The result is a failure to explain why the remains of Captain Luke Oyugi, one of the chopper’s two pilots, had an abnormally high level of carbon monoxide in his bloodstream.
The Commission of Inquiry into the air crash that killed former Vice-President George Saitoti and five others also extended same accusation to other Government agencies that handled forensic investigations into the deaths.
The commission said due to lack of co-ordination or consultations among the specialists, the country lost an opportunity to know what exactly killed Saitoti, Ojode, their two bodyguards and two pilots.
The bodies involved include the Government Chemist, Government Pathologist, the Kenya Police Scene of Crime unit and the Aircraft Accident Investigators.
“Due to lack of co-ordination among departments dealing with the post-mortem examinations and tests, it’s possible that crucial evidence was lost which could have helped the commission arrive at conclusive observation on the cause of death,” the report finds. “The commission inferred professional negligence in the way the post mortem and toxicological processes were handled.”
In their report on the inquiry, the commission paints a picture of glaring inadequacies in the investigations conducted by the Police, the Government Chemist and the Kenya Civil Aviation Authority. In particular, the commission expressed disappointment with the fact that evidence of carbon monoxide in Oyugi’s body was not properly investigated as a probable cause of death.
It concluded that, in absence of evidence of a fire during the flight or of an explanation for the carbon monoxide in the co-pilot’s blood, the most probable cause of the accident was “loss of aircraft control due to loss of situational awareness”. In layman’s terms, the pilots got confused while flying in mist and bad weather, and could not see where they were going, leading to the crash.
Postmortem reports presented before the commission headed by Court of Appeal Judge Kalpana Rawal indicated that the six died from traumatic injuries sustained in the crash and the fire. The post mortem process started at the scene and proceeded to the actual autopsy by Government pathologists. Samples were extracted from Prof Saitoti and the two pilots and taken to the Government Chemist for toxicological tests and analysis. The sample from Saitoti’s body and that of one of the pilots returned negative results but that of the other pilot indicated carbon monoxide poisoning of 68.6 per cent, the commission observed.
“It was argued before the Commission that such a high level of carbon monoxide poisoning, would point to inhalation of the gas before the crash, since injuries sustained at impact were incompatible with life. It was also submitted that there was a source of carbon monoxide prior to the crash, possibly from an in-flight fire and that the co-pilot with such a high dose was probably dead before the crash,” the report says. “The commission was shocked to learn that toxicological results were not taken into account in the determination of the cause of death and that it’s not common practice for the Government pathologists to do so,”
“After incisive examination of the wreckage and in absence of identification of the source of ignition, the Commission did not find any of the classic telltale signs of an in-flight fire,” it went on. Thus, the carbon monoxide in Oyugi’s body remains unexplained. The commission noted that the pathologists did not consult before they made their final conclusions on the cause of the deaths. The conditions under which they performed the exams were also an issue.
“It was depressing to hear that even simple refrigeration facilities were lacking and no samples had been preserved from which the commission could conduct its own validation tests,” the report says. “The Government departments did not appreciate the importance of autopsy investigation in general and especially for air accident investigation.”
The commission was informed that there were no enough facilities to conduct examination on the six bodies in a day. There was no gridding and mapping of the body positions at the accident site to assist the pathologists in determining the mechanisms of injuries.
“The post mortem report did not take into consideration various areas like histology (tissue exam), spinal cord and other injuries. The time taken was considered not adequate for conducting post mortem on six bodies.”
The commission observed that the presence of soot in the trachea (throat) as observed by some pathologists was not exhaustively addressed. There was no radiological examination (x-ray) done to reveal all injuries. The commission also noted that the police photographer left before completion of the autopsy.
“The upshot of this is that an opportunity was lost to conclusively and accurately determine the cause of death. Was it due to carbon monoxide, traumatic injuries, fire injuries or a combination of any of these?”
The commission recommended for establishment of a National Forensic Teaching and Research facility to train forensic professionals and sustain forensic standard commensurate with international practices.
Source: Standard Digital
