At approximately 0622 local Beirut time on 23 October 1983, an explosion of enormous magnitude destroyed the BLT Headquarters building. This catastrophic event resulted in 241 deaths and approximately 112 wounded in action (WIA). The only medical officer ashore was killed and a majority of the hospital corpsmen billeted at the building were either killed or wounded. The battalion aid station was destroyed.
Within minutes of the explosion, the CTF 61/62 Mass Casualty Plan was implemented. The remaining medical assets of the MAU Service Support Group (MSSG) were organized into two triage teams. Additional medical support was mobilized from afloat units and rapidly transported ashore. As wounded were recovered from the rubble they were immediately treated. Many were initially taken to local civilian hospitals or to the Italian military field hospital while U.S. forces were recovering from the first shock and were regrouping.
The majority of the wounded were trans[ported by helicopter to the USS Iwo Jima, LPH (Amphibious Helicopter Platform) which served as the primary casualty receiving and treatment ship. Necessary resuscitation and surgery were accomplished. After appropriate stabilization, and as air evacuation aircraft arrived, the wounded were transferred to the airport runway area for evacuation to definitive medical care facilities.
Within 30 minutes of the explosion, the British offered the use of the Royal Air Force hospital at Akrotiri, Cyprus. The offer was accepted. The support of the RAF proved to be invaluable. Aeromedical evacuation aircraft of the USAF, USN and RAF were directed to BIA. Casualties were evacuated to Cyprus, Germany and Italy, where there had been virtually a total mobilization of all major medical treatment facilities. Following definitive medical treatment at these overseas facilities, patients were returned to hospitals in the United States as their conditions permitted.
II. ON-SCENE MEDICAL CARE
A. Principal Findings.
On-scene medical personnel and resources were both ashore and afloat. Ashore were a General Medical Officer, two Dental Officers, a Medical Preventive medicine Officer (entomologist), two Dental Technicians and almost 70 Hospital Corpsmen. The explosion killed the Medical Officer and killed or wounded 19 Hospital Corpsmen.
Aboard the ships of the Amphibious Task Force there were, as part of normal ships' and embarked aircraft squadron's complement, seven General Medical Officers including one Flight Surgeon) and 62 Hospital Corpsmen. In addition, a Surgical Team was embarked aboard the USS Iwo Jima, the principal afloat medical facility. The Surgical Team consisted of a general surgeon, an orthopedic surgeon, and anesthesiologist, a nurse anesthetist, and operating room nurse, a medical administrative officer, and thirteen Hospital Corpsmen. Medical spaces aboard the USS Iwo Jima included two operating rooms.
There were ample medical supplies available both ashore and afloat. Despite the destruction of the battalion aid station, sufficient supplies were initially available in the MSSG Headquarters building, and, prior to 23 October, the USS Iwo Jima had received additional medical supplies ensuring the capability to manage at least one hundred casualties for several days.
Immediately following the explosion, the Mass Casualty Plan was implemented by CTF 61. Before help arrived from the ships, other actions were underway. Marine and Navy personnel turned immediately to rescuing the wounded from the wreckage and giving them first aid. The two Navy dentists and the remaining corpsmen established one triage and casualty receiving station adjacent to the demolished building and another one at the MSSG Headquarters. Ambulances, medical personnel,, and volunteers from the Italian contingent of the MNF, and from local Lebanese medical facilities, arrived and evacuated casualties to
By 0640B (local Beirut time), approximately twenty minutes after the explosion, radio communication was established between the MSSG casualty receiving station and the helicopter landing zone at the airport (LZ Brown). By 080B, all surviving casualties at the MSSG had been triaged, treated, and sent to LZ Brown for medical evacuation (MEDEVAC) to USS Iwo Jima by helicopter. By approximately 0730B, as medical personnel arrived from the ships, another triage and casualty receiving station was established close to the destroyed BLT Headquarters building. Here too, patients received immediate treatment, were triaged, and then moved to LZ Brown for subsequent MEDEVAC to the ship. The first wounded arrived aboard USS Iwo Jima at 0740B, approximately one hour and twenty minutes after the attack, having first been triaged and provided field medical treatment ashore.
The goal of the medical personnel on USS Iwo Jima was to treat, stabilize, and evacuate the casualties as rapidly as possible, in order to be prepared for the arrival of subsequent casualties.
Triage aboard USS Iwo Jima was performed on the hanger deck. Several surgical procedures were required aboard ship the main task was to stabilize and prepare the wounded for subsequent aeromedical evacuation. Of the 62 WIA's brought to the USS Iwo Jima on 23 October, one died onboard and the remainder were evacuated to the RAF hospital in Akrotiri, Cyprus, or the U.S. military hospitals in Landstuhl, Frankfurt, and Wiesbaden, Germany and Naples, Italy.
On-scene immediate medical care appears to have been appropriate, adequate, and timely.
The Commission's inquiry confirmed that CTF 61/62 executed a well-understood, and frequently exercised, mass casualty plan. Execution of the plan provided timely response to the mass casualty requirement for on-scene medical care despite the destruction of the battalion aid station and the death of the only doctor ashore.
The immediate aftermath of the massive explosion was, understandably, a scene of disorientation and initial confusion. This sudden, unexpected attack of enormous destruction devastated an entire unit. (It was during this initial period that numerous Lebanese and Italian volunteers arrived on-scene and provided early, needed casualty assistance.) The recovery of the shattered unit was rapid. There was a heroic rescue effort to pull survivors from the rubble and efficient and appropriate field medical treatment was instituted without delay. There were ample assets for the rapid transfer of the wounded from the disaster site to the treatment areas. No delays were encountered in the helicopter transfer of patients to the ship.
The CTF 61/62 Mass Casualty Plan for the MAU ashore placed the BLT medical officer and/or the Leading Chief Petty Officer in charge of triage and medical regulating. When both were killed, there was no longer a well-defined medical command structure ashore. Future medical planning should anticipate such losses. A medical regulating team should be include in the normal CTF 61 medical complement.
The Commission concludes that the speed with which the on-scene U.S. military personnel reacted to rescue their comrades trapped in the devastated building and to render medical care was nothing short of heroic. Additionally, the rapid response by Italian and Lebanese medical personnel was invaluable.
III. AEROMEDICAL EVACUATION/CASUALTY DISTRIBUTION
A. Principal Findings.
Standard EUCOM operating procedures were in effect prior to 23 October 1983 to enabling CTF 61/62 to call upon EUCOM medical evacuation (MEDEVAC) aircraft as needed. No medical evacuation aircraft were specifically deployed for full time support to CTF 61/62.
CTF 61 called for aeromedical evacuation support within 15 minutes of the explosion. Fortuitously, the nearest U.S. MEDEVAC aircraft, a USAF C-9, was in Incirlik, Turkey. CTF 61 was given an ETA of 1030B for its arrival in Beirut. The ETA proved inaccurate; the actual time of arrival of the C-9 was 1240B.
The British offer to provide MEDEVAC aircraft was accepted at 10B, when it became clear that the original ETA for the Incirlik C-9 was in error. A RAF C-130 aircraft arrived at 1310B, thirty minutes after the arrival of the USAF C-9 aircraft from Incirlik.
Two additional MEDEVAC aircraft were used on 23 October 1983: the first, a U.S. Navy C-9 from Sigonella, Italy, arrived at BIA at 1340B, while the second, a USAF C-141, arrived at BIA at 1940B.
Aeromedical evacuation of patients out of the Beirut area began at approximately 1230B with the initial helicopter lift of casualties to BIA from USS Iwo Jima. The fixed wing MEDEVAC aircraft departed BIA as follows: The RAF C-130 left at 1421B for Akrotiri; the USAF C-9 left at 1512B for Germany; the USN C-9 left at 1551B for Naples, Italy; and the C-141 left at 2249B for Germany. It is apparent to the Commission that all patients received excellent care by medical personnel enroute.
The early British offer of the RAF hospital at Akrotiri, Cyprus was important. Since CTF 61 medical officers had visited and were familiar with the RAF hospital at Akrotiri,
The initial intention of CTF 61 was to transport the seriously wounded patients to Akrotiri. At some point, however, a decision was instead made to transport many of the seriously wounded to Germany. The Commission has been unable to determine who made this decision.
The evacuation of patients to U.S. military hospitals in Germany and Italy was in accordance with existing procedures, but was deficient in several respects: First, erroneous ETA's (Estimated Time of Arrival) were initially provided to CTF 61 regarding the C-9 MEDEVAC aircraft being dispatched from Incirlik, Turkey; this aircraft arrived two hours later than the initial ETA provided. Logistical considerations (obtaining medical supplies) appear to have been the delaying factor. Second, seriously wounded patients were flown to Germany, a flight of just over four hours, while a competent and closer Royal Air Force facility was available and ready at Akrotiri, Cyprus just one hour away. And, third, the first MEDEVAC aircraft was directed to Rhein-Main air base, rather than Ramstein air base, resulting in additional transport time for the most seriously wounded.
There was no evidence to indicate that any patients were adversely affected from the longer evacuation flights. The Commission is concerned, however, that under other circumstances the outcome could have been less favorable.
Aeromedical evacuation and medical support plans do not recognize or provide for the peculiar and unique situation of CTF 61/62. USCINCEUR's aeromedical evacuation plans and resources are designed for routine, peacetime operations.
There was a lack of adequate numbers of experienced medical planning staff at all levels of theater chain of command from CTF 61 up through COMSIXTHFLT, CINCUSNAVEUR, and USCINCEUR. In consequence, responsibility for medical
Naval Warfare Publications, such as The Amphibious Task Force Plan (NWP 22-1) and Operational Medical Dental Support (NWP 6) provide an adequate framework for effective planning of operational medical support. The end result of the process should be a plan addressing such items as a statement of the medical situation; a statement of the evacuation policy (including alternate plans); clear delineation of medical responsibilities throughout the operational and administrative chains of command; and procedures for keeping necessary records and reports of the flow of casualties. Directives from higher echelons should provide the guidance and support to permit effective execution of the plans. Responsibilities for casualty evacuation and medical regulating must be clearly defined, sufficiently detailed for comprehension at all levels, capable of implementation, and regularly exercised.
Inflight medical care for the first 56 patients evacuated from Beirut was uneventful, with the exception of one patient who expired approximately 20 minutes after departure for Germany. This patient died of massive injuries sustained in the explosion and had not been expected to live.
The last MEDEVAC flight of 23 October 1983 departed at 2249B for Germany with 13 wounded. Subsequent MEDEVAC flights on following days moved patients who had been treated in local civilian hospitals to U.S. treatment facilities in Germany.
Distribution of patients among medical facilities in Germany was directed by USAFE personnel at Rhein Main vice the appropriate Joint Medical Regulating Office (JMRO). Procedures used were not in consonance with current directives. There is, however, no evidence that this patient distribution irregularity affected patient care or
The Commission found no evidence that any of the wounded died or received improper medical treatment as a result of the evacuation or casualty distribution procedures. Nevertheless, the Commission concludes that overall medical support planning in the European theater was deficient and that there was an insufficient number of experienced medical planning staff officers in the USCINCEUR chain of command.
The Commission found that the evacuation of the seriously wounded to U.S. hospitals in Germany, a transit of more than four hours, rather than to the British hospital in Akrotiri, Cyprus, a transit of one hour, appears to have increased the risk to those patients. Similarly, the Commission found that the subsequent decision to land the aircraft at Rhein Main rather than Ramstein, Germany, may have increased the risk to the most seriously wounded. in both instances, however, the Commission has no evidence that there was an adverse medical impact on the patients.
The Commission recommends that the Secretary of Defense direct the Joint Chiefs of Staff, in coordination with the Services, to review medical plans and staffing of each echelon of the operational and administrative chains of command to ensure appropriate and adequate medical support for the USMNF.
The Commission further recommends that the Secretary of Defense direct USCINCEUR to conduct an investigation of the decisions made regarding the destination of aeromedical evacuation aircraft and the distribution of casualties on 23 October 1983.
IV. DEFINITIVE MEDICAL CARE.
A. Principal Findings.
Medical care provided to the wounded by the various treatment facilities was excellent. The disaster plan of The Princess Mary RAF hospital at Akrotiri, Cyprus was exceptionally effective in concept and execution. The ability to use this facility, under these extreme circumstances, significantly minimized mortality and morbidity.
Mortality and morbidity sustained by casualties could be predicted on the basis of the injuries and does not appear to have been adversely affected by any of the definitive medical care.
The RAF effort was extraordinary. During the flight on their C-130 to Akrotiri, one patient received intubation and ventilation. The entire base was prepared to facilitate the casualty care. Patients were rapidly triaged and moved by ground ambulances to the hospital where further resuscitation was continued and surgery performed. Approximately 150 people volunteered to donate blood, and 50 were drawn. There were thirty nurses and two physicians from amongst the spouses of the military personnel who also volunteered their services. Back-up medical personnel and supplies were flown to Cyprus from the U.K. One patient died shortly after arrival at the Akrotiri facility, but his wounds were of such magnitude to preclude survival.
In Europe, patients were transferred either to U.S. Army hospitals in Frankfurt and Landstuhl, the U.S. Navy hospital in Naples or the U.S. Air Force hospital in Wiesbaden. These hospitals had implemented their disaster plans, recalled their entire medical staffs, organized resuscitation teams, discharged ambulatory inpatients to
The Commission concludes that the definitive medical care provided the wounded at the various treatment facilities was excellent, and that as of 30 November 1983, there is no evidence of any mortality or mobidity resulting from inappropriate or insufficient medical care.
V. ISRAELI OFFER OF MEDICAL ASSISTANCE
A. Principal Findings.
The Government of Israel communicated an offer of medical assistance to the United States Government approximately two hours (0830 Israel/Beirut local time) after the bombing attack. The initial of assistance was made by telephone from the IDF Chief of External Affairs to the . Defense Attaché in Tel Aviv who immediately directed the Duty Officer to report to the Embassy and send a message to CTF 61 informing him of the offer. The offer was general in nature and specifics were not requested because the Duty Officer was not aware of the enormity of the disaster or the nature of the on-scene require.
The Israeli offer of assistance was relayed within an hour (0922B) by flash message to CTF 61 stating: "REFERENCE THE ATTACK ON THE BLT HQ AT BIA THIS MORNING. PER TELECOM WITH COL ALTER, CHIEF OF EXTERNAL RELATIONS, IDF, THE GOI OFFERS WHATEVER ASSISTANCE MAY BE DESIRED BY THE USG IN THE EVACUATION/MEDICAL TREATMENT OF CASUALTIES."
CTF 61 saw the message at approximately 1030 to 1045 local time. His message response, after consultation with his medical staff, to the U.S. Defense Attaché Office in Tel Aviv at 1145B stated: "OFFER OF ASSISTANCE REFERENCE (A) SINCERELY APPRECIATED. CURRENTLY HAVE AMPLE ASSETS ENROUTE OR ON STATION TO MEET REQUIREMENTS."
Similar Israeli offers were subsequently transmitted by telephone calls involving the Secretary of Defense, Chairman of the Joint Chiefs of Staff, USCINCEUR and COMSIXTHFLT.
CTF 61 asked separately for Israeli support in providing 200 body bags for the dead. Israeli authorities in Tel Aviv immediately provided the bas which were forwarded to Beirut by U.S. Navy aircraft.
The Commission found no evidence that any considerations other than a desire to provide immediate, professional care for the wounded influenced the decision not to take advantage of the Israeli offer of medical assistance. The Commission's interview with CTF 61 revealed that his only concern was for the appropriate care and evacuation of the casualties. He did not review the message from Tel Aviv immediately upon receipt because of the large volume of critical traffic requiring his attention. When he did review it (between 1030 and 1045 local time) he had a reasonable estimate of the casualty situation (including the number of wounded requiring further care); of the estimated time of arrival of aeromedical aircraft then enroute; and of the fact that the RAF Hospital at Akrotiri, Cyprus, was prepared to receive the most seriously wounded. Thus, after consultation with the medical staff, CTF 61 felt that adequate capabilities were already available or enroute.
CTF 61 ad his medical staff had nor direct communications with the Israelis (as they did with the British through the British liaison officer onboard USS Iwo Jima). Further, CTF 61 had not details about the Israeli offer; whether, for example, it included MEDEVAC aircraft, or the nature of available hospital facilities in Israel.
When asked why he did not pursue these questions, CTF 61 replied that there was no need -- the facility at Akrotiri was already mobilized and evacuation to Cyprus had been arranged.
Discussions between a Commission member and senior officials of the IDF confirmed the substance and spirit of the offers. The discussions also revealed, however, that the Israeli authorities were not really aware of the resources CTF 61/62 had available locally or enroute.
The Commission found no evidence that any factor other than the desire to provide immediate, professional treatment for the wounded influenced decisions regarding the Israeli offer; all offers of assistance by Israel were promptly and properly referred to the theater and on-scene commanders. At the time the initial Israeli offer was reviewed by CTF 61, it was deemed not necessary because the medical capabilities organic to CTF 61 were operational and functioning adequately, the RAF hospital at Akrotiri was mobilized and ready, and sufficient U.S. and RAF medical evacuation aircraft were enroute.
VI. IDENTIFICATION OF THE DEAD
A. Principal Findings.
Current USCINCEUR instructions direct that the handling of deaths occurring in Lebanon will be the responsibility of United States Air Forces Europe (USAFE). Following the bombing attack no the BLT Headquarters and the resultant mass casualties, HQ USAFE was appointed by USCINCEUR as the executive agent responsible for coordinating the evacuation, identification, and preparation of the human remains.
The decision was made at Headquarters Marine Corps, in coordination with the Naval Medical Command and Army Mortuary Affairs personnel, to use the Frankfurt mortuary facility. Once the estimate of human remains requiring processing was reasonably established, a split operation was established to accomplish initial identification at a temporary facility at Rhein Main Air Base, with completion of the process and final preparation of the remains at the Frankfurt mortuary.
The first 15 remains were returned to the United States on 28 October. The final shipment occurred on 9 November. The total number of remains processed at Frankfurt was 239. Of these, 237 were U.S. military personnel, one was a French soldier, and one is believed to be a Lebanese civilian. Two additional remains were sent on 10 November to the U.S. Army Identification Facility in Hawaii for final identification.
The decision to process the remains of the U.S. military personnel in Germany was premised on the fact that the Frankfurt facility is the largest of the U.S. mortuaries in the EUCOM area, and that it is located near a major USAF air terminal (Rhein Main AB). (When that decision was made, it was estimated that tthe total KIA would be less than 100.)
The one other facility actively considered was Dover Air
When it became apparent that additional support facilities would be required, the split operation utilizing a temporary identification facility at Rhein Main, was a logical and practical solution problem of saturation of the Frankfurt facility. The Commission wishes to make special note of the superb and spontaneous offers of support from virtually every quarter. personnel augmentation was rapidly provided by all the services and included assistance from the Federal Bureau of Investigation. Invaluable assistance was provided by approximately 800 volunteers from local commands.
Positive identification of human remains is a slow, detailed, and laborious process. Even so, over 98 percent of the human remains were processed within one week of the bombing. Identification of the dead was accomplished expeditiously and precisely.
Complicating factors in the identification process included the destruction or temporary loss of medical and dental records, and the fact that most of the casualties did not have dog tags on their person. The medical and dental records were stored in the building that was bombed. Duplicate medical and dental records are no longer maintained by the Services, and this complicated and prolonged the identification process. Fingerprint files were not available for all personnel; the FBI team provided critical support to obtain fingerprints.
One set of human remains have been tentatively identified as those of a Lebanese civilian, presumably the custodian who lived in the building.
The Commission concludes that the process for identification of the dead following the 23 October catastrophe was conducted very efficiently and professionally, despite the complications caused by the destruction and/or absence of identification data.
The Commission recommends that the Secretary of Defense direct the creation of duplicate medical/dental records and assure the availability of fingerprint files, for all military personnel. The Commission further recommends that the Secretary of Defense direct the Service Secretaries to jointly develop improved, state-of-the-art identification tags for all military personnel.