Antiquated paper record-keeping and lack of oversight led to the mishandling of dozens of remains at the nation's most important military burial ground, according to a three-month review of Arlington National Cemetery's operations by a consortium of technology companies.
"The current reliance on paper-only records, combined with technical obsolescence and undocumented handling and oversight procedures, has contributed to [the cemetery's] inability to fully account for remains," according to a report issued Monday by the Northern Virginia Technology Council. "The confusion that results from poor records management leads to loss of public trust."
To regain that trust, the cemetery must digitize its records, improve its scheduling system and establish a rigorous chain of custody for remains as they move from funeral homes to burial, the report said.
During a news conference Monday, Sen. Mark R. Warner (D-Va.), who enlisted the Tech Council's help last summer, called the cemetery's operations a "disaster."
"They relied on three-by-five cards, which anyone in today's age knows is a totally inadequate way to keep track of records of the remains," he said.
The cemetery also used just one fax machine, which Warner said "created an enormous bottleneck for the thousands of families trying to call in and schedule an interment for their loved ones. Backing up this fax machine was a manual system with paper and pencil."
Warner also said urns at the cemetery, rather than being stored properly while awaiting inurnment, would "sit for extended periods of time on a desk with simply a paper record attached to it."
Kathyrn Condon, executive director of the Army National Cemeteries Program, said that some of the report's recommendations had been implemented. Last month, Arlington set up a call center so it could take many more calls from families scheduling burials. Before, she said, "people were put on hold for hours and hours."
The fax system was also updated. "We can do faxes right on our computer," she said. "To me, it was mind-boggling we didn't do that before. But we're moving forward into this century at Arlington."
After their review of the cemetery's procedures, the tech companies - including Booz Allen Hamilton, Science Applications International Corp. and Mitre - did not find "an overall strategy or plan of action" and said the cemetery was plagued with a "counterproductive and error-prone working environment."
The group found "duplicate records initiated for the same person" and "multiple instances of inaccurate headstone orders."
An investigation by the Army inspector general last summer found that dozens of graves had been mislabeled or misidentified and that at least four urns had been dug up and dumped in a landfill. The probe also found that the cemetery had spent millions to digitize its records but that the system was never brought into working order.
The cemetery recently discovered other burial problems. In one instance, a single gravesite that was supposed to hold one set of cremated remains held eight. Criminal investigators are probing that incident.
Last summer, the cemetery's top two leaders were ousted, and a new team was installed to fix the problems. The tech companies said that they found the new leaders eager to take positive steps but that fixing the mess "will take a significant amount of time." The report did not say how much the fixes would cost.
Some of the technology the cemetery needs has been available for years, the report said. The cemetery could use the tracking technology that hospitals use to account for the transfer of human organs or the systems that rental car and package delivery companies use to account for their products.
The report, prepared for the cemetery at no cost, also said that each set of remains should be given a file with a unique case number to link all relevant paperwork.