We determined from our review of DNAUI operations and our analysis of interview responses that there are various communication and operational inefficiencies within the DNAUI.
a) Communications
During our interviews with DNAUI staff members and management, we inquired about the way that information is communicated within the Unit. This issue was of particular interest to us because of the importance of communication to the proper implementation and improvement of DNAUI protocols. We asked interviewees the following questions:
• How are staff members kept apprised of changes in work routine, procedures, and resources?
• What options are available to you if you were to have a
recommendation, request, suggestion, or a critique regarding Unit operations or protocols?
We observed from interview responses that although members of upper management think that communication within the Unit, and between the Unit and Laboratory management, is functioning well, several staff members do not feel that they are kept informed about operational information and believe that communications are at times dysfunctional. Further, several comments we received indicate that some staff members do not believe that Laboratory management actively solicits and considers their input on issues that affect their work.
Management and staff members identified similar methods that are used to keep staff members updated on operational and protocol-related
information, including e-mail and Unit or program meetings. However, it was clear from staff member responses that these methods are not consistently effective. Staff members explained that the dissemination of information,
including protocol-related information, is erratic. Examiners made reference to this problem and said that some Examiners are better than others in passing along information, a point that also was noted by both a PCR Biologist and
Serologist. One Examiner stated that changes in technical operations that affect the quality of work are always passed on to staff members, but that Examiners may not pass on administrative information. However, we question whether Examiners are as consistent as this Examiner claims in conveying operational information, given the lack of a requirement that Examiners disseminate protocol-related information promptly and accurately to those under their supervision.
In addition, one Serologist added that even when decisions and other important information are communicated to staff members, the rationale behind them often is not explained, leaving staff members unclear on the goal that management is trying to achieve.98 One Examiner said that he felt that
information does not flow effectively up the hierarchy either, and identified a situation where the PCR Biologists decided to initiate a technical change in Unit procedures and failed to ensure that all the Examiners were made aware of it.
The types of communication weaknesses mentioned by staff members pose a risk to the efficiency and effectiveness of the Unit’s operations and
should be addressed. Of particular concern is the perception of Laboratory and Unit management that communication lines are functioning well, while many staff members describe a different perspective that questions whether they are being kept well informed of procedural changes and whether management properly considers technical input in operational matters.
b) Operations
During our review of protocol vulnerabilities, we 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. A LIMS allows a laboratory to:
• Reduce the incidents of human error associated with the manual entry of tracking information;
• Improve evidence handling efficiency, saving time particularly for those staff members who have numerous evidence processing and transfer responsibilities;
• Prevent the unauthorized alteration of tracking information;
• Allow management to trouble-shoot problems and to identify causes related to equipment, reagents, and personnel; and • Document who has accessed and/or contributed to the
information contained in the LIMS.
Because of these capabilities, we believe such a system would strengthen the Unit’s internal controls and allow DNAUI staff members to be more efficient in their duties. As revealed in their interview responses, Laboratory and Unit management, as well as staff members, share this assessment and believe that acquisition of a LIMS is a priority for the Laboratory. We were informed that Laboratory management began to lay the groundwork for the implementation of a LIMS in 2002. During our March 2003 fieldwork, we met with personnel involved in LIMS development at the Laboratory and reviewed available documentation concerning the progress of implementation. From this
information, we determined that the Laboratory had completed the bid process for a contractor who would design and implement the LIMS, and that all Unit Chiefs had been involved in determining the capabilities that the LIMS would need in order to suit the activities of their Unit.99 In October 2003, we were
informed that the LIMS had been procured and that the system should be on- line in December 2003 and functioning fully in the Laboratory by
approximately March 2004. The Laboratory Director told us in March 2004 that he expected the LIMS to be fully operational this fiscal year, and that the Laboratory was waiting on security clearances for the staff of the LIMS
contractor before commencing implementation of the system.
We recommend that the Laboratory’s LIMS work remain one of its top priorities. Specifically, successful implementation requires that all appropriate personnel have ready access to the system, have received adequate training, and are afforded the resources needed to convert their current methods and operations to those that will maximize the capabilities of the LIMS. Further, we recommend that Laboratory management continue to set aside sufficient
resources for the LIMS to ensure that it keeps pace with the changes and developments in technology that invariably will occur over time.
99 We also were informed by the DNAUI Unit Chief that the DNAUI is implementing a
unit-specific tracking system that will feed into the Laboratory-wide LIMS, called the Sample Tracking and Control System (STaCS). While initially STaCS has been used to track federal offender samples that are received as part of the Federal Convicted Offender Program (the federal database of convicted offender samples), management intends to expand STaCS for application to case evidence tracking.
CHAPTER SIX
OIG RECOMMENDATIONS
Jacqueline Blake’s misconduct has required the FBI Laboratory to
reassess its oversight of DNA testing in the DNAUI. The objective of this review was to identify ways to make the DNAUI less vulnerable to undetected
inadvertent or willful noncompliance with the protocols that govern DNA
analysis. Our recommendations focus on two general types of vulnerabilities: protocol vulnerabilities and practice vulnerabilities. In addition, we provide recommendations that we believe will address several of the issues of concern that we identified regarding the management response of the FBI and DOJ to Blake’s misconduct. Our recommendations are listed below.