Introduction

In the aftermath of the March 11, 2004, Madrid train bombing, 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 to 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[2]. The unit implemented a corrective-action process that included the following: (1) suspending all casework assignments for the three FBI examiners, (2) reviewing the three examiners’ casework for periods of not less than two years, (3) appointing different examiners in the laboratory to review the case and prepare a revised report, (4) forming an external review committee, and (5) implementing remediation measures, as deemed appropriate. Additional corrective actions may be implemented upon the completion of this report and the above processes.

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 comment on.

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 also served as resources for the committee.

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 the Quality Assurance and Training Unit. This report is a synopsis of the major points made in the reports submitted by the committee members.

Time Line

Committee Assessment Objectives and Synopses

1. Determine whether the process and procedures used in this matter were appropriate.

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 error and not a methodology or technology failure.

The prescribed methodology [Analysis, Comparison, Evaluation, and Verification (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 comprehensible why IAFIS provided him as a candidate and why the initial examiner did not immediately dismiss him.

The power of the IAFIS correlation, coupled with the inherent pressure of working an extremely high-profile case, was thought to have inf luenced the examiner’s initial judgment and subsequent examination. This inf luence 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 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 and yet those results do not inf luence the examiner’s conclusions. However, because of the inherent pressure of such a high-profile case, the power of an IAFIS correlation in conjunction with the similarities in the candidate’s print, and the knowledge of the previous examiners’ conclusions (especially because 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 an expected 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 of 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 the 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 conf lict (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 conf licting procedural or legal requirements), the examination that occurred by the agency with legal jurisdiction will most likely prevail.

On the basis of 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 ACEV 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 conf licting analyses and results, would require open communication and discussion among examiners, and would require resolution.

The verifiers must do an independent and complete ACEV examination of each print that they are verifying. The verifiers must be willing to oppose any examiner if the verifiers 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 a 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 highprofile 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 committee recommends that 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 ref lect 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.) The FBI Laboratory does not agree with the concept that comparison ability should be a primary consideration in case assignment. All trained and proficiency-tested examiners are considered equal in the case assignment process.

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.

The committee recommends that 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, Scientific Working Group on Imaging Technology, and Scientific Working Group on Digital Evidence 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 committee recognizes that 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.

Acknowledgment

On behalf of the FBI Laboratory, I wish to thank the committee members for their participation and efforts to assist the FBI Laboratory in reviewing this case and making recommendations. The committee’s work will no doubt be reviewed by the entire latent print community and by members of the U.S. Congress. The Laboratory is taking the committee’s recommendations seriously and firmly believes that the it will be made better as a result of the committee’s work.

Footnotes

1. In the forensic community, the terms individualization and identification are interchangeable.
2. The ASCLD/LAB Manual defines Class I as “The nature and cause of the discrepancy raises immediate concern regarding the quality of the Laboratory’s work product.”