28, was shot to death in a
Pennsylvania parking lot on
Nov. 5, 2001.

Turner had obtained bail from
the Newfoundland Supreme
Court, and gave birth to
Zachary,Bagby's son, while
fighting extradition to the United
States to stand trial for the
murder of Bagby. About two
months before the
murder-suicide,a judge cleared
the way for Turner's extradition.

Responding to Markesteyn's
child death review, Community
Services Minister Tom Osborne
said the provincial government
accepted the report and would
examine the 29
recommendations to see which
ones could be acted on

Headded that the province had
already addressed someof the
issuesraised by Zachary's

Serious flaws pinpointed

Markesteyn, based in
Winnipeg, found fundamental
flaws through child protection
system that dealt with the
Turner case in the months
leading up to the

In finding that Zachary's death
could have been prevented, he
determined poor
communication between
officials contributed to the
sequence of events that
triggered the tragedy.

Darlene Neville, Newfoundland
and Labrador's child and youth
advocate,called immediately for
an external review of the child,
youth and family services

Neville, who said she is
concerned that other children
in the province are in similar
circumstances, described the
results of the investigation as

Shirley Turner was fighting
extradition to the U.S. to
stand trial for the murder of
Andrew Bagby, Zachary's
father. ((CBC))

"The fact that a whole
organization could be so out
of touch with the reality
everyone else was
wondering about is
baffling," she told reporters.

Neville said two things were
evident from reading the
report. "One: Zachary
Turner's death was
preventable. And two:
Zachary was in his mother's
care when he should not
have been."

Markesteyn found that
officials, who were working
on the presumption of
Turner's innocence,were
more concerned about the
welfare of the woman than
for her infant.

Turner frequently asked for,
and received, help from social
workers, with dozens of visits
made on her behalf.

Neville said she found it difficult
that no one was putting
Zachary's interests first.

"Given the amount of resources
that were put in to meeting Dr.
Shirley Turner's needs and
demands, and what she
identified as necessary, if those
same resources had been
taken and put in to assessing
what Zachary's needs were and
how could his rights would be
best protected, I would suggest
there would be a strong
likelihood we would have had a
different outcome," Neville said.

Markesteyn, who was asked to
review the case in 2005,
not delve into an issue
pressed by the Bagby family:
how Turner was able to
obtain bail from the
Newfoundland Supreme

Courts beyond mandate

David Bagby, Zachary's
grandfather, said the report is
an important step but he is
disappointed the issue of the
bail process could not have
been addressed thoroughly in
the review.

"My focus is bail," he said
adding that a suspect in a
brutal crime shouldn't be
"walking around free so
they could do it again.
said it a hundred times."  Bagby
travelled from California forthe
release of the report.

Markesteyn nonetheless raised
question after question about
how bail was granted to Turner,
particularly about the actions of
federal government counsel.

As well, herecommended that a
separate review of the justice
system's handling of the
casebe launched.

Withthe social services
system, Markesteyn
sharply criticized a lack
of critical analysis and
sound judgment among
officials who dealt with
Turner while she was on

Markesteyn found that social
workers worked co-operatively
with the review and that "the
impression they conveyed was
they believed they had done
everything they could, given
their legislative and policy
mandate, to assist the
children's mother, Dr. Turner,
in caring for her children."

'An obvious difference of

He also noted"an obvious
difference of opinion" between
case workers and their
managers, who recognized a
possible need for long-term
intervention. Their concerns,
he wrote, were not
communicated to frontline staff.

Turner's daughter, who stayed
with her mother for periods of
time during which she was on
bail, also suffered in terms of
her educational development,
as well as from guilt over her
mother's and half-brother's
deaths, Markesteyn said. The
girl is in the care of other family

As well, he found a lack of
accountability within the social
services system.

"Yes, individuals were upset
and sad when Zachary was
murdered, but
what was
really confusing was the
limited sense of
accountability in terms of
the hierarchy and lines
of authority," he wrote

Markesteyn also critiqued the
office of the child and youth
advocatefor its handling
ofTurner's case while she was
still alive. He suggested an
intervention shouldhave been

"To me, it is most relevant that
there had been considerable
media exposure and resulting
knowledge of the Pennsylvania
criminal charges whichDr.
Turner was facing," he wrote.

Met at medical school

Turner had been married twice
before meeting Bagby while
both were medical students at
Memorial University in the

Markesteyn's research,which
involved interviews and reading
scores of documents about
Turner,found numerous cases
indicating that shehad
personality and emotional
problems, including during her
medical training at Memorial.

A supervisor there described
her as "putting on a show" for
superiors, and found she was
confrontational, manipulative
and unwilling to address
negative evaluations.
Markesteyn noted that the
Turner experience led to
changes in how residents are

Among other things, the report
found Turner had ingested
drugs in either an attempted
suicide or what Markesteynsaid
could have beena "suicide
gesture." In a 1999 letter sent
to a would-be paramour before
she ingested prescription
drugs, she described herself: "I
am not evil, just sick."

Markesteyn also found that
Turner had been under the
care of at least four
psychiatrists during her lifetime.
False police report in
Chula Vista Elementary School
California Teachers
Association / Richard Werlin /
Robin Donlan
false accusations
Innocence Project (Role Model
Lawyers Blog)

Innocence Project (Law
Enforcement Blog)

Innocence Project (SDER)
Baby Santiago killed in
his stroller
Dishonesty in schools

Dishonesty in government

Dishonesty in court cases
Lying and Truth
Girl culture among
Team dysfunction
II site)
Motivated reasoning
Emotional maturity
Delusions of "normal"
No good deed goes
Blog posts
Web pages
False accusations
Mental health
Ethics in education
Ethics in law
Cal Western ethics
Awards: Go along, get along
Evaluating People
Navy report: Failure at every level for US ships
captured by Iran
By Tom LoBianco and Ryan Browne
June 30, 2016

  Up to six more sailors could be disciplined
  The report paints a picture of mistakes, bad judgment, poor planning

Washington (CNN)A devastating new report by military investigators released
Thursday found that the
10 sailors captured by Iranians in January
suffered from "failed leadership" at all levels on a mission that was
plagued by mistakes from beginning to end.

"This incident was the result of failed leadership at multiple levels from
the tactical to the operational
," investigators wrote in the detailed, partially
redacted, report.

The report found the crews were poorly prepared, their boats not
properly maintained, communication almost entirely lacking, and their
conduct after being captured by the Iranians wasn't up to military

In a stunning finding, the report said the sailors veered off course almost
immediately after heading out to sea and had no idea where they were
when a mechanical failure struck one of the boats.

"The boat crews could visually see Farsi Island, but were not
concerned as they were unaware that it was Iranian or that they were
in Iranian waters,
" the report said.

The report details a
lax culture for U.S. Navy sailors who routinely patrol the
Persian Gulf which ultimately led to a highly embarrassing incident for the U.S.
military just as crippling economic sanctions were set to be lifted as part of the
Iranian nuclear deal.

"The culture ... (was) characterized by informality. They conducted
no patrol
briefings, and missions were supported by no formal mission analysis,
standard planning factors, risk assessment, or overwatch,
" investigators

At a news conference to release the report, Chief of Naval Operations, Adm.
John Richardson, said, "This will be a case study going forward. There are
lessons that apply across our entire Navy."

One of the only
bright spots noted in the report was a sailor who
"showed presence of mind and fighting spirit when she attempted to
activate" at tracking beacon at some point during the incident.

And after the U.S. crew members were captured, more mistakes were made.

The report found that during the 24 hours they were held some crew
provided more information to their Iranian captors than they should
and that they ate food while being filmed -- something they should not
have done because it can be and was used as propaganda.
One crew
member disobeyed a direct order, the report said.

Asked by their captors how it was possible a boat like theirs could have
traveled such a distance, one sailor replied, "Yeah, I wish you could tell my
people that because we told them these boats don't do that" -- a statement
investigators said was inappropriate.

The report concluded, however, that the Americans didn't violate international
law, while the Iranians did.

"The investigation concluded that Iran violated international law by impeding
the boats' innocent passage transit, and they violated our sovereign immunity
by boarding, searching, and seizing the boats, and by photographing and
video recording the crew," Richardson said at the news conference.

In their report, investigators called the mission a "complex transit" of 259
nautical miles from Kuwait to Bahrain that r
equired more than the 24-hours
advance notice the crews were given.

"Essentially, there was no time given for the team to think through the
task before executing.
The collective team felt a sense of urgency for a
mission that had previously been rescheduled and had no required
accomplishment date," the report said.

The Iranian Revolutionary Guard captured the sailors January 12 after an
engine died on one of their two boats. As the sailors waited for repairs, the
Revolutionary Guard approached in several boats and took them captive with
guns drawn.

"The engine casualty in Iran's territorial seas is the culmination of
failures in multiple areas, including maintenance, personnel
qualification, sustainment training and crew rest,
" they wrote.

After the sailors had breached both Iranian and Saudi Arabian territorial waters
and been forced to stop, the
sailors did not have a plan for
communicating their location or progress with officers...

The report also found that the crew was never familiarized with the region, and
didn't know about weather, geography or potentially hostile threats.
In addition, before going out to sea, there's supposed to be a written patrol
briefing. But personnel couldn't recall seeing that, the report said, and the
investigation couldn't find it and questioned if it had existed.

The U.S. craft were also undermanned, and couldn't be
operated at the same time the weapons were being manned...

The report said that mission leaders showed "blatant disregard for the genuine
concern of sailors," not listening to their concerns or empowering them.

Two officers have already been fired after the fiasco -- Capt. Kyle S.
Moses and Cmdr. Eric Rasch -- and the report indicated that six more
crew members of the Coastal Riverine squadron could be punished.
News, information and ideas about our
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by Maura Larkins