United States Government Accountability Office Report to Congressional Committees GAO December 2011 ARLINGTON NATIONAL CEMETERY Management Improvements Made, but a Strategy Is Needed to Address Remaining Challenges GAO-12-105 December 2011 ARLINGTON NATIONAL CEMETERY Management Improvements Made, but a Strategy Is Needed to Address Remaining Challenges Highlights of GAO-12-105, a report to congressional committees Why GAO Did This Study What GAO Found Arlington National Cemetery (Arlington) The Army has taken positive steps to address management deficiencies at contains the remains of more than Arlington and has implemented improvements across a range of areas. However, 330,000 military service members, GAO identified opportunities to build upon these improvements. Specifically, family members, and others. In June GAO found that ANCP: (1) has invested in information-technology improvements 2010, the Army Inspector General and has begun projects to further enhance capabilities, but is not yet basing its identified problems at the cemetery, investments on an enterprise architecture, or modernization blueprint, that could including deficiencies in management, help ensure the planned investments will meet the organization’s needs; (2) has burial errors, and a failure to notify next taken steps to improve its workforce planning, but its plans were based on an of kin of errors. In response, the incomplete understanding of ANCP’s requirements and outdated business Secretary of the Army assigned new processes that have since been revised, with the result that ANCP lacks an leadership for the cemetery and issued guidance to address deficiencies. The updated and validated workforce structure; (3) is in the initial stages of Executive Director, Army National developing a program for assessing and improving cemetery operations, but until Cemeteries Program (ANCP), is ANCP completes this program, it may be limited in its ability to evaluate and responsible for overseeing operations improve aspects of cemetery performance; and (4) has improved its coordination at Arlington. In response to Public Law with other Army organizations, but is experiencing challenges coordinating with 111-339, GAO assessed (1) the some operational partners due in part to a lack of written agreements. Finally, Army’s efforts to address identified because ANCP officials have focused on addressing the immediate crisis at management deficiencies, (2) the Arlington, they have not yet developed a strategic plan aimed at prioritizing and Army’s process for providing achieving long-term goals. Without a strategic plan, ANCP’s actions may not be information and assistance to families well coordinated and its resources may be used ineffectively. regarding efforts to detect and correct burial errors, and (3) factors affecting ANCP has a process to verify burial locations when requested to do so by a the feasibility and advisability of family. GAO collected records for 1,194 cases that ANCP concluded did not have transferring jurisdiction for the Army’s burial discrepancies and drew a generalizable sample of 60 cases to evaluate national cemeteries to the Department ANCP’s implementation of its burial verification process. GAO’s review found that of Veterans Affairs (VA). GAO ANCP implemented this process, and did not find documentation discrepancies analyzed Army guidance, records, pertaining to burial locations. GAO found documentation discrepancies for two plans, and other documentation and cases pertaining to decedents’ personal information and could not determine interviewed knowledgeable Army and from the records how these discrepancies were addressed. In cases where a VA officials, among other steps. burial error occurred, ANCP’s Executive Director or Chief of Staff contacted the What GAO Recommends affected families. ANCP’s Executive Director—in consultation with cemetery officials and affected families—made decisions on a case-by-case basis about GAO recommends that Arlington the assistance provided to each family. Confirmed errors were fixed by the implement actions relating to cemetery based on the next-of-kin’s wishes. ANCP has not developed written information-technology planning, guidance that identifies the factors ANCP’s Executive Director considers when workforce planning, assessments of assisting families in these instances. Written guidance can improve families’ and operations, and coordination; develop policymakers’ visibility into ANCP’s decision making in these circumstances. a strategic plan; and develop written guidance for assisting families. A transfer of jurisdiction for the Army’s two national cemeteries to VA is feasible, Additionally, GAO recommends that but GAO identified several factors that may affect the advisability of making this the Army and VA institutionalize a change, such as potential costs and benefits, transition challenges, and the effect mechanism for collaboration. In written on Arlington’s unique characteristics. In addition, given the improvements the comments on a draft of this report, Army has made and continues to make at Arlington, it may be premature to DOD and VA generally agreed with transfer jurisdiction for these cemeteries to VA if other changes can achieve GAO’s recommendations. similar results or improve operations. For example, GAO identified opportunities where enhanced collaboration between the Army and VA may improve View GAO-12-105. For more information, contact Brian J. Lepore at (202) 512-4523 or operations with less disruption. However, the Army and VA have not established [email protected]. a formal mechanism for collaborating and therefore could miss opportunities to improve the efficiency and effectiveness of cemetery operations. United States Government Accountability Office Contents Letter 1 Background 5 Army Has Taken Positive Steps to Address Deficiencies at Arlington and Would Benefit from Implementing Additional Actions and a Strategic Plan 6 ANCP Has Processes to Provide Information and Assistance to Families Regarding Efforts to Detect and Correct Burial Errors 20 Several Factors May Affect the Advisability of Transferring Jurisdiction for the Army’s National Cemeteries to VA 25 Conclusions 35 Recommendations for Executive Action 35 Agency Comments and Our Evaluation 37 Appendix I Scope and Methodology 42 Appendix II Arlington National Cemetery’s Procedures to Ensure Chain-of-Custody for Remains 45 Appendix III Army Gravesite Accountability Process 48 Appendix IV Supplemental Figures and Tables 53 Appendix V Comments from the Department of Defense 60 Appendix VI Comments from the Department of Veterans Affairs 65 Appendix VII GAO Contact and Staff Acknowledgments 67 Page i GAO-12-105 Arlington National Cemetery Tables Table 1: Missing Records or Discrepancies in ANCP Burial Verification Documentation That Were Not Noted in Its Case Files 22 Table 2: Army and VA Mission and Vision Statements 30 Table 3: Chain-of-Custody for Casketed Remains 53 Table 4: Chain-of-Custody for Cremated Remains 55 Figures Figure 1: Columbarium Complex at Arlington 19 Figure 2: Military Honor Guard with Caisson 31 Figure 3: Chain-of-Custody Procedures for Casketed Remains 46 Figure 4: Chain-of-Custody Procedures for Cremated Remains 47 Figure 5: Business Process for Gravesite Accountability Process Tier 1 Assessment 50 Figure 6: Business Process for Gravesite Accountability Process Tier 2 and 3 Assessment 51 Figure 7: Gravesite Accountability Task Force Quality Assurance Process 52 Figure 8: Business Process for Gravesite Accountability Process Tier 1 Assessment 57 Figure 9: Business Process for Gravesite Accountability Process Tier 2 and 3 Assessment 58 Figure 10: Business Process for Gravesite Accountability Quality Assurance 59 Page ii GAO-12-105 Arlington National Cemetery Abbreviations ANCP Army National Cemeteries Program Arlington Arlington National Cemetery Army IG Army Inspector General DOD Department of Defense VA Department of Veterans Affairs This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page iii GAO-12-105 Arlington National Cemetery United States Government Accountability Office Washington, DC 20548 December 15, 2011 Congressional Committees The Army’s management of Arlington National Cemetery (Arlington) has come under scrutiny following the discovery of burial errors and the identification of serious management deficiencies affecting cemetery operations. Established during the Civil War, Arlington contains the remains of more than 330,000 military service members, family members, and other individuals, including two U.S. Presidents. Arlington conducts an average of 27 funerals each day, hosts hundreds of ceremonies throughout the year, and has approximately 4 million visitors annually. In July 2009, a news website began publishing a series of articles claiming that Arlington was being mismanaged and that human remains had been improperly buried. On July 23, 2009, the Army began to investigate these reports, and in August 2009 the Secretary of the Army directed the Army Inspector General (Army IG) to review the cemetery’s management and operations. The Army IG’s review was subsequently broadened in November 2009 to address the Secretary of the Army’s concerns