Dead Center

by Shiya Ribowsky

  Despite such minor setbacks, by December 12 our OCME team had identified all the victims of Flight 587—a record short time for identification in a mass-fatality disaster. Years later, the National Transportation Safety Board (NTSB) identified the cause of the crash as a combination of pilot error and an overly sensitive rudder-steering mechanism. Following in the wake of a larger aircraft, the plane had encountered turbulence, and the pilot overreacted to that turbulence with a violent rudder maneuver, tearing off the tail stabilizer and putting the plane into a dive from which it was unable to recover.

  This explanation has not satisfied some of the victims’ families as well as some aviation experts, and today, long after we determined who the victims were, the legal assessment of blame is still under way.

  Late in November 2001, with the WTC effort well in hand and Flight 587 all but wrapped up, I traveled to London as OCME’s representative to a memorial service at Westminster Abbey for the British victims of the WTC attacks. Her Majesty’s government had invited members of NYPD, FDNY, and other city agencies who had been instrumental in the recovery and identification of British victims of 9/11 and had given us round-trip tickets and hotel rooms for several days. Former president George H. W. Bush was the official leader of the American delegation, and as we were preparing to go into the chapel, he spotted a pin on my lapel that had been given to me by a British friend to wear for the occasion. It was two flags, the British and American ones, side by side. President Bush admired the pin, said he ought to be wearing something like that. Of course I offered to exchange mine for the American flag pin he had in his lapel. We switched pins, and I became the proud owner of a pin that had graced the lapel of a former president.

  While in London, I received a telephone call with the following message: “One of our ID mistakes is on the front page of the New York Times. Above the fold.” I was on the next plane home. The identification effort had been going along as well as we could hope, with a goal of zero error. Unrealistic, perhaps, but nonetheless we were striving for perfection, and though we knew we’d made a few mistakes, we were trying to hold ourselves to an incredibly high standard. Though a significant mistake, the one that had me on that plane hadn’t been our first. That first erroneous identification happened back in the second week of our work but wasn’t caught until late in October. It entailed a partial torso that had arrived downstairs in the morgue with a portion of a white shirt still on it, and with a photo ID card in the pocket of that white shirt. We checked the antemortem folder of the man on the ID card; his family’s description of what he had been wearing on 9/11 included the mention of a white shirt. This, we supposed, was a slam-dunk identification, and we labeled the remains by the name of the ID card’s owner and gave them to that family for burial. Then in October, our DNA laboratory came up with bad news: the DNA from the torso and the DNA from a toothbrush used by the ID card holder did not match. They were from two different people.

  By this time, the torso had been buried in South New Jersey.

  I immediately informed Dr. Hirsch. If I hoped he would respond by picking up the phone and talking to the family himself, I was mistaken. “When are you going to tell the family?” he asked. “This afternoon,” I answered. “And I’ll go and see them.”

  Which I did, accompanied by two Port Authority police detectives; the remains I was about to take away from the family were those of a Port Authority employee. We had also taken the precaution of asking the family to meet us at their funeral home and requesting that the funeral director notify the family priest and ask him to be present when we got there. The funeral director graciously did as requested.

  I walked into a room at the funeral home and found the family seated in chairs arranged in a semicircle around one single empty chair in the center. Taking a deep breath, I sat in the chair and began to talk to the family.

  On the way down to South Jersey, I had tried to put myself in the family’s shoes. Our call had alerted them to our visit, and they were no doubt expecting something dire and waiting for a city official to come and tell them that “the system” had screwed up the most important thing in their lives at that moment—their attempt to make the transition from mourning to getting on with their lives.

  My attitude was apologetic, humble, and straightforward.

  Many years earlier, Dr. Hirsch had given me important guidance in matters of mistakes. “Perfect is not in our job description,” he’d said, “but honesty is.” The key was complete honesty and candor—more candor, I suspect, than many families might expect in such circumstances. I told this family in South Jersey that we had made a mistake—not that “a mistake had been made,” but that we had done it, and we were owning up to it—and I explained how it had been made. Perhaps naively, we had presumed that the ID card belonged with the torso, and had made a positive identification too fast, not waiting for the DNA evidence to confirm the identification. Now the DNA evidence had shown that the identification had been in error.

  To this day, no one can be certain exactly what happened to produce the odd situation of an ID belonging to one person showing up in someone else’s pocket. My guess is that the owner of the white shirt survived the initial hit of the airplane, but that some of his colleagues did not; the white-shirted man probably picked up the ID of a coworker, thinking he would take it outside as evidence for that family of their loved one’s death, and then a little while later he himself died with it in his pocket. We later began to notice just such things among the remains: One man was found wearing another’s backpack. Several people had the wallets of others in their pockets. Another dead man came in with five cell phones in his body bag, and we had quite a time trying to figure out which of those, if any, was his. I don’t think any of these folks were stealing. Rather, I firmly believe that in the interval between the planes hitting and the towers collapsing, the survivors of the initial attack attempted to gather identifying objects from their colleagues who were already dead. September 11 is like an onion: the more layers you peel away, the more heroism you find.

  Considering how painful the news that I brought to this South Jersey family was, they took it very well. After all they had been through, losing their son, their brother, here I was about to take away the one comfort they had retained, the knowledge that they had given him a proper burial. That family displayed stunning graciousness to me under the most trying of circumstances. Similarly, in the several other cases in which we made mistakes necessitating a dreaded pilgrimage to a devastated family, I was treated far better than I might have treated the authorities if the mistake had happened to my family or me. I came to believe that my good treatment at the hands of these families was due to their understanding that the error had not been born of neglect, but rather, had come about because we had not had all the facts in front of us when the identification was made.

  Such families wanted to know that we were rectifying the mistake and that we were working to make sure that this sort of error would not happen again and afflict any other families. On that, at least, I could be somewhat reassuring. As in the case of all our mistakes, we tried to learn their lessons and perfect our system through such feedback. In this instance, we learned never to rush an identification on the basis of what we presumed (but had not yet confirmed) as conclusive evidence.

  We are proud, justly proud I think, of being able to say that we never made the same mistake twice.

  Still, a lot of damage followed from our occasional mistakes. One young widow was distraught. She had been left with three small children—and no income, since the breadwinner was now gone—and had been taking the children to the grave of their father, every week, so they could at least have some contact with him. Now even that modest consolation was to be taken from her and the children. How could she explain to them that their father was not only not alive but not in that grave any more? The young widow swore me to secrecy and did not tell the rest of her family that we had retrieved the remains. She continued to take her children to a
grave—now an empty one—to help them grieve. Mercifully, about a year later, we did identify (correctly) her husband and gave the remains to her. She had them buried in the grave, without the children’s knowledge. I learned from subsequent conversations with her that this final burial eased some of her immense burden.

  On the whole, though, our error rate was extremely low, well under a half percent, and many of the mistakes we made were caught in-house and rectified before they could lead to false identifications and remains being released to the wrong family.

  Another early mistake we didn’t catch was the result of the mislabeling of a toothbrush. Initially we matched the DNA extracted from a toothbrush to the remains and released the remains for burial. Still later, we learned from next-of-kin DNA testing that the DNA of the remains did not match the family’s DNA and had to recall the remains. The only conceivable explanation for the mismatch (after confirming that the decedent had not been adopted) was that the toothbrush had been mislabeled. It must have been given to us by a different family and somehow had ended up with the wrong case number and family name. Now we had a perfectly good identification for some remains that were sitting around with no family to go home to, and we had an “orphan” toothbrush without proper pedigree. In plain English, we hadn’t the foggiest idea whose toothbrush it was. In this and in every instance in which a mistake was made, I found myself surprised that Dr. Hirsch never made any personal attempt to reach out to the families, choosing instead to cede that responsibility to me.

  One case that was particularly difficult to handle on my own was one of the worst identification mistakes we made and the one that became the basis for the story on the front page of the New York Times. As noted earlier, FDNY and other uniformed services were fantastic about bringing in the remains of their own. In this instance, firefighters had brought in, and positively identified to us, the remains of a firefighter named Jose Guadalupe from Engine Company 54. The firefighters who brought in the remains were adamant that they belonged to Jose because FDNY had logged his last known location by radio transmission. He was the driver of the engine, and the remains had been found precisely where they had expected to find them.

  Unfortunately, also among the missing was another firefighter from the same company named Christopher Santora. The two men had been close friends; Santora was a devoted “student” of Guadalupe, who was about fifteen years older. Santora mimicked his mentor in every way, down to wearing the same sort of herringbone-pattern gold chain, cutting his hair in the same style, and so on. Even more important was something unknown to them: Both men had a relatively rare bone defect, a bifurcated C-spine, a split in a high vertebra (the one that sticks out when you bend your neck forward). Only one in a hundred thousand people has this defect. In truth it is more an anomaly than a defect, in that it causes no symptoms or hindrance; some experts even describe it as a normal variant. Whatever the case, it is certainly uncommon, and the odds of it appearing twice within the same fire company are astronomically low.

  As a result, we never even considered that the remains might belong to Santora. Pointed in the direction of Guadalupe by the firefighters who brought in the remains, we obtained an antemortem X-ray of Jose’s neck, and sure enough there was the bifurcated C-spine. Combined with his jewelry and with the bunker gear he was wearing, this seemed to be another straightforward identification. But we did not realize, when we identified the remains as Guadalupe based on the FDNY’s labeling and on the X-ray with the peculiarity, that both men had the same defect. Once again, DNA testing revealed our error; that happened when the “Guadalupe” remains matched samples taken from Santora’s toothbrush. Unfortunately this did not occur until after the Guadalupe family had their funeral—which, ironically enough, was attended by the Santora family.

  When I learned of the mistake, I informed Dr. Hirsch, as I did on every such occasion, and then contacted the fire department. FDNY Chief of Operations Sal Cassano and I met up at a firehouse in Queens where we talked with the widow of Jose Guadalupe. I gently told her what had happened, and why, and that we were going to have to remove Santora’s remains from her husband’s grave to give them to the Santora family. I am unable to adequately describe to you how painful this was for her. I wasn’t sure if she was grieving more for herself or for the pain that the Santora family was about to experience. Next, Sal and I headed to the Santora family residence and met with them. I did my best to explain what had happened and why; by the end of the day, we had a plan in place to retrieve Chris’s remains from Jose’s grave and return them to the correct family.

  Thus, the problem had been handled, as best we could handle it before I went to London.

  When I received the call in London, two thoughts entered my mind. First, that I must return home to deal with the public relations fallout from the Times story; and second, that it was no surprise that this particular mistake would be the one that found its way to the public, given the firefighters’ zealousness in protecting their families and the families of their fallen comrades.

  Identifying the remains was our primary task, especially after the bulk of the DX (judicial decree) death certificates had been issued. We wanted very much to be able to replace these with DM (physical remains) certificates and for many families, we eventually did. The total of DM certificates issued to families after we had already issued them DX certificates was a staggering 1,196, covering more than two-thirds of the victims whom we were able to identify positively.

  Families wanted and needed to have burials and other funeral ceremonies that allowed them to complete their bereavement journeys, get on with their lives, and assimilate the shock of losing a loved one. That need was why we worked so hard, and so incessantly, at identifying the WTC victims.

  It was a process that entailed both science and, if not exactly art, then certainly the use of our capacities for reasoning and imagination. Although 853 victims would eventually be identified solely by DNA matches, in almost as many instances DNA was not sufficient by itself to make a match and had to be supplemented. Again, it’s a matter of numbers. Some fifteen thousand of the twenty thousand remains we had received were small, and many of the small ones were in bad shape, which made identifications harder. About 40 percent of the identifications we made were what we called “composite IDs”—that is, they were the result of several fragmentary clues rather than of one big match. For these “multiple modalities” matches, to supplement the DNA we used dental X-rays, regular body X-rays, fingerprints, photos, tattoos, and “personal effects” (the objects found on or near the bodies).

  The lay public usually thinks of the identification of a dead person in terms of how such activities are usually portrayed on television. The family comes in to the ME’s office and a somber staff member pulls out one of the refrigerated drawers lining the walls of every television morgue, pulls back the sheet and the family bravely nods and says, “Yup, that’s our Timmy.” This depiction of an identification is not all that far from reality, aside from the fact that those individual-drawer refrigerators are not efficient and most jurisdictions no longer use them. Today we use multiple body, room-sized refrigerators and Polaroid pictures of decedents, showing the actual body only if the family absolutely insists.

  We call that kind of in-the-morgue identification a “one-to-one” matching process. One family looks at one body, and answers one question: “Is it him or is it not him?”

  There is also a “one-to-few” matching process, an example of which is that of a police lineup. The cops have a suspect in a crime, and they try to have him positively identified as the perpetrator, by having witnesses pick him out of a lineup that typically consists of a half-dozen people. A larger identification of this “one-to-few” type is what the FBI does with a fingerprint from a suspect. They put the print into the hopper, compare it to those on file, and it is either an exact match or no match at all. That kind of identification we call a “one-to-many” process.

  Unfortunately, in the WTC disaster, w
e couldn’t do either of these two matches, at least not initially. We had a universe of perhaps ten thousand people who were initially reported missing to be matched against some twenty thousand pieces of remains and maybe another thirty thousand exemplars and objects from the families. This is a “many-to-many” matching situation, of the sort that is impossible for a lone human mind to complete. Actually, it’s even difficult for a computer—it could overload the computer’s circuits.

  So our task at OCME was to do everything we could to reduce this “many-to-many” to something like a “few-to-few.”

  Any adult walking down the street may have as many as a thousand points of potential identification, including eye color, eye position on face, hair length, hair color, hair texture, scars, teeth, dentures, jewelry, contact lenses, clothing, girth, shape, calluses, habitual gait and its resulting wear pattern on shoe soles and foot bones, as well as what he or she was carrying. A woman’s shirt can be described by means of its color, size, style, designer label, position or number of buttons, and so on. Tattoos are marvelous for identification purposes, providing as many as a dozen or more unique points for comparison. The list of potential identification points goes on for pages and pages.