Robert
B. Stacey: Unit Chief
Quality Assurance and Training Unit
Federal Bureau of Investigation, Quantico, Virginia
Introduction
In
the aftermath of the March 11, 2004, train bombing in Madrid, Spain, personnel
from the FBI Latent Print Unit performed a fingerprint analysis and reported an
individualization of a latent print with a candidate print from an Integrated
Automated Fingerprint Identification (IAFIS) search. It was subsequently
determined that the individualization was in error, and the latent print was
ultimately identified with a different subject. This report provides information regarding the corrective
actions the FBI Laboratory implemented upon recognizing the error, an outline of
significant events surrounding the FBI's fingerprint investigation, and a
synopsis of the comments by an international committee regarding the erroneous
fingerprint conclusion.
Corrective
Action
In accordance
with American Society of Crime Laboratory Directors/Laboratory Accreditation
Board (ASCLD/LAB) guidelines and FBI Laboratory policies, the FBI's Quality
Assurance and Training Unit was notified upon discovery of the Class I error.
The ASCLD/LAB Accreditation Manual defines Class 1 as, "The nature
and cause of the discrepancy raises immediate concern regarding the quality of
the Laboratory's work product." (ASCLD/LAB 2003)The Unit implemented a
corrective-action process that included the following:
International
Review Committee
As part of the
corrective-action process, an international committee of distinguished latent
print examiners and forensic experts was formed. Their task was to review the
analysis performed by the FBI Laboratory and make recommendations that will
help prevent this type of error from occurring in the future. The Quality
Assurance and Training Unit established seven assessment objectives for the
committee to discuss.
The committee
met at the FBI Laboratory at Quantico, Virginia, on June 17 and 18, 2004. They
were given access to the FBI case file, case documentation, and Laboratory
operational and quality assurance manuals.
The committee also met with the Laboratory personnel involved in the
case. The committee members prepared individual reports and submitted them to
Quality Assurance and Training Unit personnel. This report is a synopsis of
the major points made in the reports submitted by the committee members.
The committee
members consisted of Mr. Alan McRoberts, who is retired from the Los Angeles
County Sheriff's Department and is the chairman of the Scientific Working
Group on Friction Ridge Analysis, Study, and Technology. Mr. McRoberts also
served as the committee chairman. Messrs. Ron Smith of Ron Smith and
Associates, Bruce Grant of New Scotland Yard, Gregoire P. Michaud of the
Michigan State Police, Chandler Lee Fraser of the Royal Canadian Mounted
Police, Frank Fitzpatrick of the Orange County Sheriff-Coroner Laboratory, and
Ken Smith of the U. S. Postal Inspection Service, Forensic and Technical
Services Division were the other committee members.
Mr. Frank Fitzpatrick was selected by the American Society of Crime
Laboratory Directors, and Mr. Ken Smith was selected by the International
Association for Identification to serve on the committee.
Mr. Juan Antonio Rodriguez San Roman of the Spanish National Police
Latent Print Unit served as a resource for the committee. Dr. Richard Vorder
Bruegge from the FBI's Investigative Technology Division and Mr. Thomas Hopper
of the FBI's Criminal Justice Information Services Division also served as
resources for the committee.
Madrid
Bombing Case - Time Line …
March 11,
2004
Train bombing
occurred in Madrid, Spain.
March 13,
2004
Interpol Washington requested the analysis of latent fingerprints that had
been collected during the bombing investigation. An FBI Latent Print Unit
Chief assigned the case to a supervisory fingerprint examiner.
The Spanish National Police through Interpol Madrid sent electronic
images of the latent prints to the supervisor.
Eight latent images were of low resolution and without a scale.
IAFIS searches were conducted without effecting an identi-fication.
Latent Print Unit personnel asked Interpol Washington to obtain higher
resolution latent images with a scale so that the ridge detail would be more
visible and the latent prints could be printed in their natural size to ensure
the reliability of IAFIS searches.
March 14,
2004
Interpol Washington submitted additional emails with the latent prints and the
known fingerprints of five individuals. The latent print images were
high resolution and displayed a scale. They were compared with the five
suspects insofar as possible, but no conclusion could be made because the
images of the known prints were of low resolution.
March 15,
2004
The supervisory fingerprint examiner encoded seven minutiae points for the
high-resolution image of latent fingerprint #17 and initiated an IAFIS search.
March 16,
2004
The supervisory fingerprint examiner reviewed the candidate list. The
misidentified subject was the number four candidate. The supervisory
fingerprint examiner identified the subject on the basis of a comparison using
the on-screen images and examination of the high-resolution digital printouts
of the latent fingerprint and the known fingerprint record from IAFIS. The
Unit Chief was notified and reviewed the on-screen images.
The Unit Chief assigned the case to a verifier (a retired supervisory
fingerprint examiner working as a contractor). The verifier requested original
fingerprint cards from the FBI's Criminal Justice Information Services
Division.
March 19,
2004
The contractor verified the supervisory fingerprint examiner's identification
on the basis of his examination of the same high-resolution digital copy of
the latent fingerprint and the original fingerprint cards that were forwarded
to the Latent Print Unit by the Criminal Justice Information Services
Division. The Latent Print Unit provided their initial report confirming that
latent fingerprint #17 was the same as the known prints of the number four
candidate. The Unit Chief provided this information by telephone to Interpol
Washington. The Unit Chief did not complete a thorough examination of the
identification prior to making the telephone call.
March 20,
2004
The Spanish National Police confirmed that latent fingerprint #17 was
collected from a plastic bag. An official FBI Laboratory report was issued
identifying latent fingerprint #17 with the number four candidate.
April 2,
2004
In response to an
official request made by the Spanish National Police, the FBI Legal Attaché
in Madrid provided copies of the known fingerprints of the number
four candidate to the Spanish National Police.
April 13,
2004
Spanish National Police
fingerprint examiners arrived at an inconclusive finding that the latent
fingerprint discovered on a plastic bag belonged to the number four candidate.
Consequently, the Spanish requested further clarification of the FBI
Laboratory's analysis. The FBI Legal Attaché in Madrid informed the FBI of
the Spanish National Police report. Although the FBI Laboratory expressed
confidence in their findings, they agreed to prepare a detailed exhibit
delineating their analysis of the fingerprint in question. A three-page
exhibit was shipped overnight to the Spanish National Police.
April 21,
2004
The Unit Chief met with the Spanish National Police fingerprint examiners. He
demonstrated the comparison process using the images from the three-page
exhibit. He left the meeting thinking that the Spanish would continue their
comparison of latent fingerprint #17 to the number four candidate.
May 17,
2004
The FBI received a court
order for latent fingerprint #17from the bag obtained in the Spanish
investigation. The latent print was subsequently provided to the United States
Attorney's Office for submission to the Court. According to the Court's order,
the prints were to be independently compared to the number four candidate’s
known prints.
May 18,
2004
The Court appointed the independent examiner.
May 19,
2004
The Court's independent
examiner reported in telephonic testimony that latent fingerprint #17 was that
of the number four candidate. The Spanish National Police provided a letter to
the FBI Legal Attaché in Madrid advising that the Spanish Laboratory had
identified latent fingerprint #17 as belonging to another person.
May 21,
2004
According to FBI
Laboratory policies, Quality Assurance and Training Unit personnel were
notified of the situation.
May 23,
2004
FBI Latent Print Unit personnel returned from Spain. An overnight review of
the case was conducted, and the error was recognized.
May 24,
2004
A corrective-action plan
was initiated by the Laboratory’s Quality Assurance and Training Unit. The
Unit took control of all related evidence and documentation and formed an
international committee to review the procedures and factors.
May 27,
2004
A new team of FBI
examiners, under the direction of different Unit Chief, began a comprehensive
examination of the Madrid latent prints.
June 9,
2004
FBI Laboratory personnel
traveled to Spain and obtained a photograph from the original negative.
June 17-18,
2004
The international
committee was convened and conducted a two-day review.
July 14,
2004
A final FBI Laboratory
report was completed. This report excluded the number four candidate and
concurred with the Spanish National Police individualization of latent
fingerprint #17 to a different suspect.
August 2,
2004
The Quality Assurance
and Training Unit's report regarding the international committee was
completed.
The case assignment and general operational
procedures were applied in a manner that was consistent with the established FBI
Latent Print Unit's normal operational procedures and are consistent with many
other latent print units' operational procedures.
If the FBI had insisted on more information (e.g., an image with scale
for proper enlarging and an overall shot for orientation and proper finger
determination), this error may have been avoided. (Object photographs that were
available to the committee established that the candidate's finger determination
was not probable.) This comment was not meant to mitigate the error. The error
was a "human" failure and not a methodology or technology failure. The
prescribed methodology (Analysis, Comparison, and Evaluation–Verification or
ACE-V) used for this examination was appropriate. It was the examiners’
application of this methodology that failed.
2.
Determine where and how the examination faltered.
The IAFIS search
of latent fingerprint #17 involved the encoding of seven Level II details. The
search results provided digit seven of the fourth candidate. Upon reviewing the
encoded detail and the candidate’s print, it was understandable why IAFIS
provided him as a candidate and why the initial examiner did not immediately
dismiss him. The power of the IAFIS match, coupled with the inherent pressure of
working an extremely high-profile case, was thought to have influenced the
initial examiner’s judgment and subsequent examination. This influence was
recognized as confirmation bias (or context effect) and describes the mind-set
in which the expectations with which people approach a task of observation will
affect their perceptions and interpretations of what they observe. The apparent
mind-set of the initial examiner after reviewing the results of the IAFIS search
was that a match did exist; therefore, it would be reasonable to assume that the
other characteristics must match as well. In the absence of a detailed analysis
of the print, it can be a short distance from finding only seven characteristics
sufficient for plotting, prior to the automated search, to the position of 12 or
13 matching characteristics once the mind-set of identification has become
dominant. This would not be an intentional misinterpretation of the data, but it
would be an incorrect interpretation nevertheless. Once the mind-set occurred
with the initial examiner, the subsequent examinations were tainted. Latent
print examiners routinely conduct verifications in which they know the previous
examiners' results without influencing their conclusions. However, because of
the inherent pressure of such a high-profile case, the power of an IAFIS match
in conjunction with the similarities in the candidate's print, and the knowledge
of the previous examiners' conclusions (especially since the initial examiner
was a highly respected supervisor with many years of experience), it was
concluded that subsequent examinations were incomplete and inaccurate. To
disagree was not unexpected response. Additionally, this erroneous
individualization was not made by an examiner alone, but by an agency that for
many years has considered itself, rightfully so, as one of the best latent print
units in the world. Confidence is a vital element of forensics, but humility is
too. It was considered by the committee that when the individualization had been
made by the examiner, it became increasingly difficult for others in the agency
to disagree. This is supported because the Latent Print Unit immediately entered
into a defensive posture when the Spanish National Police issued its statements
that the FBI was wrong. Latent Print Unit personnel responded by preparing
charted enlargements using both Level II and Level III detail, and the Unit
Chiefs traveled to Spain to demonstrate to the Spanish National Police that the
FBI results were correct. This was interesting, considering that the
identification is filled with dissimilarities that were easily observed when a
detailed analysis of the latent print was conducted.
3. Assess the
effects that digital image capture, compression, and transmission on friction
ridge detail may have had on this examination.
All of the
committee members agree that the quality of the images that were used to make
the erroneous identification was not a factor.
4. Assess the
general risks of conducting forensic examinations in parallel with another
agency.
If forensic
examinations are conducted properly, there should be no risks involved. Both
agencies should come to the same conclusions. When both agencies come to the
same conclusion, the independent conclusions become supportive. If the
conclusions conflict (e.g., individualization versus exclusion), an error can
then be discovered and remedied (as in this case) to the benefit of all
concerned. If one examination is conclusive and the other examination is not
conclusive (e.g., as the result of conflicting procedural or legal
requirements),the examination that occurred by the agency with legal
jurisdiction will most likely prevail. Based upon what occurred in this case, it
appears that an agency that is in a position to conduct parallel analyses with
another country should have a written protocol for sharing results and issuing
formal reports.
If forensic
examinations are conducted in accordance with agency procedures and by
well-trained fingerprint experts, then there should be no risks involved. If
those differences are anticipated, there seems to be no inherent risk in
conducting parallel examinations.
5. Identify
policies, procedures, and guidelines to help avoid a situation like this in the
future.
The evidence
surface, processing techniques, imaging resolution, and compression are examples
of things that should be known and documented during the analysis stage of the
examination. Procedures that require descriptive documentation(graphic, textual,
or a combination of both) of the ACE-V process and blind verification (i.e.,
previous results unknown to the verifier) should be implemented on designated
cases. This documentation should also note areas of discrepancies in the prints
and explanations for these discrepancies. The original examiner’s document
should be sealed or withheld from the verifier. The verifier would then conduct
his or her examination independently and document the characteristics and
discrepancies that were considered during the examination. Technical reviews of
each examiner’s descriptive documentation would then reveal any conflicting
analyses and results, would require open communication and discussion among
examiners, and would require resolution. The verifiers must do an independent
and complete ACE-V examination of each print that they are verifying. The
verifiers must be willing to oppose any examiner if they do not see the details
needed to effect the identification decision. The quality assurance program
should make examiners feel that they can disagree about any identification. The
examiners should be encouraged to step forward, without fear of reprisal if they
disagree. This part of the scientific method must be institutionalized.
The current
quality assurance rule requiring supervisor verification of latent prints with
less than 12 Level II characteristics needs to be revised. A policy
incorporating definable quality and quantity standard, rather than the current
12-point standard, needs to be instituted for quality assurance. A
high-point-count print of poor quality may be more dangerous than some low-point
count, high-quality latent prints. Points or any concept of points should be
removed from any policy manual. It may take years for this ingrained and
habitual methodology to change, but leaving the concept of points anywhere in
the manual will just delay it further. A new quality assurance rule is needed
regarding high-profile or high-pressure cases. This would include supervisory
verification of conclusions regardless of the normal quality and quantity
standard. These and all supervisory verifications must be independent and
complete ACE-V examinations. The case assignment process should be revised.
Comparison ability should be a primary consideration, especially in high-profile
cases. It must also be recognized that years on the job may not always reflect
ability. The organizational relationship should be considered in making
assignments. Daily examination practitioners should be the primary analysts, and
situations with a supervisor as a primary examiner and a subordinate as a
verifier should be avoided. (A subordinate may not feel comfortable challenging
the conclusion of a supervisor.) Verifiers should be given challenging
exclusions during blind proficiency tests to ensure that they are independently
applying ACE-V methodology correctly and to detect skill atrophy. A new approach
to quality assurance and quality control needs to be fostered. Personnel who are
responsible for reviews of comparisons need to be considered as checkers and not
verifiers. They must be trained to look for discrepancies as well as
similarities. They also need to be extensively trained to do checking on-screen
as well as with standard magnifiers. Visual acuity is also a significant
consideration. The visual acuity of all examiners should be evaluated on a
periodic basis. Although there was no indication that the visual capability of
the examiners in this case was a factor, the early detection of visual problems
could help to avoid future errors. There should be a written policy that clearly
defines the protocols to follow when dealing with international agencies.
Included in this policy should be language that dictates the reporting of
results through proper channels (administration) and states specifically who is
to be notified when dealing with terrorist cases.
6. Identify
guidelines, if any, for the general latent print community as a result of the
lessons learned from this matter.
There has been
reluctance for the majority of latent print units to document the
characteristics used in the examination by charting latent prints and exemplars
or providing a written description of the areas of identification and
discrepancies in designated cases (i.e., high-profile cases or cases with
latents of poor quality). Such a document would provide a useful quality
management tool to determine what the examiner and verifier were using as a
basis for their conclusion. The recommendations in Section 5 apply to the
general latent print community. Additionally, agencies should adopt Scientific
Working Group on Friction Ridge Analysis, Study, and Technology and Scientific
Working Group on Digital Imaging guidelines for latent print analysis and
imaging as the backbone for their operational manuals. Erroneous
identifications, when found, need to be admitted and reported to the agency as
well as to the certifying and accrediting bodies. Many agencies are slow to do
this or refuse to admit that errors have occurred. Admitting the error is the
first step in the remediation process. A remediation process must be included in
the quality assurance manual so that when it is needed, the process can begin
promptly. The FBI had this in place.
7. Determine
additional assessment objectives that the panel members deem appropriate.
The committee examined the latent impression and
determined that it did contain sufficient ridge detail to be correctly
individualized. An erroneous individualization is considered the most serious
error a latent print examiner can make in casework and cannot be tolerated or
minimized by an agency or the forensic community. The consequences to any
examiner for any such error should reflect the agency's seriousness about issues
involving quality assurance.
Conclusion -
The consensus of the committee was that the failure
was in the application of the ACE-V methodology during this particular
examination. The committee also extended its appreciation to FBI Latent Print
Unit personnel for their forthright manner in accepting responsibility and to
the Laboratory, which took immediate steps to remedy the situation. The candor
of the personnel reporting to the committee was appreciated and important to the
credibility of the Laboratory. The committee also recognized that although this
erroneous conclusion gained worldwide recognition and that it was very
unsettling, the FBI Laboratory set an excellent example in taking corrective
actions.
Acknowledgments
- On behalf of the FBI Laboratory, the author thanks the committee
members for reviewing this case and making recommendations. The Laboratory is
taking the committee's recommendations seriously and believes that it will
improve as a result of the committee’s work.
Reference
American Society of Crime Laboratory Directors/Laboratory Accreditation Board (ASCLD/LAB).
ASCLD/LAB Accreditation Manual.
American Society of Crime Laboratory Directors/Laboratory
Accreditation Board- Garner, North Carolina, 2003.
Published as a Special Report in Forensic Science Communications, January 2005, Vol. 7, No. 1.