hawaii_wf_9.txt

Morgue Identification and Notification Task Force (M.I.N.T.)
In response to this tragic event, the Morgue Identification and Notification Task Force (M.I.N.T.) was created. The
M.I.N.T. included, but was not limited to, personnel with pertinent training and experience: traffic section officers
trained in investigating MPD vehicular traffic fatalities and family notifications; detectives investigating various
criminal and missing persons cases; police evidence specialists providing documentation and forensic science
guidance; fingerprint identification specialists; forensic pathologists leading autopsy teams; and outside agency
support from the HHS, HPD, DPAA, FBI, and ANDE.
A. M.I.N.T. Operational Success Keys
The achievement of operational success within the M.I.N.T. can be attributed to a well-organized framework that
emphasized cohesive communication, collaboration, and adaptability. This centralized hub for various agencies and
operators facilitated seamless information exchange and networking. Regular daily briefings played a pivotal role in
fostering idea sharing, problem solving, introducing new members, and aligning everyone with the overall mission.
All this work was done under the pressure of a critical time element.
A noteworthy aspect contributing to our success was the absence of ego within the team. The identification and
notification teams maintained a collective understanding of the mission's importance and demonstrated a high level
of flexibility. This flexibility was crucial, especially in the dynamic landscape where operational strategies evolved
almost daily during the initial stages.
In the moment, shortcomings were addressed proactively. The team collectively explored challenges, strategized
remedies and voted on optimal changes that enhanced accuracy and efficiency. This collaborative approach thrived,
ensuring a focus on continual improvement.
Personal interactions played a significant role, with efforts to meet team members in person and understand their
workspaces. This approach facilitated invaluable communication and information sharing. Following up with
individuals who shared information established a sense of value, encouraging prompt responses to future requests.
The police evidence specialists played central roles in facility expansion and daily operations, bridging
communication gaps between agencies and acted as the stewards of accumulated forensic disaster information.
The provision of meals directly to the forensic facility and morgue eliminated the need for breaks to procure food,
allowing nearly uninterrupted workflow. Conducting family briefings at the Hyatt Regency Maui (one of the largest
operating venues nearest the disaster zone) not only showcased compassion, but also provided an opportunity to
address questions, explain procedures, and establish personal connections with the affected families. Proactive
public briefings emerged as an essential component for managing public perception and accurate understanding of
facts. Members of the M.I.N.T. stepped forward to take on responsibilities outside their normal job descriptions in
good faith. Some of their efforts are documented, but many more efforts were not due to the ever-changing
landscape of this disaster.
RECOMMENDATION 17 – Ensure the M.I.N.T. has a dedicated intel analyst,
providing real-time intelligence critical for decision making.
Preliminary After-Action Report, August 8, 2023
64 | P a g e
B. Pre-Event Baseline for MPD Forensic Facility
The Chief of Police of the County of Maui shall be the Coroner. Hawaii Revised Statutes §841-1.
MPD employs three full time Police Evidence Specialists and one full time Fingerprint Identification Technician. One
resident forensic pathologist (serving as the coroner’s physician) is contracted through Clinical Labs of Hawaii. This
position was vacant at the time of the fire. Additionally, there is one part-time Mortuary Technician contracted
through Clinical Labs of Hawaii. MPD does not have dedicated personnel for daily mortuary operations.
The police morgue case volume of examinations has steadily increased each year. Currently, there is one full time
resident forensic pathologist for the County of Maui (assistance regularly comes from off-island). In 2021 there were
327 forensic cases and in 2022 there were 382 cases. Excluding the 204 fire related recoveries there were 341 cases
as of late November 2023.
A private contractor provides decedent transportation services from scenes, with approximately six part time staff
and two cargo vans. Approximately 350 body bags were maintained on Maui prior to the fire.
C. County Maui Police Morgue and Initial Response
The morgue is located within the MPD forensic facility, approximately a 40 minute (23 miles) drive from Front Street
in Lahaina. There is one autopsy suite (460 square feet) with one operating table without fully adequate water
drainage. The facility has refrigerated storage for 60 bodies in the walk-in refrigerator, and 40 in the auxiliary
temporary refrigerated shipping container from the COVID-19 Pandemic. At the time of the fires, the MPD morgue
had 29 bodies refrigerated in our care. There is no decedent dedicated electronic case management system.
Disaster Morgue Deployment and Recoveries
There were unique case numbers generated (chronologically as x-rayed) and assigned to each individual recovery.
Case investigation began with brief documentation of victim location and photographs of the decedent as found. In
the first day after the fire there were approximately 40 recoveries performed and approximately 90 recoveries done
in the first three days. Following autopsies of the initial recoveries, secondary searches were requested as indicated
and performed based on recovery location. The addition of experienced field anthropologists played a vital and
critical role in identifying, documenting, and recovering heat damaged and fragmented skeletal remains during these
secondary recoveries. Every lead was followed and every location was searched. Primary and secondary recovery
teams included: MPD officers, anthropologists, a victim transport contractor, and various military support personnel
RECOMMENDATION 18 – Create a part time position to coordinate daily
mortuary operational needs.
RECOMMENDATION 19 – Retrofit the autopsy suite with two new sinks and
rearrange the space to accommodate two tables to increase workflow and
ergonomics.
Preliminary After-Action Report, August 8, 2023
65 | P a g e
to assist with debris removal. Hours of operation were expanded to seven days a week with working hours from
6:00 a.m. to 11:00 p.m. As of December 12, 2023, there were 204 unique case numbers generated representing
primary and secondary recoveries of human remains (including 10 non-human remains released to the Maui
Humane Society for cremation on November 8, 2023 and four non-biological recoveries).
Dive teams from the US Navy, Maui Fire Department (near-shore to 30 feet depth), and FBI (30 feet to 100 feet
depth, 1-mile radius of Lahaina Harbor) searched the waters of the harbor and in sunken boats for remains. The FBI
deployed remote controlled submersible vehicles to search a deeper four mile stretch of shoreline.
There were approximately 42 people recovered from inside structures, 39 from outdoor locations, 15 from inside
vehicles, and one in the water. An additional three deaths were later reported to have occurred in hospital on Oahu
due to fire related injuries.
Chart 3.
Recovery Transportation
Coordinated efforts were made with field detectives and Grey Tech for recovery transportation. Recovery date,
time, location, and the body bag’s unique identification number were recorded on paper. One copy remained
attached to the body bag and another remained with the contractor. The contractor transporting recoveries set up
two command locations: the Lahaina site and forensic facility, to coordinate responsibilities specific to each aspect
of the transportation process. They increased their teams by including retired Maui firefighters and other volunteers
(26 at their peak on August 14, 2023), and increased their vehicle capacity through established partnerships with the
RECOMMENDATION 20 – Continue death investigation education for MPD
officers, as some of the initial documentation and photography could have
offered more context with better coverage and details.
42
39
15 1
Number of recoveries by type
Inside Structure Outdoors Inside Vehicle Ocean
Preliminary After-Action Report, August 8, 2023
66 | P a g e
three mortuaries serving Maui County. The MPD radio shop provided five portable radios to facilitate
communications between their fleet. One mortuary van was dedicated to supporting morgue activities.
Expanded Morgue Operations
Victim remains were taken from Lahaina to Maui Memorial Medical Center for a full set of x-rays. The hospital
provided dedicated staff 24 hours a day to perform this task. Decedents and CDs of the x-rays were then transported
to the forensic facility for examination. A majority of the cases (120 of the 204, 59%) were x-rayed at the hospital.
Once HHS Disaster Mortuary Operation Response Team (DMORT) arrived with a portable x-ray unit (operational
August 16, 2023), x-rays were taken on-site in the outdoor tented disaster morgue. Defense POW/MIA Accounting
Agency (DPAA) provided personnel and their portable x-ray unit once DMORT demobilized (September 1, 2023).
Additional unique identifying numbers were assigned after x-rays during autopsy and noted on exterior of each body
bag. These numbers were used as a pair of identifiers.
Figure 1. Overhead view of expanded morgue.
RECOMMENDATION 22 – Procure a dedicated x-ray machine at the morgue,
eliminating dependence on off-site services and additional transportation.
RECOMMENDATION 21 – Incorporate/procure a morgue electronic case
management software program.
Preliminary After-Action Report, August 8, 2023
67 | P a g e
The morgue autopsy suite operating area was increased from 460 square feet interior space to 1,727 square feet
(including tented area 35’x20’ and adjacent covered asphalt area 27’x21’ at the rear of the forensic facility, see Figure
2). The outdoor morgue expansion included eight portable tables for anthropology and dental examinations, tables
for computers, and photography stations. Morgue storage capacity increased from 100 shelves to 300 shelves
(including five additional refrigerated shipping containers). Remains were placed on sequentially numbered racks
within the refrigerated containers and logged on white boards and excel spreadsheets. During the fire the cases
were managed with multiple excel spreadsheets, Word documents, emails, and paper notes at the morgue.
Authorized personnel at the forensic facility increased from seven to nearly 127 throughout the operation, requiring
increased accommodations for meals all day, solid waste and wastewater services (dumpsters and portable toilets),
biohazard waste disposal, morgue operating supplies (PPE, tools, etc.), parking, and computer enhancements (work
stations, printers, databases, telephones, conference tools). An early challenge was delayed access to essential
digital resources, which took up to 11 days to procure.
PC: Courtesy
Figure 2. Images A and B represent the expanded disaster morgue with staff and portable equipment. Images C and
D are three bone fragments recovered separately and reunified.
D. Security Measures
The MPD forensic facility is a two-story building built in 1990 with 8,400 square feet (and a 40 foot refrigerated
shipping container obtained during the COVID-19 pandemic) on a 25,000 square foot parcel. Two vacant adjacent
parcels to the west provided an additional 24,200 square feet of available space for temporary expanded morgue
RECOMMENDATION 23 – Have permanent resources required to perform
various expanded duties such as phone lines, computers, printers, and
network access, coordinated by an expanded information technology services
section within MPD.
Preliminary After-Action Report, August 8, 2023
68 | P a g e
operations, consisting of five refrigerated and four non-refrigerated shipping containers (used for logistics for
DMORT).
The forensic facility is a secure police facility with access by electronic identification badges, so access was expanded
for the additional temporarily authorized 120 personnel. All event-related badges were deactivated effective
September 25, 2023. Various representatives of local, state, and federal agencies and their security detail were
given tours of the forensic facility.
Twenty-four-hour security forces were posted in several key locations of the expanded mortuary operation. Officers
from the ATF, Bureau of Indian Affairs, FBI Los Angeles Field Office Rapid Deployment Team, Maui Police
Department, and U.S. Marshal Services assisted.
Air space flight restrictions were implemented by the Federal Air Administration to include 1-mile radius of the
forensic facility on August 26, 2023 and lasted for approximately one month.
Hawaiian Blessing at Forensic Facility
To show respect and aloha for decedents, families, Maui first responders and all agencies and organizations helping
with the disaster efforts, a Hawaiian blessing was held at the forensic facility on August 19, 2023.
E. Expanded Mortuary Operations Team
Clinical Labs of Hawaii provided one resident pathologist, two off-island rotating pathologists, two locum
pathologists, one on-island autopsy technician, and two off-island autopsy technicians. The DMORT assessment
team consisting of one commander, one deputy commander, one pathologist, one medical investigator, and one
representative at the Family Assistance Center (FAC) arrived August 12, 2023. This team moved into assigned
positions within the operations; the entire DMORT team was fully functioning by August 15, 2023. The DMORT team
consisted of the following:
Deputy Commander (1) – DMORT Operations Chief at Location
Pathology (4) – This section of DMORT personnel was downgraded to two pathologists on August 24, 2023.
Anthropology (1) – This section had one DMORT personnel always assigned.
Radiology (1) – This section had one DMORT personnel always assigned.
Dental (2) – This section had one odontologist always present with a personnel rotation on August 24, 2023.
MLI / Autopsy Tech / Data Entry (8) – This section had personnel performing multiple tasks during the deployment.
On August 24, 2023 three personnel returned home, and no other personnel replaced them.
Administrative Officer (1) – This individual handled all administrative duties and time keeping. This person returned
home on August 24, 2023 and no replacement was required.
Disaster Medical Assistance Team (DMAT) (5) – This medical team is deployed with a DMORT team to provide
medical support. This included a commander and a four-person team. This team also included support to the Family
Assistance Center (FAC) facility.
The DMORT forensic operation ended on September 1, 2023. A small data entry support team remained until
September 7, 2023. Two commanders remained on virtual deployment until September 15, 2023 available to Maui
County officials for any further fatality management support.
At the FAC there was one section chief and 18 personnel that were trained to interview family/friends at the FAC
locations set up by the County of Maui. As the demand for the FAC decreased so did the number of personnel
assigned by DMORT to the FAC.
Preliminary After-Action Report, August 8, 2023
69 | P a g e
The Incident Management Team (IMT) supported DMORT and other federal resources assigned to the Fatality
Management Mission. This team was demobilized on August 30, 2023.
The Logistics Response Team was staffed with eight personnel. Logisticians transported, set-up, and maintained
Deployable Portable Morgue Unit (DPMU), 22.5 tons of equipment and materials moved from MSC Frederick MD to
the forensic facility. They were demobilized on September 2, 2023.
Mental health experts connected with workers on several visits and were available in-person and by phone. A
comfort/therapy dog from Texas State University Police Department was also brought to the forensic facility for an
afternoon to spend time with personnel.
Autopsy Processes
The majority of the primary exams were conducted in the small interior autopsy suite. All of the shelving and
everything else that was occupying space was moved into the hallway to accommodate two more tables and three
autopsy documentation teams. Autopsies were conducted in shifts (early morning to late evening) and divided
between five Clinical Labs of Hawaii forensic pathologists (FPs), and three DMORT FPs. Non-fire Maui County cases
continued to be handled each morning, along with fire cases, by Clinical Labs of Hawaii.
The first forensic exam was conducted on August 11, 2023. Remains were not examined in chronological order,
instead, autopsies were first conducted on those with more intact remains and the potential for fingerprint
identification. Autopsy documentation was initially performed by MPD police evidence specialists, who later trained
DMORT and FBI Evidence Response Team members on proper documentation procedures. The autopsy exam
consisted of full body photographs followed by an external exam with a directed internal exam. The condition of
the remains ranged from superficial thermal injuries involving skin only, to deep thermal artifacts with extensive soft
tissue and bone loss. Personal property was photographed, documented, collected, and submitted as evidence.
Tissue samples were submitted for DNA analysis and for carboxyhemoglobin detection (smoke exposure). In-process
relevant notes were recorded for each case. A final autopsy report was generated for all cases by Clinical Labs of
Hawaii. A total of 204 sets of remains were recovered and examined representing 97 decedents.
Multiple systems were created to control and organize information. Folders for each case were made to keep track
of the paper notes. One master excel spreadsheet was generated including the unique number assigned at x-ray,
the unique number assigned during autopsy, any information from the recovery team, personal property, and
autopsy information. Once positive identification was made all relevant information was added to the excel sheet,
including when family was notified and when the remains were eventually released. Word documents were made
to track recovery locations and secondary searches which aided communication with teams at the disaster site.
DMORT entered decedent and unaccounted for information into their Victim Identification Program (VIP) which
tracked antemortem information provided by family members at the FAC along with decedent information gathered
during autopsy.
Anthropology
There were teams of anthropologists (from multiple organizations) deployed to search the recovery zone. Their
efforts were vital in the recovery of fragmented remains that could otherwise be lost. There were also
anthropologists (from multiple organizations) stationed at the disaster morgue seven days a week. Each set of
remains was reviewed and examined multiple times to secure a positive identification and reunite remains. There
were directed secondary searches conducted, the majority of which recovered additional remains. Anthropologists,
Preliminary After-Action Report, August 8, 2023
70 | P a g e
MPD officers, and military personnel cleared secondary search sites by sorting and removing debris until they
reached the foundation of the site so nothing was left behind (Figure 3).
Once secondary recoveries were complete, the remains were evaluated to determine the number of humans
represented and to exclude non-human remains. The remains were sorted by performing a skeletal profile.
Secondary remains were reunited with primary remains by direct bone fragment refitting, DNA matching, and
contextual recovery location mapping (see Figure 2). The primary and secondary cases with multiple case numbers
were consolidated. There was no contracted anthropologist on island at the time of the fires.
PC: MPD
Figure 3. Image A is a representative structure showing floor composed of white charred building materials. Image
B is a mid-range photo with charred building materials surrounding human bone fragments (arrow and circle). Image
C shows an anthropologist searching for remains. Image D shows post recovery location – once remains are found
the location is searched until all substrate is removed and the foundation is exposed.