The Commission also conducted a thorough examination of certain
civil aviation security requirements, policies and procedures
surrounding Flight 103. It is a disturbing story.
Preventing Flight 103 Destruction
The destruction
of Flight 103 may well have been preventable. Stricter baggage
reconciliation procedures could have stopped any unaccompanied checked
bags from boarding the flight at Frankfurt. Requiring that all baggage
containers be fully secured would have prevented any tampering that may
have occurred with baggage left in a partially filled, unguarded baggage
container that was later loaded on the flight at Heathrow. Stricter
application of passenger screening procedures would have increased the
likelihood of intercepting any unknowing "dupe" or saboteur from
checking a bomb into the plane at either airport.
The international criminal investigation has not yet determined
precisely how the device was loaded onto the plane. Until that occurs
and subject to the conclusions reached, the Commission cannot say with
certainty that more rigid application of any particular procedure
actually would have stopped the sabotage of the flight.
Enforcing Existing Regulations
This Report
contains more than 60 detailed recommendations designed to improve the
civil aviation security system to deter and prevent terrorist attacks.
Before new laws are passed and more regulations are promulgated,
existing ones must be fully enforced and properly carried out. The
Commission emphasizes that no amount of governmental reorganization or
technological developments can ever replace the need for well trained,
highly-motivated people to make the security system work.
The Commission salutes the thousands of men and women in the public
and private sectors of the U.S. civil aviation security system. The
recommendations in this report are designed to help them perform their
jobs more effectively. The Commission urges management to face up to the
security system failures disclosed by this investigation.
Facts About Pan Am 103
A few facts can be stated
with certainty about Pan Am 103. A terrorist element did succeed in
having a bomb placed aboard the aircraft. That bomb blew the aircraft
apart at 31,000 feet over Lockerbie, killing 259 persons on the airplane
and 11 on the ground.
The criminal investigation has indicated that the bomb was placed in
a radio cassette player and packed in a suitcase loaded into the plane's
baggage hold. The Commission, therefore, was able to concentrate its
investigation on security procedures for checked baggage.
Authorities also believe that the bomb was made of a very small
quantity of semtex, a plastic explosive, and that it probably was placed
aboard at Frankfurt, West Germany, where the flight began.
At the end of an October 1988 inspection of Pan Am's security
operations at Frankfurt, the FAA inspector was troubled by the lack of a
tracking system for interline bags transferring from other airlines and
the confused state of passenger screening procedures. Overall, the
inspector wrote, "the system, trying adequately to control approximately
4,500 passengers and 28 flights per day, is being held together only by
a very labor intensive operation and the tenuous threads of luck." Even
so, the inspector concluded, "it appears the minimum [FAA] requirements
can and are being met."
Unaccompanied Baggage
Passenger/baggage
reconciliation is the bedrock of any heightened civil air security
system. Under current FAA requirements for international flights,
implemented since Pan Am 103, every bag carried on an aircraft must
belong to someone who is also on that flight.
A key focus of the Commission's inquiry was the FAA written
regulation in effect in December 1988 that unaccompanied baggage should
be carried only if it was physically searched.
When Pan Am Flight 103 pushed away from the gate at Frankfurt and
again at Heathrow, on December 21, 1988, no one knew whether the plane
was carrying an "extra" interline bag that had been checked through to
Pan Am from another airline. Months before Pan Am stopped reconciling or
searching interline baggage and began simply X-raying this luggage.
Records examined by this Commission indicate that Pan Am Flight 103
might have carried one such interline bag that did not belong to a
passenger on the flight. While this extra bag would have been X-rayed,
the explosive semtex cannot be reliably detected by X-ray used at
airports.
Pan Am officials told the Commission that the FAA Director of
Aviation Security had given the airline verbal approval to X-ray
interline bags rather than searching or reconciling them with
passengers. The FAA official denied this.
Passenger Screening
Passenger screening
procedures required by FAA at Frankfurt and Heathrow included
questioning to identify for additional screening those fitting a
"profile" as most likely--knowingly or unknowingly--to be carrying an
explosive in any manner, including checked baggage.
The subsequent FAA investigation of Pan Am 103 found that several
interline passengers who boarded at Frankfurt were not even initially
screened. Several others identified at the check-in counter for further
screening did not receive that additional screening at the gate. A large
container holding baggage waiting to be loaded on Flight 103 arriving at
Heathrow from Frankfurt was left open and unattended for half an hour.
At the time, however, that practice did not violate any FAA regulations.
Pan Am Security Violations
The FAA investigation
of the Pan Am 103 disaster began immediately and concluded on January
31, 1989. While the results were not announced for over three months,
the FAA proposed fines totaling $630,000 against Pan Am for violations
of regulations, both on December 21 and during the five-week period
thereafter.
The FAA, significantly, did not cite Pan Am for substituting X-ray
for interline passenger/baggage reconciliation. The official FAA report
made no reference to the fact that the investigation had found that one
interline bag loaded on Flight 103 could not be accounted for in any
passenger records. The agency also noted in its announcement that none
of the violations cited by its investigation had contributed in any way
to the bombing.
Both the public and the regulatory spotlight were focused on just
those types of security problems throughout early 1989. Congressional
hearings were held. The Secretary of Transportation set up a task force
expressly to look into the matter. The Commission would have expected
the FAA to give top priority to security operations at the two airports
that loaded and dispatched Flight 103.
Separate from the Flight 103 probe, the FAA found numerous security
discrepancies by Pan Am at Frankfurt and London in January and February
of 1989, but took no official action against the airline.
In a major inspection conducted May 8-23, 1989, the FAA found that
major security violations still existed in Pan Am's Frankfurt
operations.
One FAA inspector wrote in the report dated June 7, 1989, that while
the operations of the four other U.S. carriers operating at Frankfurt
were "good," Pan Am was "totally unsatisfactory."
Wrote the FAA inspector: "Posture [of Pan Am] considered unsafe, all
passengers flying out of Frankfurt on Pan Am are at great risk."
When the FAA Associate Administrator with responsibility for the
security division learned of the May inspection results, he called a
June 14 meeting with Pan Am officials, who presented a plan for
corrective action while contesting some of FAA's allegations.
Continuing Violations
Still, the security
violations and deficiencies at Pan Am's Frankfurt station continued. An
unannounced inspection in August of 1989 found that many of the same
security problems from the May inspection remained uncorrected,
especially unguarded airplanes and failure to search personnel
maintaining the aircraft.
Pan Am came to a September 12 meeting with FAA on security at
Frankfurt with yet another "action plan." A later gathering, however,
included a private session between the FAA Administrator and the chief
executive officer of the airline. That same evening, a team of
high-level Pan Am managers, accompanied by FAA security inspectors, flew
to Frankfurt.
Within one week, personnel changes at the station had been ordered
and all security violations and deficiencies corrected. At the next FAA
regular inspection, Pan Am at Frankfurt was rated a model station. This
corrective action occurred nine months after the Flight 103 bombing.
Warnings of Bombing
The bombing of Flight 103
occurred against the background of warnings that trouble was brewing in
the European terrorist community. Nine security bulletins that could
have been relevant to the tragedy were issued between June 1, 1988 and
December 21, 1988. One described a Toshiba radio cassette player, fully
rigged as a bomb with a barometric triggering device, found by the West
German police in the automobile of a member of the Popular Front of the
Liberation of Palestine--General Command (PFLP-GC). The FAA bulletin
cautioned that the device "would be very difficult to detect via normal
X-ray," and told U.S. carriers that passenger/baggage reconciliation
procedures should be "rigorously applied."
On December 5, 1988, an anonymous telephone caller to the U.S.
Embassy in Helsinki, Finland, said that sometime within the next two
weeks a Finnish woman would carry a bomb aboard a Pan Am aircraft flying
from Frankfurt to the United States. The FAA Security Bulletin on the
threat was issued December 7 and was redistributed by the State
Department to its embassies worldwide December 9.
Passenger Warnings
At the U.S. Embassy in Moscow,
the senior staff, with concurrence of the Ambassador, decided that the
warning should be made public. Thus the Helsinki threat information was
publicly posted at the Embassy on December 14 and was generally made
available throughout the 2,000-member community of Americans, including
news media and private contractor personnel, in Moscow. For these
Americans, Pan Am through Frankfurt was the most accessible and most
commonly used route to the United States.
The Commission found no passenger who changed his or her travel plans
because of the Helsinki threat except one civilian who was scheduled to
fly Pan Am to the United States through Frankfurt on December 16 and
switched to a direct flight on December 18. While there were no
passengers from Moscow on flight 103, the connecting Pan Am flight from
Moscow was not scheduled to fly on that date.
Any distribution of threat information to one segment of the
population, such as the posting of the Helsinki threat in Moscow,
creates the perception of a "double standard"--the intentional choice to
warn some people but not others. At the same time, the Commission
believes that the public notification of aviation threat information is
appropriate under certain circumstances, described in detail in this
Report. Therefore, the Commission recommends that a mechanism be
established to consider in individual cases when and how to provide
public notification.
As for the Helsinki threat, Finnish police quickly determined that
the call was unreliable. All subsequent investigations by other
governments have also concluded that the call had no connection to
Flight 103. The Commission found no evidence suggesting otherwise.
Aftermath Response
The Pan Am 103 families
registered bitter complaints over the treatment they received from the
State Department, and the Commission found that the Department was
unprepared to respond effectively and compassionately to the largest
aviation terrorist disaster in U.S. history.
The Commission found that the Department failed to obtain a list of
passengers, develop a list of next of kin, and notify the families in a
timely and compassionate fashion, and failed to staff adequately its
consular services effort in Lockerbie.
Although the State Department appears to have begun to recognize the
scope of its Pan Am 103 failures, it has only begun to institutionalize
mechanisms that will remedy the problems. More must be done, and the
Commission's recommendations help point the way.
The Commission firmly believes the U.S. Government owes victims of
terrorist act directed against this country more than just processing
the return of remains and personal effects, however important that may
be. Accordingly, the Commission recommends that the United States extend
financial benefits to these victims and develop appropriate ceremonies
to recognize their sacrifice. The outdated Warsaw Convention should be
revised to speed increased compensation to passengers families.
Keeping Pace with Terrorist Technology
The
Commission also finds that the FAA's research and development program
should be significantly intensified to keep pace with the changing
terrorist threat to civil aviation. Under a contract awarded in 1985 to
Science Applications International Corp. (SAIC), the FAA has purchased
six thermal neutron analysis (TNA) machines to detect plastic
explosives.
These machines, by design specification and by actual performance as
observed by the Commission at JFK Airport in New York, will detect
plastic explosives in an operational mode only in amounts far greater
than the weight of the most sophisticated bombs actually used by
terrorists. For example, the bomb that destroyed Pan Am Flight 103 is
believed to have weighed half or less than the amount the TNA machine
would reliably detect in an operational mode at an international
airport.
Despite these limitations, FAA has announced a program to require
U.S. airlines operating internationally to purchase 150 TNA machines (or
the equivalent, although there is no competing equipment available) and
to install them at 40 international airports at an estimated cost of
$175,000,000. The Commission recommends that this program be differed,
pending development of more effective TNA machines or an alternative
technology.
Strengthening Security Programs
The Commission's
examination of the security program applied by U.S. carriers at foreign
airports revealed that much has been done to strengthen them since
December 1988, especially at high threat airports. However, foreign
governments have not imposed equally stringent requirements on carriers
under their jurisdiction, and the U.S. has relied on weak international
standards for foreign carrier security. As a result, there are
significant imbalances. The Commission recommends steps to improve
aviation security internationally and to promote the use of bilateral
agreements negotiated by the State Department as the mechanism to
achieve a consistently high level of international aviation security.
As part of its mandate, the Commission assessed the coordination and
evaluation and dissemination of intelligence information collected. The
Commission found that, because of the government's increased
intelligence activities targeted at terrorism and the increased
resources being devoted to intelligence functions by the FAA, the system
is working reasonably well.
The Commission's review showed that no warnings specific to Flight
103 were received by U.S. intelligence agencies from any source at any
time. It also showed that no information bearing upon the security of
civil aviation in general and flights originating in Frankfurt in
particular was received beyond that which was promptly disseminated to
the FAA and, in turn, immediately to U.S. air carriers.