SHERIFFDOM OF SOUTH STRATHCLYDE, DUMFRIES And GALLOWAY DETERMINATION by SHERIFF PRINCIPAL JOHN S MOWAT QC in the FATAL ACCIDENT INQUIRY relating to the LOCKERBIE AIR DISASTER held at Easterbrook Hall Crichton Royal Hospital DUMFRI ES 1 October 1990 to 13 February 1991 DETERMINATION by JOHN STUART MOWAT, Esquire Queen’s Counsel Sheriff Principal of South Strathclyde Dumfries and Galloway under Section 6 of THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976 The Sheriff Principal Determines: (1) that ELISABETH NICOLE MARIE AVOYNE, born on 5 May 1944, and residing at 2 Avenue Francois Patrocle, 78290 Croissy Sur Seine, France JERRY DON AVRITT, born on 30 July 1942, and residing at 14031 Bexley Street, Westminster, California 92683, USA NOELLE LYDIE BERTI, born on 24 December 1947, and residing at 1 Rue D’Armenomville, Paris, France 754017 SIV ULLA ENGSTROM, born on 21 September 1937, and residing at 6 Rays Avenue, Windsor, Berkshire STACIE DENISE FRANKLIN, born on 16 February 1968 and residing at 1366 Thomas Avenue, San Diego, California 92109, USA PAUL ISAAC GARRETT, born on 16 November 1947, and residing at 482 Cross Street, Napa, California 94559, USA ELKE ETHA KUHNE, born on 17 March 1945, and residing at Langensalza Strasse 20, 3 Hanover, West Germany MARIA NIEVES LARRACOECHEA, born on 3 March 1949, and residing at Castello 83, Madrid 28006, Spain JAMES BRUCE MacQUARRIE, born on 30 September 1933, and residing at 32 North Road, Kensington, New Hampshire, 03833, USA LILIBETH TOBILA MACALOLOOY, born on 2 November 1961 and residing at Morfelder Strasse 97, 6092 Kelsterbach, West Germany MARY GERALDINE MURPHY, born on 14 May 1937, and residing at 1 Cranebrook Manor Road, Twickenham, Middlesex JOCELYN REINA, born on 26 May 1962, and residing at 732 Great Western Road, Isleworth, Middlesex MYRA JOSEPHINE ROYAL, born on 20 December 1958 and residing at 30 Clitherow Avenue, Hanwell, London IRJA SYHNOVE SKABO, born on 3 July 1950 and residing at Ankerveien 17-0390, Oslo, Norway MILUTIN VELIMIROVICH, born on 14 October 1953, and residing at 33 Dorset Way, Heston, Hounslow, Middlesex RAYMOND RONALD WAGNER, born on 18 January 1936, and residing at 165 Pennington-Harbourton Road, Pennington, New Jersey 08534, USA. died from multiple injuries at about 1905 hours on Wednesday 21 December 1988 at or near Lockerbie, Dumfriesshire in the course of their employment with Pan American World Airways 2 as members of the flight crew of Pan American World Airways Flight 103 on Boeing 747-121 Registration N739PA en route from London Heathrow Airport to John F Kennedy Airport, New York. (2) That JOHN MICHAEL GERARD AHERN, born on 16 April 1962, and residing at 127 Sherman Avenue, Rockville Centre, New York 11570, USA SARAH MARGARET AICHER, born on 9 February 1959, and residing at 30E Stanhope Gardens, London JOHN DAVID AKERSTROM, born on 20 May 1954, and residing at 6822 Ryan Road, Medina, Ohio 44256, USA RONALD ELY ALEXANDER, born on 15 July 1942, and residing at 425 East 58th Street, New York, New York 10022, USA THOMAS JOSEPH AMMERMAN, born on 6 August 1952, and residing at 2 Forrest Avenue, Old Tappan, New Jersey 07676, USA MARTIN LEWIS APFELBAUM, born on 16 August 1929, and residing at 2505 18th Street, Philadelphia, Pennsylvania 19103, USA RACHEL MARIE ASRELSKY, born on 26 November 1967, and residing at 605 Water Street, New York, New York 10002, USA JUDITH ELLEN BERNSTEIN or ATKINSON, born on 18 January 1951, and residing at Flat 3, 32 Cranley Gardens, South Kensington, London WILLIAM GARRETSON ATKINSON III, born on 18 August 1955, and residing at Flat 3, 32 Cranley Gardens, South Kensington, London CLARE LOUISE BACCIOCHI, born on 15 March 1969, and residing at 21 Hillside, Kingsbury, Tamworth, Warwickshire HARRY MICHAEL BAINBRIDGE, born on 16 November 1954 and residing at 9 Marisa Court, Montrose, New York 10548, USA STUART MURRAY BARCLAY, born on 28 November 1959, and residing at Honey Hill Farm, Barnard, Vermont 05031, USA JEAN MARY CRISPIN or BELL, born on 16 March 1944, and residing at The Silver Suite, Mellor House, Charles Street, Windsor, Berkshire JULIAN MacBAIN BENELLO, born on 28 December 1962, and residing at 143 Longwood Avenue, Apartment 4, Brookline, Massachusetts 02146, USA LAWRENCE RAY BENNETT, born on 5 November 1947 and residing at 2828 McKinley Street, Chelsea, Michigan 48118, USA PHILIP VERNON BERGSTROM, born on 21 December 1966, and residing at 400 South Lake Street, Apartment 9, CMA Forest Lake, Minnesota 55025, USA ALISTAIR DAVID BERKLEY, born on 11 April 1959, and residing at 30 Sutton Square, London MICHAEL STUART BERNSTEIN, born on 3 July 1952, and residing at 6012 Cairn Terrace, Bethesda, Maryland 20817, USA STEVEN RUSSELL BERRELL, born on 19 June 1968, and residing at 1216 South Ninth Street, Fargo, North Dakota 58103, USA SURINDER MOHAN BHATIA, born on 21 May 1937, and residing at 810 Camino Real Road, 202 Redondo Beach, Los Angeles, California 90277, USA KENNETH JOHN BISSETT, born on 19 December 1967, and residing at 120 East Hartsdale Avenue, Apartment 1K, Hartsdale, New York 10530, USA DIANE ANN BOATMAN-FULLER, born on 8 January 1953, and residing at 58 Swinburn Court, Blanchedowne Road, Denmark Hill, London STEPHEN JOHN BOLAND, born on 28 September 1968, and residing at 4 Century Road, Nashua, New Hampshire 03060, USA GLENN JOHN BOUCKLEY, born on 24 February 1961, and residing at 7300 Cedarpost Road, Apartment Cl, Liverpool, New York 13088, USA PAULA MARIE ALDERMAN or BOUCKLEY, born on 14 October 1959 and residing at 7300 Cedarpost Road, Apartment Cl, Liverpool, New York 13088, USA NICOLE ELISE BOULANGER, born on 28 October 1967, and residing at 46 Worthington Avenue, Shrewsbury, Massachusetts 01545, USA FRANCIS BOYER, born on 22 June 1945, and residing at 4 Place De L’Eperon, Lotissement, Auzeville, Toulosane 31320, France NICHOLAS BRIGHT, born on 29 August 1956, and residing at 7 Beals Street, Brookline, Massachusetts 02146, USA DANIEL SOLOMON BROWNER, (BEER), born on 20 August 1965 and residing at Kibbutz, Parod, Northern Israel COLLEEN RENEE BRUNNER, born on 4 January 1968 and residing at 7164 Parkside Drive, Hamburg, New York 14075, USA TIMOTHY GUY BURMAN, born on 9 October 1964, and residing at 49A Hotham Road, London MICHAEL WARREN BUSER, born on 10 August 1954, and residing at 99 Teaneck Road, Ridgefield Park, New Jersey 07660, USA WARREN MAX BUSER, born on 22 September 1926, and residing at 169 Hillman Avenue, Glenrock, New Jersey 07452, USA STEVEN LEE BUTLER, born on 30 August 1953, and residing at 1141 South Clarkson Street, Denver, Colorado 80210, USA WILLIAM MARTIN CADMAN, born on 10 September 1956, and residing at 13 Surrendale Place, London FABIANA BENVENUTO or CAFFARONE, born on 30 September 1960, and residing at 21 Donne Place, London HERMAN LUIS CAFFARONE, born on 14 December 1960, and residing at 21 Donne Place, London VALERIE CANADY, born on 29 June 1963, and residing at 127 Jackson Avenue, South Park, Morgantown, West Virginia 3 26505-6567, USA GREGORY JOSEPH CAPASSO, born on 12 December 1967, and residing at 1841 East 33rd Street, Brooklyn, New York 11234, USA TIMOTHY MICHAEL CARDWELL, born on 5 July 1967, and residing at RD1, Box 203, Cresco, Pennsylvania 18326, USA BERNT WILMAR CARLSSON, born on 21 November 1938 and residing at Apartment 30, 207 West 106th Street, New York, New York 10025, USA RICHARD ANTHONY CAWLEY, born on 9 July 1945, and residing at 241 Central Park West, New York, New York 10024, USA FRANK CIULLA, born on 6 August 1943, and residing at 29 Clifford Drive, Parkridge, New Jersey 97656, USA THEODORA EUGENIA COHEN, born on 10 September 1968, and residing at 67 Wisconsin, Long Island, New York 11561,USA ERIC MICHAEL COKER, born on 23 April 1968, and residing at 137 Hilltop Road, Mendham, New Jersey 07945, USA JASON MICHAEL COKER, born on 23 April 1968, and residing at 137 Hilltop Road, Mendham, New Jersey 07945, USA GARY LEONARD COLASANTI, born on 1 August 1968, and residing at 60 Garfield Road, Melrose, Massachusetts 02176, USA BRIDGET MULROY or CONCANNON, born on 13 July 1935, and residing at 20 Nuffield Drive, Banbury, Oxfordshire SEAN CONCANNON, born on 18 February 1972, and residing at 20 Nuffield Drive, Banbury, Oxfordshire THOMAS CONCANNON, born on 21 November 1937, and residing at 20 Nuffield Drive, Banbury, Oxfordshire TRACEY JANE CORNER, born on 4 May 1971, and residing at 12 Springfield Avenue, Millhouses, Sheffield SCOTT MARSH CORY, born on 27 September 1968, and residing at 25 Chadwick Drive, Old Lyme Court, Connecticut 06371, USA WILLIS LARRY COURSEY, born on 25 August 1948, and residing at 307 Cresham Drive, San Antonio, Texas 78218, USA PATRICIA MARY COYLE, born on 4 June 1968, and residing at 62 Seiter Hill Road, Wallingford, Connecticut 06492, USA JOHN BINNING CUMMOCK, born on 31 May 1950, and residing at 271 Vistalmar Street, Coral Gables, Florida 33143, USA JOSEPH PATRICK CURRY, born on 21 March 1957, and residing at 885B Beach Street, Fort Devens, Massachusetts 01433, USA WILLIAM ALAN DANIELS, born on 28 March 1948, and residing at 20 Sweet Briar Court, Belle Mead, New Jersey 08502, USA GRETCHEN JOYCE DATER, born on 17 May 1968, and residing at 27 Mohawk Drive, Ramsey, New Jersey 07446, USA SHANNON DAVIS, born on 19 February 1969, and residing at 32 Isinglass Road, Shelton, Connecticut 06484, USA GABRIELE DELLA-RIPA, born on 3 April 1942, and residing at 406 Plainfield Avenue, Floral Park, New York 11001, USA OM DIKSHIT, born on 29 December 1933, and residing at 2955 Wylie Drive, Fairborn, Ohio 45324, USA JOYCE CHRISTINE DIMAURO, born on 9 May 1956, and residing at 352 East 18th Street, New York, New York 10003, USA GIANFRANCA DINARDO, born on 14 October 1962, and residing at Flat 4, 24 Cranley Gardens, South Kensington, London PETER THOMAS STANLEY DIX, born on 6 May 1953, and residing at 52 Coborn Road, Bow, London SHANTI DEVI or DIXIT, born on 14 December 1934, and residing at 2955 Wylie Drive, Fairborn, Ohio 45324, USA DAVID SCOTT DORNSTEIN, born on 3 April 1963, and residing at 7703 Seminole Avenue, Philadelphia, Pennsylvania 19126, USA MICHAEL JOSEPH DOYLE, born on 21 May 1958, and residing at 17 Arcadia Drive, Voorhees, New Jersey 08043, USA EDGAR HOWARD EGGLESTON III, born on 13 October 1964, and residing at RD4, Box 296A, Glen Falls, New York 12801, USA TURHAN ERGIN, born on 14 May 1966, and residing at 97 Cliffmore Road, West Hartford, Connecticut 06105, USA CHARLES THOMAS FISHER IV, born on 24 December 1953, and residing at 19 Beaufort Gardens, Flat 4, Chelsea, London CLAYTON LEE FLICK, born on 23 February 1963, and residing at 68 Rugby Road, Binley Woods, Coventry JOHN PATRICK FLYNN, born on 24 November 1967, and residing at 10 West Lake Drive, Montville, New Jersey 07045, USA ARTHUR JAY FONDILER, born on 12 December 1955, and residing at 9 Seymour Place, West Armonk, New York 10504, USA ROBERT GERARD FORTUNE, born on 24 July 1948, and residing at 34-05 80th Street, Jackson Heights, New York 11372, USA PAUL MATTHEW STEPHEN FREEMAN, born on 2 April 1963, and residing at 19 Manor Mansions, Belsize Grove, London JAMES RALPH FULLER, born on 17 September 1938, and residing at 351 Lonepine Court, Bloomf ield Hills, Michigan 48013, USA IBOLYA ROBERTNE DRUCKER or GABOR, born on 14 June 1909 and residing at Wesselenyi 6, Budapest, Hungary AMY BETH GALLAGHER, born on 30 August 1966, and residing at 246 Vista, Pointe Claire, Quebec, Canada 3 MATTHEW KEVIN GANNON, born on 11 August 1954, and residing at 611 North Ardmore, Los Angeles, California 90004, USA KENNETH RAYMOND GARCZYNSKI, born on 17 October 1951, and residing at 1673 Hudson Avenue, North Brunswick, New Jersey 08902, USA KENNETH JAMES GIBSON, born on 16 February 1968, and residing at 6/502 Infantry Army Post Office, New York, New York 09742, USA WILLIAM DAVID GIEBLER, born on 8 July 1959, and residing at 52 Radcliffe Square, London ANDREW CHRISTOPHER GILLIES-WRIGHT, born on 2 May 1964, and residing at 5 Esher Mews, Mitcham, Surrey OLIVE LEONORA GORDON, born on 9 March 1963, and residing at 182 William Bonney Estate, London LINDA SUSAN GORDON-GORGACZ, born on 15 September 1949, and residing at 5 Devere Gardens, Kensington, London ANNE MADELENE CHABACK or GORGACZ, born on 27 September 1912 and residing at 5 East Wallace Avenue, Apartment 201, Newcastle, Pennsylvania 16101, USA LORETTA ANNE GORGACZ, born on 15 March 1941, and residing at 5 East Wallace Avenue, Apartment 201, Newcastle, Pennsylvania 16101, USA DAVID JAY GOULD, born on 3 January 1943, and residing at 5883 Bartlett Street, Pittsburg, Pennsylvania 15217, USA ANDRE NIKOLAI GUEVORGIAN, born on 11 November 1956, and residing at 8 Carrpenter Place, Sea Cliff, Long Island, New York 11579, USA NICOLA JANE HALL, born on 3 February 1965, and residing at 34 Second Avenue, Illovo, Sandton 2196, South Africa LORRAINE FRANCES BUSER or HALSCH, born on 6 November 1957, and residing at 24 Camborne Circle, Fairport, New York 14450, USA LYNNE CAROL HARTUNIAN, born on 13 March 1967, and residing at 5 Tamarack Lane, Schenectady, New York 12309, USA ANTHONY LACEY HAWKINS, born on 13 November 1931, and residing at 805 East 21st Street, Brooklyn, New York 11210, USA PAMELA ELAINE HERBERT, born on 27 March 1969, and residing at 378 Parkway Drive, Battle Creek, Michigan 49017, USA RODNEY PETER HILBERT, born on 19 July 1948, and residing at 117 South Congress Street, Newtown, Pennsylvania 18940, USA ALFRED HILL, born on 29 June 1959, and residing at Heimenhofenstrasse 3, 8972 Sonthofen, West Germany KATHERINE AUGUSTA HOLLISTER, born on 26 August 1968, and residing at 64-11 99th Street, Apartment 604, Rego Park, New York 11374, USA JOSEPHINE LISA HUDSON, born on 14 May 1966, and residing at Flat 4, Arton Wilson House, North Wing, Roehampton Lane, London MELINA KRISTINA HUDSON, born on 25 January 1972, and residing at 124 Lancaster Street, Albany, New York 12210, USA SOPHIE AILETTE MIRIAM HUDSON, born on 22 September 1962, and residing at 14 Rue Therese, Paris 75001, France KAREN LEE HUNT, born on 7 January 1968, and residing at 477 Maplewoods Lane, Webster, New York 14580, USA ROGER ELWOOD HURST, born on 12 July 1950 and residing at 43 Lake Riconda Drive, Ringwood, New Jersey 07456, USA ELIZABETH SOPHIE IVELL, born on 21 April 1969, and residing at 24 High Street, Roberts Bridge, East Sussex KHALED NAZIR JAAFAR, born on 1 May 1968, and residing at 6519 Manor Street, Dearborn, Michigan 48126, USA ROBERT VAN HOUTEN JECK, born on 8 October 1931, and residing at 145 Lake Drive, Montain Lakes, New Jersey 07046, USA PAUL AVRON JEFFREYS, born on 13 February 1952, and residing at 8 Orchard Cottages, Clifton Road, Kingston-Upon-Thames, Surrey RACHEL MARY ELIZABETH JONES or JEFFREYS born on 29 April 1965, and residing at 8 Orchard Cottages, Clifton Road, Kingston-Upon-Thames, Surrey KATHLEEN MARY JERMYN, born on 27 December 1967, and residing at 35 Sheridan Place, Staten Island, New York 10312, USA BETH ANN JOHNSON, born on 24 March 1967, and residing at 226 Wren Drive, Greensburg, Pennsylvania 15601, USA MARY LINCOLN JOHNSON, born on 14 June 1963, and residing at 18 Adams Lane, Wayland, Massachusetts 01778, USA TIMOTHY BARON JOHNSON, born on 30 November 1967, and residing at 2024 West Lake Avenue, Neptune Township, New Jersey 07753, USA CHRISTOPHER ANDREW JONES, born on 4 March 1968, and residing at Courts Lane, Claverack, New York 12513, USA JULIANNE FRANCES KELLY, born on 27 June 1968, and residing at 31 Massachusetts Avenue, Dedham, Massachusetts 02026, USA JAY JOSEPH KINGHAM, born on 3 March 1944, and residing at 10821 Stanmore Drive, Potomac, Maryland 20854, USA PATRICIA ANN KLEIN, born on 16 June 1953, and residing at 1108 Hamilton Avenue, Trenton, New Jersey 08629, USA GREGORY KOSMOWSKI, born on 8 October 1948, and residing at 3253 Tipisco Lake Road, Milford, Michigan 48042, USA MINAS CHRISTOPHER KULUKUNDIS, born on 17 December 1950, and residing at 6 Shalcomb Street, London RONALD ALBERT LARIVIERE, born on 19 November 1955, and residing at 200 North Pickett Street, Apartment 903, Alexandria, Virginia 22304, USA ROBERT MILTON LECKBURG, born on 12 October 1958, and residing at 601 Plainfield Avenue, Piscatawa, New Jersey 08854, USA WILLIAM CHASE LEYRER, born on 24 August 1942, and residing at 52 Maple Avenue, Bayshore, New York 11706, USA WENDY ANNE LINCOLN, born on 21 January 1965, and residing at 294 Notch Road, North Adams, Massachusetts 01247, USA ALEXANDER LOWENSTEIN, born on 25 February 1967, and residing at 24 Old Orchard Road, Mendham Township, Morristown, New Jersey 07960, USA LLOYD DAVID LUDLOW, born on 6 February 1947, and residing at Headquarters HQ Company, 4th Brigade, Army Post Office, New York, New York 09185, USA MARIA THERESIA LURBKE, born on 26 November 1963, and residing at Arnsberger Strasse 47, 5983Balve-Beckum, West Germany WILLIAM JOHN McALLISTER, born on 18 October 1962, and residing at 124 Peregrine Road, Sunbury on Thames, Middlesex DANIEL EMMET McCARTHY, born on 2 November 1957, and residing at 127 92nd Street, Brooklyn, New York 11209, USA ROBERT EUGENE McCOLLUM, born on 12 May 1927, and residing at 1248 Thomas Road, Wayne, Pennsylvania 19087, USA CHARLES DENNIS McKEE, born on 3 December 1948, and residing at HOS USA Intelligence Section Command, Arlington Hall Station, Virginia 22212, USA BERNARD JOSEPH McLAUGHLIN, born on 2 December 1958, and residing at 108 Norwood Avenue, Cranston, Rhode Island 02905, USA WILLIAM EDWARD MACK, born on 24 April 1958, and residing at 202 East 92nd Street, New York, New York 10128, USA DOUGLAS EUGENE MALICOTE, born on 31 August 1966, and residing at 97th Signal Battalion, Army Post Office, New York, New York 02028, USA WENDY GAY FORSYTH or MALICOTE, born on 31 July 1967, and residing at 97th Signal Platoon, US Army Base, Mannheim, West Germany ELIZABETH LILLIAN MAREK, born on 17 February 1958, and residing at 202 West 92nd Street, New York, New York 10025, USA LOUIS ANTHONY MARENGO, born on 9 February 1955, and residing at 1579 Stoney Creek Drive, Rochester, Michigan 48063, USA NOEL GEORGE MARTIN, also known as Joseph Emmanuel Barzey, born on 31 May 1961, and residing at 1 Ashdon House, North Old Road, Clapton, Gloucestershire DIANE MARIE MASLOWSKI, born on 10 August 1958, and residing at 130 Prospect Road, Haddonfield, New Jersey 08033, USA JANE SUSAN MELBER, born on 1 January 1961, and residing at 17 Melrose Gardens, Burnt Oak, Middlesex JOHN MERRILL, born on 11 July 1953, and residing at 1 Heath Hall, High Street, Baldock, Hertfordshire SUZANNE MARIE MIAZGA, born on 31 July 1966, and residing at RDl, Box 221, Benton Road, Marcy, New York 13403, USA JOSEPH KENNETH MILLER, born on 27 May 1932, and residing at 381 Westwood Road, Woodmere, New York 11598, USA JEWEL COURTNEY MITCHELL, born on 14 June 1956, and residing at 1154 Union Street, Brooklyn, New York 11225, USA RICHARD PAUL MONETTI, born on 11 September 1968, and residing at 1615 Longfellow Drive, Cherry Hill, New Jersey 08003, USA JANE ANN MORGAN, born on 19 March 1951, and residing at Flat 1, 10 Brompton Square, London EVA INGEBORG FUCHS or MORSON, born on 29 April 1940, and residing at 185 East 85th Street, New York, New York 10028, USA HELGA RACHAEL MOSEY, born on 21 September 1969, and residing at 42 Titford Road, Oldbury, Warley, West Midlands INGRID ELISABETH SVENSSON or MULROY, born on 22 April 1963, and residing at Kamnarsvagen 9L126, 22246 Lund, Sweden JOHN MULROY, born on 1 April 1929, and residing at 35 Cherrywood Drive, East North Port, New York 11731, USA SEAN KEVIN MULROY, born on 3 May 1963, and residing at Kamnarsvagen, 9L126, 22246 Lund, Sweden KAREN ELIZABETH NOONAN, born on 26 December 1967, and residing at 11901 Glenmill Road, Potomac, Maryland 20854, USA DANIEL EMMETT O’CONNOR, born on 22 September 1957, and residing at 17 Lawley Street, Dorchester, Massachusetts 02122, USA MARY DENICE O’NEILL, born on 2 April 1967, and residing at 1675 Metropolitan Avenue, Bronx, New York 10462, USA ANNE LINDSEY OTENASEK, born on 13 January 1967, and residing at 110 Tunbridge Road, Baltimore, Maryland 21212, USA BRYONY ELISE OWEN, born on 29 April 1987, and residing at 59 Chelsea Park, Easton, Bristol GWYNETH YVONNE MARGARET OWEN, born on 3 May 1959, and residing at 59 Chelsea Park, Easton, Bristol LAURA ABIGAIL OWENS, born on 8 January 1980, and residing at 101 Rockingham Road, Cherry Hill, New Jersey 08034, USA MARTHA IVES or OWENS, born on 2 June 1944, and residing at 101 Rockingham Road, Cherry Hill, New Jersey 08034, USA ROBERT PLACK OWENS, born on 5 March 1943, and residing at 101Rockingham Road, Cherry Hill, New Jersey 08034, USA SARAH REBECCA OWENS, born on 9 December 1974, and residing at 101 Rockingham Road, Cherry Hill, New Jersey 08034, USA ROBERT ITALO PAGNUCCO, born on 20 October 1937, and residing at Oscaleta Road, South Salem, New York 10590, USA CHRISTOS MICHAEL PAPADOPOULOS, born on 11 November 1943, and residing at 217 Harborview, North Lawrence, New York 12938, USA PETER RAYMOND PEIRCE, born on 28 September 1948, and residing at 860 East Boundry Street, Perrysburg, Ohio 43551, USA 4 MICHAEL COSIMO PESCATORE, born on 6 September 1955, and residing at 5482 Banbery Drive, Medina, Solon, Ohio 44139, USA SARAH SUSANNAN BUCHANAN PHILIPPS, born on 15 August 1968, and residing at 78 Hull Street, Newtonville, Massachusetts 02160, USA FREDERICK SANDFORD PHILLIPS, born on 8 May 1961, and residing at 12 Van Lee Drive, Little Rock, Arkansas 72205, USA JAMES ANDREW CAMPBELL PITT, born on 6 November 1964, and residing at 96 College Street, South Hadley, Massachusetts 01075, USA DAVID PLATT, born on 13 December 1955, and residing at 76 Belfast Avenue, Staten Island, New York 10306, USA WALTER LEONARD PORTER, born on 10 March 1953, and residing at 85, Remsen Avenue, Brooklyn, New York 11212, USA PAMELA LYNN POSEN, born on 30 January 1968, and residing at 88 Haviland Road, Harrison, New York 10528, USA WILLIAM PUGH, born on 29 February 1932, and residing at 103 South Claremont Avenue, Margate City, New Jersey 08402, USA CRISOSTOMO ESTRELLA QUIGUYAN, born on 16March 1945, and residing at 37 Park View, Monks Park, Wembley, London RAJESH TARSIS PRISKEL RAMSES, born on 26 May 1953, and residing at 10 Eastfield Court, Eastile Road, Leicester ANMOL RATTAN, born on 24 September 1986, and residing at 24301 Panama, Warren, Michigan 48091, USA GARIMA DIXIT or RATTAN, born on 15 July 1959, and residing at 24301 Panama, Warren, Michigan 48091, USA SURUCHI RATTAN, born on 20 June 1985, and residing at 24301 Panama, Warren, Michigan 48091, USA ANITA LYNN REEVES, born on 3 September 1964, and residing at 801 Fairlawn Avenue, Apartment 4, Laurel, Maryland 20707, USA MARK ALAN REIN, born on 12 February 1944, and residing at 220 East 63rd Street, New York, New York 10021, USA DIANE MARIE RENCEVICZ, born on 13 July 1967, and residing at 325 West Union Street, Burlington, New Jersey 08016, USA LOUISE ANN ROGERS, born on 13 February 1967, and residing at 3508 Sundown Farms Way, Olney, Maryland 20832, USA EDINA ROLLER, born on 24 November 1983, and residing at Vac, Koto Utca 7, H-2600, Hungary JANOS GABOR ROLLER, born on 26 March 1959, and residing at Vac, Koto Utca 7, H-2600, Hungary ZSUZSANNA PISAK or ROLLER, born on 21 December 1961, and residing at Vac, Koto Utca 7, H-2600, Hungary HANNE MARIA MAIJALA or ROOT, born on 15 December 1962, and residing at 20 West 72nd Street, Apartment 609, New York, New York 10023, USA SAUL MARK ROSEN, born on 24 November 1953, and residing at 116 Burnham Road, Morris Plains, New Jersey 07950, USA ANDREA VICTORIA ROSENTHAL, born on 5 February 1966, and residing at 784 Park Avenue, New York, New York 10021, USA DANIEL PETER ROSENTHAL, born on 2 June 1968, and residing at 36 Hamilton Avenue, Staten Island, New York 10301, USA ARNAUD DAVID RUBIN, born on 18 May 1960, and residing at 68 Avenue Des Croix Du Feu, Waterloo 1410, Belgium ELYSE JEANNE SARACENI, born on 1 June 1968, and residing at Mews Room 17, 1 Park Crescent Mews East, London SCOTT CHRISTOPHER SAUNDERS, born on 20 May 1967, and residing at 2996 Macungie Road, Macungie, Pennsylvania 18062, USA; TERESA ELIZABETH JANE WILSON or SAUNDERS, born on 24 October 1960, and residing at 124 Peregrine Road, Sunbury on Thames, Middlesex JOHANNES OTTO SCHAEUBLE, born on 8 August 1947, and residing at Kappellenweg 6, 7407 Rottenburg, Wurmlingen, West Germany ROBERT THOMAS SCHLAGETER, born on August 1968, and residing at 814 West Shore Road, Warwick, Rhode Island 02889, USA THOMAS BRITTON SCHULTZ, born on 5 January 1968, and residing at 142 Wilton Road, Ridgefield, Connecticut 06877, USA SALLY ELIZABETH SCOTT, born on 17 January 1966, and residing at 4 Woodvale Lane, Hungtingston, New York 11743, USA AMY ELIZABETH SHAPIRO, born on 28 October 1967, and residing at 77 Brook Run Lane, Stamford, Connecticut 06905, USA MRIDULA SHASTRI, born on 12 February 1964, and residing at Room 1, St Johns College, 11 St Johns Street, Oxford JOAN LICHTENSTEIN or SHEANSHANG, born on 16 December 1942, and residing at 4 East 89th Street, New York, New York 10128, USA IRVING STANLEY SIGAL, born on 23 May 1953, and residing at 120 East Delaware Avenue, Pennington, New Jersey 08574, USA MARTIN BERNARD CARRUTHERS SIMPSON, born on 25 October 1936, and residing at 249 Garfield Place, Brooklyn, New York 11215, USA CYNTHIA JOAN SMITH, born on 6 October 1967, and residing at 340 Brook Road, Milton, Massachusetts 02186, USA INGRID ANITA LEADGARD or SMITH, born on 12 November 1957, and residing at Malthouse Cottage, Church Lane, Bray, Berkshire JAMES ALVIN SMITH, bornon 11 March 1933, and residing at 139 East 35th Street, New York, New York 10016, USA MARY EDNA HALL or SMITH, born on 14 July 1954, and residing at 97th Signal Battalion, Army Post Office, New York, New York 09028, USA GERALDINE ANNE O’GARA or STEVENSON, born on 31 March 1951, and residing at 44 Manor Road, South Hinchley Wood, Esher, Surrey HANNAH LOUISE STEVENSON, born on 23 September 1978, and residing at 44 Manor Road, South Hinchley Wood, Esher, Surrey JOHN CHARLES STEVENSON, born on13 September 1950, and residing at 44 Manor Road, South Hinchley Wood, Esher, Surrey RACHAEL STEVENSON, born on 1 September 1980, and residing at 44 Manor Road, South Hinchley Wood, Esher, Surrey CHARLOTTE ANN McGUIRE or STINNETT, born on 7 February 1952, and residing at 1526 Lime Leaf Lane, Duncanville, Texas 75137, USA MICHAEL GARY STINNETT, born on 27 May 1962, and residing at 1526 Lime Leaf Lane, Duncanville, Texas 75137, USA STACEY LEANNE STINNETT, born on 30 July 1979, and residing at 1526 Lime Leaf Lane, Duncanville, Texas 75137, USA JAMES RALPH STOW, born on 18 July 1939, and residing at 205 East 95th Street, Apartment 31D, New York, New York 10128, USA ELlA G STRATIS, born on 17 June 1945, and residing at 57 Longridge Road, Montvale, New Jersey 07645, USA ANTHONY SELWYN SWAN, born on 15 May 1959, and residing at 41 Halsey Street, Brooklyn, New York 11216, USA FLORA MacDONALD MARGARET SWIRE, born on 22 December 1964, and residing at William Goodenough House, Mecklenburgh Square, Bloomsbury, London MARC ALEX TAGER, born on 3 August 1966, and residing at 3 Cedars Close, Hendon, London HIDEKAZU TANAKA, born on 13 May 1962, and residing at Flat 6, 110 Gloucester Terrace, London ANDREW ALEXANDER TERAN, born on 31 August 1968, and residing at Pearson College, Yale University, New Haven, Connecticut 06520, USA ARVA ANTHONY THOMAS, born on 26 April 1971, and residing at 14075 Marlowe, Detroit, Michigan 48227, USA JONATHAN RYAN THOMAS, born on 29 September 1988, and residing at 15838 Harden Circle, Southf ield, Michigan 48075, USA LAWANDA COLEMAN or THOMAS, born on 17 February 1967, and residing at 15838 Harden Circle, Southfield, Michigan 48075, USA MARK LAWRENCE TOBIN, born on 4 April 1967, and residing at 36 St Paul’s Road, North Hempstead, New York 11550, USA DAVID WILLIAM TRIMMER-SMITH, born on 26 April 1937, and residing at 222 East 56th Street, Apartment SA, New York, New York 10022, USA ALEXIA KATHRYN TSAIRIS, born on 6 July 1968, and residing at 379 Vance Avenue, Franklyn Lakes, New Jersey 07417, USA BARRY JOSEPH VALENTINO, born on 25 February 1960, and residing at 119 Haight Street, Apartment 16, San Francisco, California 94102, USA TOMAS FLORO VAN TIENHOVEN, born on 30 May 1943, and residing at Jose C Paz, 738 Accassuso, Buenos Aires, Argentina and also at 11 Argylle Road, London ASAAD EIDI VEJDANY, born on 24 February 1942, and residing at 32 Somerset Drive South, Great Neck, New York 11020, USA NICHOLAS ANDREAS VRENIOS, born on 20 August 1968, and residing at 6628 32nd Street, NW Washington DC 20015, USA PETER VULCU, born on 1 August 1967, and residing at 1541 Overlook, Alliance, Ohio 44601, USA JANINA JOZEFA RUSNIAK or MITKA or WAlDO, born on 19 March 1927, and residing at 2257 North Lavergne Avenue, Chicago, Illinois 60639, USA THOMAS EDWIN WALKER, born on 11 December 1941, and residing at 192 Taylor Street, Wallaston, Quincy, Massachusetts 02170, USA KESHA WEEDON, born on 2 October 1968, and residing at 2525 Aqueduct Avenue, Bronx, New York 10468, USA JEROME LEE WESTON, born on 11 November 1943, and residing at 3134 Eastern Parkway, Baldwin, Long Island, New York 11510, USA JONATHAN WHITE, born on 14 July 1955, and residing at 11229 Blix Street, North Hollywood, California 91620, USA BONNIE LEIGH RAFFERTY or WILLIAMS, born on 12 January 1967 and residing at 516th Engineer Company, Army Post Office, New York, New York 09165, USA BRITTANY LEIGH WILLIAMS, born on 13 October 1988, and residing at 516th Engineer Company, Army Post Office, New York, New York 09165, USA ERIC JON WILLIAMS, born on 15 August 1964, and residing at 516th Engineer Company, Army Post Office, New York, New York 09165, USA GEORGE WATERSON WILLIAMS, born on 17 May 1964, and residing at 305 Garnett Road, Joppa, Maryland 21085, USA STEPHANIE LEIGH WILLIAMS, born on 23 May 1987, and residing at 516th Engineer Company, Army Post Office, New York, New York 09165, USA MIRIAM LUBY WOLFE, born on 26 September 1968, and residing at 120 Kennedy Drive, Severna Park, Maryland 21146, USA CHELSEA MARIE WOODS, born on 6 February 1988, and residing at Apartment 1151, 6750 Vogelweh Housing, West Germany DEDERA LYNN COPELAND or WOODS, born on 4 February 1961, and residing at Apartment 1151, 6750 Vogelweh Housing, West Germany JOE NATHAN WOODS, born on 5 March 1960, and residing at Apartment 1151, 6750 Vogelweh Housing, West Germany JOE NATHAN WOODS, JNR, born on 24 September 1986, and residing at Apartment 1151, 6750 Vogelweh Housing, West Germany MARK JAMES ZWYNENBURG, born on 14 October 1959, and residing at 151 Foxwood Road, West Nyack, New York 10994, USA, who were passengers on said aircraft, died from multiple injuries at about 1905 hours on Wednesday 21 December 1988 at or near Lockerbie, Dumfriesshire, 5 (3) That JOANNE FLANNIGAN, born on 13 June 1978, KATHLEEN MARY DOOLAN or FLANNIGAN, born on 26 January 1947, and THOMAS BROWN FLANNIGAN, born on 20 December 1944, all residing at 16 Sherwood Crescent, Lockerbie, Dumfriesshire; DORA HENRIETTA MOFFAT or HENRY, born on 27 March 1932 and MAURICE PETER HENRY, born on 18 July 1925, both residing at Arranmore, 13 Sherwood Crescent, Lockerbie, Dumfriesshire; MARY BROWELL or LANCASTER, born on 12 January 1907, and residing at 11 Sherwood Crescent, Lockerbie, Dumfriesshire; JEAN AITKEN MURRAY, born on 29 November 1906, and residing at Westerly, 14 Sherwood Crescent, Lockerbie, Dumfriesshire; and JOHN SOMERVILLE, born on 25 March 1948, LYNSEY ANNE SOMERVILLE, born on 13 July 1978, PAUL SOMERVILLE, born on 21 January 1975, and ROSALEEN LEITER HANNAY or SOMERVILLE born on 31 May 1948, all residing at 15 Sherwood Crescent, Lockerbie, Dumfriesshire, all died from multiple injuries and/or severe burning at about 1905 hours on Wednesday 21 December 1988 at Sherwood Crescent, Lockerbie, Dumfriesshire. (4) That the cause of all the said deaths was the detonation of an improvised explosive device located in luggage container AVE 4041 situated on the left side of the forward hold of said aircraft Registration N739PA. The detonation caused the nose and flight deck of the aircraft to become detached and the rest of the aircraft to descend out of control and to break up, eventually crashing into the ground at or near Lockerbie. The wing and centre fuselage section crashed in the Sherwood Crescent area of the town and caused the deaths referred to in Finding (3) hereof. The deaths referred to in Findings (1) and (2) hereof resulted from injuries sustained either as a direct result of the explosion and the disintegration of the aircraft or from impact with the ground. (5) That the said device consisted of Semtex-type plastic explosive concealed in a Toshiba radio-cassette player contained in a Samsonite suitcase which was one of the pieces of baggage placed in the said luggage container by employees of Pan American World Airways at Heathrow Airport, London. The contents of said container consisted of six or seven pieces of baggage collected from the interline shed and about thirty five pieces of baggage which had been unloaded from Pan American flight 103A from Frankfurt to Heathrow and were labelled as destined for airports in the United States, including JFK Airport New York and Detroit. The bags from the interline shed had been checked in by passengers booked on flights into Heathrow on airlines other than Pan American World Airways to connect with Pan American Flight 103 to New York. (6) That the primary cause of the said deaths was a criminal act of murder. (7) That the aircraft involved arrived at Heathrow at about 1210 hours on 21 December 1988 from San Francisco and was under constant guard until it left Heathrow as Flight 103 that evening. The aircraft was fully airworthy when it took off from Heathrow at 1825 hours. (8) That the bags transferred from Pan American Flight 103A were taken directly from that aircraft in the said baggage container to Pan American Flight 103. They were not counted or weighed so as to check that they corresponded to the baggage checked in at Frankfurt by passengers proceeding to New York or reconciled in any other way with such passengers. They were not x-rayed at Heathrow. (9) That the suitcase containing the said explosive device was among the said pieces of baggage transferred from Pan American Flight 103A and was unaccompanied both on the flight from Frankfurt to Heathrow and on the flight from Heathrow. (10) That the said suitcase probably arrived at Frankfurt on a flight or an airline other than Pan American and so was interlined to Pan American there. It was loaded on to and allowed to fly on Flight 103A without being identified as an unaccompanied bag. (11) That bags interlined to Pan American at Heathrow were subjected to x-ray screening but there was no reconciliation procedure there to ensure that interline passengers and their baggage travelled on the same aircraft. The same procedure probably applied at Frankfurt. 6 (12) That Khaled Nazir Jaafar originated as a passenger at Frankfurt. He checked in two bags, neither of which was the suitcase containing the device and neither of which contained any traces of illegal drugs. There was nothing to connect him with the said suitcase containing the device. (13) That in 1988 it was accepted (a) that there was a danger of an explosive device being concealed in a piece of baggage and loaded on to an aircraft; (b) that such a piece of baggage was likely to be unaccompanied; and (c) that such a bag was likely to be introduced by being interlined at a particular airport from another airline and that the person introducing it would not check in as a passenger at that airport. (14) That positive passenger/baggage reconciliation was recognised as an important element in any system designed to prevent the carriage of an unaccompanied bag on an aircraft. (15) That the limitations of x-ray screening as a means of detecting plastic explosives contained in electronic equipment were generally recognised as at December 1988. (16) That in all the circumstances the procedure of transferring baggage from Flight 103A to Flight 103 without any security check involved a substantial risk that an unaccompanied bag containing an explosive device would be so transferred. (17) That it would have been a reasonable precaution to have instituted or reverted to a positive passenger/baggage reconciliation procedure in relation to interline baggage at Frankfurt designed to detect the presence of any unaccompanied bag. Such a precaution might have avoided the deaths. (18) That in the absence of such a procedure at Frankfurt, it would have been a reasonable precaution to have instituted a positive passenger/baggage reconciliation procedure in relation to bags transferred from Flight 103A to Flight 103, either by counting the bags so transferred or by a physical match. Such a precaution might have prevented the deaths. (19) That reliance on x-ray screening alone in relation to interline baggage at Heathrow and Frankfurt was a defect in a system of working which contributed to the deaths. (20) That the Department of Transport’s direction (Production71) and the Circulars (Productions 21/1 and 64), as interpreted by the Department, afforded insufficient protection against the possibility that an undetected unaccompanied bag would be transferred from Flight 103A to Flight 103. SHERIFF PRINCIPAL’S CHAMBERS AIRDRIE: 18 March 1991. NOTE This is a Fatal Accident Inquiry which was ordered by me on the application of the Procurator Fiscal for the District of Dumfries in terms of Section 1(1) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976. It has been a very unusual example of an Inquiry of this type. While Section 1(3)(c) of the Act provides that an application for an Inquiry may relate to more than one death, an Inquiry into 270 deaths is unprecedented. Again, the application was made on two separate grounds. In relation to the crew members of Pan American Flight 103 who died in the course of their employment an Inquiry required to be held in terms of Section 1(1)(a) of the Act. In relation to the other deaths, it appeared to the Lord Advocate to be expedient in the public interest that an Inquiry under the Act should be held. In terms of Section 3 of the Act, I was bound to answer the application by making an order fixing a time and place for the Inquiry. At that stage, I had to contemplate the possibility 7 (1) that the next-of-kin of all the deceased would exercise their right to appear or be represented; (2) that large numbers of the public might have to be accommodated and (3) that an unusual amount of space would have to be allocated to the Press. For these reasons, I decided that none of the courthouses in the Sheriffdom would be a suitable place and I am grateful to the Dumfries and Galloway Health Board for making available the premises and facilities at Easterbrook Hall and to the Scottish Courts Administration for adapting the Hall for use as a court-room and equipping it in such a way as to make the proceedings readily available to the public. In the end of the day most of the relatives of the deceased were served by two teams of representatives and the well of the court was less crowded than had been feared. I should express my appreciation of the contribution made by the late Mr Michael Hughes in keeping the Clerk to the Inquiry and myself informed of the arrangements being made for the representation of the majority of the relatives resident in the United States of America. I heard evidence from 131 witnesses in the course of 55 days and then heard submissions from the Crown, from those representing the next of kin of the deceased, and on behalf of Pan American Corporation and its associated companies, the British Airports Authority, and the Department of Transport as to the form and content of my determination under Section 6(1) of the Act. There was general agreement as to the findings I should make in terms of sub paragraphs (a) and (b) of that Section. It was inevitable that some of the submissions in relation to sub paragraph (c) of the Act proposed findings which would, in my view, have constituted a determination that certain persons or organisations had been negligent in some respect. I have, therefore, had to consider how far it is proper for the presiding Sheriff to make such findings in a Fatal Accident Inquiry. It is generally recognised that such an Inquiry is not the proper forum for the determination of questions of criminal or civil liability. This was reaffirmed in the case of Black v Scott Lithgow Ltd 1990 SLT 612. The reasons for such a decision are clear. In a criminal case, or in a civil action based on delict, the accused or the defender is given full notice of the allegations made against him either in the form of a complaint or an indictment or by the written pleadings. In the vast majority of cases he is entitled to hear all the evidence against him before putting forward his defence. In a Fatal Accident Inquiry no such notice is given and the bulk of the evidence, indeed in most cases all the evidence, is led by the Crown with a view to eliciting the facts of the situation surrounding the death or deaths. It is true that one of the recognised purposes of the Inquiry is to ascertain the facts in such a way as to enable the relatives of the deceased to consider whether they provide a basis for a civil action but it is not for the presiding sheriff to make a judgment on that question in his determination. The present Inquiry is, as I have said, a very unusual one and one special feature is that it has taken place some two years after the deaths to which it relates and that one of the organisations represented is the defendant in a civil action elsewhere and so has had some notice of what was likely to be the line of any attack made upon it in the proceedings before me. That does not, to my mind, alter the fact that the procedure of this Inquiry is not designed to enable a proper defence to be mounted against such an attack. Section 6(1)(c) of the Act allows the Sheriff to make findings relating to “reasonable precautions, if any, whereby the death or any accident resulting in the death, might have been avoided”. Section 6(1)(d) relates to “the defect, if any, in any system of working which contributed to the death or any accident resulting in the death99. It is clear that in some cases a statement that a reasonable precaution might have prevented the deaths carries with it the implication that a certain person or organisation owed a duty to take that precaution and so was negligent. The same situation applies even more clearly to a finding under sub paragraph (d). It is for that reason, it seems to me, that Section 6(3) of the Act provides that the sheriff’s determination in a Fatal Accident Inquiry may not be founded upon in any other judicial proceedings. In that situation, I have come to the view that any finding under Section 6(1)(c) should avoid, so far as possible, any connotation of negligence. Accordingly, it should not contain any 8 indication as to whether any person was under a duty either at common law or under statute, to take the precaution identified in the finding. The same consideration applies to any finding under Section 6(1)(e) of the Act which can relate to “any other facts which are relevant to the circumstances of the death”. I recognise on the other hand that it will be impossible in this Note, in which I try to explain how I have dealt with the submissions made to me, to avoid giving some indication of my view as to how far the evidence appears to point towards the existence of a duty to take certain precautions. While on the subject of limitations to the scope of the Inquiry I should say that I had no hesitation in accepting the objections of the Crown to the leading of evidence the publication of which might, in the view of the Lord Advocate, impede the criminal investigation which is still continuing or, perhaps, more importantly, render it impossible to bring the criminals to trial if they were discovered. Equally, I had no hesitation in upholding the objection of Mr McEachran, for the Department of Transport, to any evidence relating to the operation of the intelligence agencies of the United Kingdom, as being contrary to the national interest. On the other hand, I did allow Dr Swire, who appeared on his own behalf, to elicit in cross-examination and to lead evidence in relation to the part which the Government should be expected to play in promoting aviation security. This was tenuously linked to the state of technology in relation to the detection of explosive substances at the time of the disaster and how far the Government was responsible, through the Department of Transport, for the lack of research and development in that field. I should say now that I have no intention of making any findings or comment on these matters which to my mind lie, and should remain, in the field of politics. I did not, however, allow him to lead evidence, at a very late stage of the Inquiry, into the state of airport security at Heathrow. This was because no questions in relation to any specific deficiencies had been put to airport officials who had given evidence earlier in the Inquiry. SUBMISSIONS The submissions made as to the findings I should make were supported by argument and detailed reference to the evidence but I find it convenient to list the submissions themselves at this stage and to deal with the arguments and the evidence in relation only to those which were controversial. I had circulated draft findings in relation to matters which I considered were unlikely to be controversial before submissions were made to me, and after some amendment, these now form findings (1) to (5) of my determination. For the Crown, Mr Hardie submitted firstly that the aircraft had been proved to have been airworthy when it took off from Heathrow and that it had been under guard continuously during its time on the ground there, so that there had been no opportunity to plant an explosive device on the aircraft before it was loaded with baggage. He concurred, with one reservation, in the draft findings which had been circulated and went on to submit that three additional findings under Section 6(1)(e) of the Act should be made. (1) The Samsonite suitcase in which the device was contained was unaccompanied. (2) It was among the bags from Flight 103A which arrived at Heathrow from Frankfurt and which were loaded into container 4041 and transferred to Flight 103. (3) There was no reconciliation of the bags so transferred with passengers booked to fly to New York. Turning to the question of precautions which might have prevented the accident or deaths, he submitted that no deficiency in the response to the disaster of the people of Lockerbie, the emergency services or the voluntary organisations could be said to have contributed to any of the deaths. He then submitted that Pan American Airways had failed to comply with Section 15 of the Air Carrier Standard Security Program (ACSSP) which set out the requirements of the Federal Aviation Administration in relation to special risk airports such as Frankfurt and Heathrow and, in particular, with Section 15C (1) (a) which required baggage/passenger reconciliation. Pan American had used x-ray in place of reconciliation in respect of interline 9 baggage. They suggested that they had been allowed to do so by a waiver from Mr Salazar, then director of FAA, but Mr Hardie submitted that on the evidence, any decision as to an exemption had no bearing on the requirements of Section 15. Had Section 15C (1)(a) been complied with in relation to interline baggage, the unaccompanied bag containing the device should have been detected and the accident might have been prevented. He then submitted that Pan American Airways had failed to comply with the requirements of the Department of Transport in relation to the arrival of Flight 103A from Frankfurt and the departure of Flight 103 from Heathrow. He maintained that the circular issued by the Department in September 1985 (Production 12/1) recommended that there should be a reconciliation between baggage to be conveyed aboard Flight 103 and passengers who boarded the aircraft. Had Pan American sought to make such a reconciliation in relation to the baggage being transferred, the unaccompanied bag containing the device might have been identified. Mr Hardie said that while the Crown made no submission that the bag containing the device came to Frankfurt as an interline bag it would not “seek to discourage” such a finding. That would indicate that Alert employees at Frankfurt had failed to identify the radio cassette player under x-ray and might raise questions as to the training and competence of these employees and the desirability of relying on x-ray alone. It might justify a finding that had Pan American not relied on x-ray alone, the accident might not have occurred. There might also be room for a finding that the Alert management failed to pass on significant information to their employees. Mr Hardie then considered the position of the Department of Transport. He submitted firstly that there was insufficient evidence to justify a finding that there was available at the material time equipment which, had it been installed at Heathrow, might have prevented the disaster. He went on to submit that if the Department’s view of their directive and circulars was correct and they did not provide measures which would identify an unaccompanied bag in the absence of a “no show” passenger, the issuing of a circular containing such measures would have been a reasonable precaution which might have prevented the accident. If the circular (21/1 of Process) did recommend such a measure, it would have been a reasonable precaution for the Department to check whether the recommendation had been followed by operators and, if not, to issue and enforce a direction to the same effect. Mr Hardie had made it clear that the Crown was anxious that if I were concerned about any aspect of aviation security but felt unable to make a finding that it was “relevant to the circumstances of the deaths” I should bring it to the attention of the authorities in the public interest by way of comment in this Note. He suggested that I might consider (a) whether the establishment of a properly funded inspectorate within the Department might have avoided the disaster and (b) the inordinate delay between the initial telex to UK operators relating to the “Toshiba warning” and the ultimate circular dated 19 December 1988 but not issued until January. In this connection he suggested that it would not be appropriate to say that had the photographs been produced immediately the accident might have been avoided. Mr Gill, appearing on behalf of a group of bereaved relatives known as the Lockerbie Air Disaster Group, summarised his submissions as follows: (1) Pan American Airways, knowing the dangers involved, risked the lives of their passengers and crew by abandoning passenger/baggage reconciliation procedures in relation to interline baggage for reasons of commercial advantage. (2) The Department of Transport failed effectively to inspect and supervise the operation of the airline, to implement and enforce their own security requirements and to appreciate the risks involved in Pan American’s continuation of an x-ray only policy in regard to interline baggage and the tarmac transfer procedure. He concurred with Mr Hardie in accepting the draft findings which had been circulated but considered that it should be made plain that the likeliest explosive to have been used in the device was of the Semtex type. He submitted that three further conclusions could be drawn in relation to the suitcase; (i) It was unaccompanied; (ii) It 10 came on to Flight 103 from the feeder flight from Frankfurt; and (iii) On a balance of probabilities it was interlined into the Pan American system at Frankfurt. He submitted that on a balance of probabilities the quality of Alert security at Frankfurt was unsatisfactory. He then submitted that on all the evidence, Pan American’s decision to rely on x-ray alone in relation to interline baggage was reckless and dangerous as was the failure to review it in the latter half of 1988. In the absence of any waiver it clearly breached Section 15C(1)(a) of the ACSSP. He submitted that the evidence in support of a waiver which effectively excluded the provisions of Section 15 was virtually non-existent. In any event, if x- ray only was a dangerous procedure the airline was not entitled to rely on any such waiver, which was overtaken by subsequent events. The tarmac transfer procedure at Heathrow was in breach of the Department of Transport’s requirement that hold baggage be reconciled with passengers. In these circumstances, Mr Gill submitted that I should make a finding under Section 16(1)(c) of the Act to the following effect: That the deaths might have been avoided had Pan American implemented a proper system of passenger/baggage reconciliation at Frankfurt and Heathrow and if they had not followed the practice of x-ray only of interline baggage at these stations and the practice at Heathrow of tarmac transfer of hold baggage without any security checks. He invited me to consider whether any of the background matters to which he had referred might be the subject of findings under Section 6(1)(e) of the Act. In relation to the Department of Transport, Mr Gill submitted that I should consider making a finding under Section 6(1)(c) to the following effect: The deaths might have been avoided if (a) the Department had carried out an effective system of inspection of Pan America’s operations at Heathrow; (b) the Department had enforced the security principles set out in its own circulars and directions; (3) the Department had stopped the practice of tarmac transfer of baggage between flights such as 103A and 103; and (d) the Department had taken effective action to enforce passenger/baggage reconciliation of all hold baggage on Heathrow-originating flights in response to the warnings they received in November and December 1988. Finally, Mr Gill referred to the position of his clients in relation to the aftermath of the disaster and the future. He stated that he did not submit that any of the policy decisions taken as to the recovery of bodies, the access by relatives to those bodies, and the methods of identification to be applied were unreasonable per se. There was, however, a question as to whether they were effectively communicated and explained to those affected by them. For the future, he suggested that consideration might be given to the earliest possible establishment of lines of communication with the next of kin and to the appointment of a representative for all the relatives who would have official status. He should have the fullest access possible to available information and authority to disclose it to those relatives whom it concerned. Relatives should be spared having to deal with a multiplicity of officials, particularly in relation to the repeated requests for intimate details of the deceased. Further consideration should be given to the question of access to the bodies in the light of the recommendations of Professor Rosser. Dr Swire, who appeared in the latter stages of the Inquiry on his own behalf, was mainly concerned with his regrets that certain matters had not been covered more fully. As I under- stood him, his main submission was that I should find that had the British Government given a reasonable degree of financial and scientific support to the development of technology in the field of aviation security, such techniques as back-scatter x-ray and CT scan could have been developed to such an extent that the explosive device which caused the disaster could have been discovered in December 1988 and the disaster could have been prevented. He relied on the evidence of Professor Wilkinson, who had challenged the evidence of Mr Doney, the scientific adviser to the aviation security branch of the Department of Transport, on this point. He criticised the continuing delay in the formulation by the Department of a structured programme of assessment of airline operators which, according to Professor Wilkinson might have exposed the deficiencies in security at Heathrow and led to improvements at Frankfurt. He criticised the delay on the part of the Department in obtaining copies of the colour photo-