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The FBI DNA Laboratory: A Review of Protocol and Practice Vulnerabilities
Office of the Inspector General
Deoxyribonucleic acid, or DNA, is a molecule that contains the genetic code for living organisms. Within the last 15 years, researchers gained the ability to produce a computerized record containing a person's DNA characteristics (a DNA profile), a development with far-reaching forensic implications. Through comparison of DNA samples, investigators now reliably can conclude whether a particular suspect is or is not the source of DNA found at a crime scene. The Federal Bureau of Investigation's (FBI) Laboratory Division has played an important role in the development of DNA science to solve crimes.
From August 1988 to June 2002, Jacqueline M. Blake was employed in a DNA analysis unit of the FBI Laboratory. Starting in March 2000, she worked as a Polymerase Chain Reaction (PCR) Biologist and was responsible for performing tests on DNA from crime scenes and convicted offenders. Laboratory Examiners used her analyses to reach conclusions regarding the characteristics and sources of DNA profiles obtained from evidence items, and testified in court in reliance on the integrity of the procedures that she employed. During her tenure as a PCR Biologist, Blake performed analyses on evidence from crime scenes in slightly more than 100 cases.
An important step in the DNA testing procedures that Blake was obligated to follow is the processing of control samples that identify whether contamination has been introduced during the testing process, called negative control tests. Starting in the late stages of her training to become a PCR Biologist and for more than two years thereafter, Blake consistently failed to complete these control tests. Her omissions rendered her work scientifically invalid and unusable in court. Without proper processing of the negative controls, a Laboratory Examiner is not able to rule out the possibility that contamination, rather than the evidence under examination, is the source of the testing results. By itself, however, the failure to process the negative controls does not change the test results or lead to a particular testing outcome (e.g., creating a match between a known and unknown evidence sample). The retesting of evidence in Blake's cases to date indicates that, while she did not properly conduct the contamination testing, the DNA profiles that she generated were accurate.
In addition to omitting the negative control tests, Blake falsified her laboratory documentation to conceal the shortcut she was taking to generate contamination-free testing results. Blake later told the Office of the Inspector General (OIG) investigators: "I knew that when I did not properly prepare the negative control samples for injection but initialed the related injection sheet anyway, I was misrepresenting that the negative control samples were properly prepared. . . ."
Blake generated more than two years' worth of testing results before her omissions were finally caught, and even then her discovery was accidental. In April 2002, a colleague of Blake was working late one evening after Blake had left the Laboratory for the day, and noticed that the testing results displayed on Blake's computer were inconsistent with the proper processing of the control samples. Further inquiry by Laboratory personnel led to the discovery that Blake had failed to complete the negative control testing in the vast majority of her cases. Blake later resigned from the Laboratory and was investigated by the Department of Justice (DOJ or Department) for her misconduct. On May 18, 2004, Blake pled guilty in the United States District Court for the District of Columbia to a misdemeanor charge of providing false statements in her laboratory reports.
Blake's actions have caused many problems. Although the FBI Laboratory has not identified a case where Blake's misconduct interfered with the content of a DNA profile, Blake's failure to process the negative controls rendered all of her DNA analyses scientifically invalid. We found that her actions caused substantial adverse effects in at least five respects. First, it required the removal of 29 DNA profiles from the national registry of DNA profiles, known as NDIS, 20 of which have yet to be restored as of March 2004.1 Until these profiles are restored there will be an ongoing risk that an investigative agency will submit a DNA profile and not generate a match with a corresponding Blake profile because the Blake profile has been removed from NDIS. Past crimes thus may remain unsolved. Second, Blake's misconduct has delayed the delivery of reliable DNA reports to contributors of DNA evidence. Retesting in many of Blake's cases has taken upwards of two years to complete, leaving evidence contributors without information that they should have had long ago. Third, in a limited number of cases, Blake's faulty analysis is the only DNA information that is available. The previously submitted evidence was consumed in the testing process and new evidence samples cannot be obtained. Fourth, Blake's misconduct has adversely impacted the resources of the FBI and DOJ. The efforts that the FBI Laboratory and DOJ have had to expend on the corrective measures needed to address Blake's actions have been substantial. Both organizations have devoted thousands of hours of work to deal with the consequences of Blake's failure to comply with the FBI Laboratory's DNA protocols, a cost that does not include the funding expended for contractor support to retest evidence. State and local investigators and prosecutors who were notified of Blake's misconduct and instituted corrective measures in their cases also have had to expend additional resources. And lastly, we believe that Blake's misconduct, and the Laboratory's failure to detect it for a period exceeding two years, has damaged intangibly the credibility of the FBI Laboratory. The Blake controversy has fed into a perception that the Laboratory has unresolved management and employee oversight issues.
The FBI's Office of Professional Responsibility notified the OIG approximately one month after the FBI discovered Blake's omission of the control tests. The OIG began an investigation of Blake and interviewed Laboratory staff members, analyzed documents, and met with representatives of the FBI's Office of General Counsel. The OIG investigation resulted in Blake signing an affidavit confessing to her misconduct. In addition, because the FBI Laboratory's application of its protocols did not lead to Blake's early detection, the OIG initiated this review of the FBI Laboratory's DNA protocols to assess whether the protocols were vulnerable to other abuse and instances of noncompliance.
This report describes the results of the OIG's review. Our objectives were twofold: 1) to analyze the vulnerability of the protocols in the FBI Laboratory's DNA Analysis Unit I (DNAUI) - the unit where Blake worked - to undetected inadvertent or willful noncompliance by DNAUI staff members; and 2) to assess the DNAUI's application of the protocols identified as vulnerable.2 The report also examines and notes several areas of concern with regard to FBI management's response to Blake's misconduct.
II. METHODOLOGY OF THE OIG'S VULNERABILITY ASSESSMENT
The OIG's vulnerability assessment proceeded in two phases. In the first phase, the OIG team reviewed the DNAUI's protocols for vulnerabilities. The second phase consisted of OIG fieldwork at the DNAUI laboratory.
To facilitate our examination, particularly the review of the protocols, we recruited three scientists from the national DNA community to consult with our assessment team. OIG staff provided the scientists with the most current version of each of the written protocols governing DNAUI activities and requested that they identify any weaknesses in them that would render the Unit vulnerable to undetected wrongdoing by staff members. The scientists reviewed the protocol documents and then met with the OIG assessment team to discuss the vulnerabilities identified.
With input from the scientists, OIG staff members then designed fieldwork to verify actual laboratory practices for the protocols deemed problematic, and to assess whether these practices served to mitigate any of the vulnerabilities identified. Our fieldwork consisted of interviews of more than 20 staff members within the DNAUI and the Laboratory Division and tours of the DNAUI facility, first at FBI Headquarters in Washington, D.C., and later at the new DNAUI facility in Quantico, Virginia. In addition to interviews, we also reviewed FBI documentation regarding: 1) the factors considered in the design of the new DNA facility; 2) the training curriculum and methods used within the DNAUI, along with various staff training records; and 3) the status of development of a computerized tracking system to be used by the Laboratory for evidence, samples, and other information. We also examined documents and interviewed personnel from the Laboratory, FBI OGC, and the Counterterrorism Section at the Department regarding FBI management's response to Blake's misconduct.
We compared the results of our fieldwork with the vulnerabilities detected by the scientists to determine whether any information gathered during fieldwork affected the extent and nature of the scientists' conclusions. We then discussed our results with the scientists. Generally, they did not make any changes to the areas they previously identified as vulnerabilities.
III. SUMMARY OF FINDINGS AND RECOMMENDATIONS
Our findings and recommendations focus on two general types of vulnerabilities that became apparent during our assessment: protocol vulnerabilities and practice or operational vulnerabilities.
Our textual analysis of the FBI protocols that govern the DNAUI concluded that 31 out of 172 topical sections are significantly vulnerable to inadvertent or willful noncompliance by DNAUI staff members. One of four reasons typically accounted for each of the vulnerabilities: 1) the protocol lacks sufficient detail; 2) the protocol fails to inform the exercise of staff discretion; 3) the protocol fails to ensure the precision of manual note taking; and 4) the protocol is outdated. In addition, in the course of completing fieldwork that examined how staff members implement the protocols that we identified as problematic, we discovered operational vulnerabilities in the areas of team functions, training, information sharing, and evidence tracking. However, our review did not identify any protocol violations in the DNAUI regarding the failure to process negative control samples, other than the failure of Jacqueline Blake. It also is important to note that our identification of a "vulnerability" should not be misconstrued as an invalidation of the science or techniques used by the DNAUI, or as an indication of the inadequacy of the entirety of DNAUI policies on a particular subject. Our use of the term "vulnerability" is limited to its definition as set forth in Chapter Five, Section I.C.
Approximately 20 percent of the written procedure and protocol sections we examined lacked the detail necessary for a technically qualified DNA scientist to reproduce all aspects of the analysis procedures in use in the DNAUI without the potential for variation. Protocols that lack essential detail can create a work environment that encourages use of disparate and unproven laboratory practices, can foster disregard for protocols, and can make it difficult for staff members and management to identify instances of protocol noncompliance. Accordingly, we recommend that DNAUI management ensure that the document sections we identified as vague describe completely and accurately management expectations, Unit procedures and policies, and "best practices" currently in use in the DNAUI.
Our review also identified protocols that do not describe adequately the decision criteria Laboratory staff should employ when their duties require them to exercise discretion in the testing process. Greater risk of abuse and error is present when testing procedures call upon the use of such judgment. If staff members are not equipped with sufficient guidance to exercise their discretion properly, they could prematurely halt the testing process when a probative DNA result might otherwise have been obtained. To address this deficiency, we believe that DNAUI management should add decision aids to its protocols, such as workflow diagrams and decision trees, that identify the factors that staff should consider when using judgment during the DNA testing process. These aids would help to structure decision-making and to ensure that staff members do not overlook relevant information.
We also determined that certain protocols lack comprehensive guidance on notetaking methods, even though compliance with the documentation requirements in those protocols depends heavily upon Laboratory staff implementing the methods properly. The DNAUI team structure makes it especially important that all staff members have a comprehensive and consistent understanding of how to record information as they complete their work, since Examiners draw their conclusions and testify in court based upon the work of the Serologists and PCR Biologists as reflected in the case file documentation. If staff members are allowed to delay recording observations and test results, their documentation of that information may not be fully accurate, may be unduly influenced by what they know should have occurred pursuant to the applicable protocols, and thus may compromise the accuracy of the resulting analytical conclusions. Therefore, we believe that the DNAUI should provide sufficient guidance to its employees to ensure that case documentation meets quality assurance requirements, and it should also guarantee that the Unit's protocols provide comprehensive guidance on notetaking requirements.
Lastly, our review of protocol vulnerabilities identified several protocols that are outdated and no longer reflect current procedures in use in the DNAUI. By retaining outdated protocols, DNAUI management risks the chance that some staff members might not be aware of new requirements and rely inadvertently upon standards that have been superseded. While the staff we interviewed were aware of the new requirements, we recommend that these protocols be revised promptly.
We found that the work practices of the DNAUI's staff members served to mitigate, at least to some degree, the effects of the protocol vulnerabilities outlined above. In other words, the practices described to us by staff members indicated that they rely upon internal controls and an understanding of management expectations, not reflected in the protocols, that diminish the risks posed by the weaknesses in the written documents. However, we believe that until the DNAUI revises its protocols in accordance with the recommendations in this report, the Unit needlessly will remain subject to an increased risk of employee error and inadvertent protocol noncompliance. Because of the importance of the DNAUI's work, we believe this problem merits significant attention from the Laboratory and should be resolved promptly.
In terms of practice vulnerabilities, we recommend that the DNAUI should work to: 1) promote greater consistency in DNAUI team operations; 2) develop a comprehensive, written training curriculum; 3) improve management and staff communications; and 4) complete implementation of an information management system to improve efficiency and evidence tracking capabilities.
During our interviews with DNAUI staff members we received many comments that highlighted the need to ensure that the DNAUI's protocols are comprehensive and address all aspects of the Unit's operations. As the interviewees explained, variations exist in staff member work practices because the Unit's written guidance is silent on many subjects. These variations can diminish staff and management sensitivity to protocol noncompliance. Therefore, to promote greater consistency and accountability in DNAUI functions, we recommend that Laboratory management document and standardize the best practices of the Unit's teams and incorporate them in protocols.
Our review of DNAUI training revealed that the Unit lacks a comprehensive, written curriculum and that training consists largely of individual discussions with a mentor and presentations given by various experienced staff members. Without a comprehensive, written curriculum, mentors and trainers can blur the distinction between team or individual preferences and the requirements of the protocols, leaving trainees unclear about which methods are mandatory and which are merely suggested. In our view, such an environment leaves the Unit vulnerable to inadvertent protocol noncompliance, since staff members may choose to alter their methods in ways that unwittingly contradict Unit requirements. To enhance the quality of its training program, we recommend that DNAUI management convert its "oral tradition" of training and other informal training methods into a comprehensive, written curriculum to ensure that trainees receive consistent instruction that comports with the Unit's protocols.
Further, our interviews revealed that the dissemination and solicitation of protocol-related information to and from DNAUI staff members are inconsistent and ineffective. Interview responses from staff members at all levels within the DNAUI revealed that the flow of information often is erratic and impeded by an incorrect management assumption that communications within the DNAUI, and between the DNAUI and Laboratory management, are functioning well. These types of communication weaknesses pose a risk to the efficiency and effectiveness of the Unit's operations and should be addressed. Consequently, we make several recommendations to Laboratory and DNAUI management that we believe will facilitate the exchange of protocol-related information.
During our review we also observed many DNAUI operations that could be made more efficient through use of a Laboratory Information Management System (LIMS). A LIMS is a computerized system of databases that track, organize, and link the information that must be maintained to document the receipt, handling, and disposition of each case and evidence item. The Laboratory currently lacks a LIMS, and therefore does not have the benefit of greater efficiency, increased detail and timeliness in documentation, and the reduced potential for human error or abuse. Accordingly, Laboratory management should ensure that a LIMS is implemented successfully and that its full utilization remains a top administrative priority of the Laboratory.
Finally, our review identified several issues of concern regarding the management response of the FBI to Blake's misconduct. These include: 1) the timeliness of the retesting of evidence and of written notifications to DNA contributors and prosecutors; 2) the sufficiency of the legal analysis provided by the FBI OGC in the months immediately following the discovery of Blake's misconduct; and 3) the scope of the Laboratory's remedial actions. We also believe that given Blake's prior work history and training experiences, the Laboratory should have paid more careful attention to her performance on her initial PCR qualifying and proficiency tests and on the first several profiles she generated after she became a PCR Biologist.
As of February 2004, nearly two years after Blake's detection, of the 90 cases where Blake did not properly complete DNA testing, the FBI Laboratory had failed to provide direct, written notification to evidence contributors in 42 of those cases that Blake failed to process properly the evidence they submitted. Of this number, 20 contributors had received no notification at all concerning Blake's processing of their evidence.3 We found that the FBI disregarded the views of the Department that written disclosures in these cases should have been completed much earlier. It also has taken nearly two years since the discovery of Blake's wrongdoing for the Laboratory to complete DNA retesting in her cases, with the result that some of these cases have languished at the Laboratory for more than four years.4
Our review further revealed that FBI OGC failed to ensure that its staff attorney assigned to the Blake matter through the fall of 2002: 1) conducted a comprehensive legal analysis of the Blake situation, and 2) fully assisted the Laboratory to provide sufficient notice to evidence contributors and prosecutors.
We also found that the Laboratory's remedial actions were too narrowly conceived in two respects. First, we believe that the Laboratory erred when it limited its review of Blake's work to the last 2 years of her 14-year career at the FBI. Second, the DNAUI should have taken steps soon after the discovery of her misconduct to reassess comprehensively its protocols for vulnerability to abuse.
In light of the management problems above, we recommend the following three corrective measures. First, the Laboratory should maintain basic case data and contact information for evidence contributors and associated prosecutors in an electronic format that can be shared conveniently as needed with other FBI components (such as FBI OPR and FBI OGC) and the Department. This step will facilitate prompt communications with evidence contributors and prosecutors in the event of future testing problems. Second, in circumstances where a protocol violation renders testing results scientifically invalid and a report from the Laboratory is not expected to issue within 180 days from the violation's discovery, the Laboratory should provide the evidence contributor with information about the violation, including whether any remedial measures have been instituted and the anticipated time to complete evidence retesting if necessary, within 90 days of the violation's detection. Lastly, the Laboratory should perform a file review of a sample of cases that Blake is known to have worked on prior to becoming a PCR Biologist to reconfirm that the procedures that were required in fact are documented as appropriate in the case files.