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Authors: Scott Bartz

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Frank Young described the poison found in the third bottle as a blip. “We think it’s an industrial contaminant,” said Young. “It’s such a small trace that it wouldn’t have done anything anyway,” he said. “It’s just so small we don’t know what it is.”

Further tests on capsules from the third bottle were completed late Thursday at the FDA laboratory in Cincinnati, but the results of those tests were never released. Nevertheless, one of the capsules in the third bottle had in fact been tampered with. Gerstenberg said it had tested positive for cyanide, and the logos printed on the capsule-halves were misaligned, clearly evidence of tampering.

The FDA minimized the relevance of the contaminant in the third bottle. “It may be a cleaner and it may be cyanide, but it was a trace or harmless amount and would not have been harmful to anyone who ingested it,” said FDA Deputy Commissioner John Norris. Norris described the contamination as “dust” from the manufacturing process that occasionally can find its way into the product. Whatever the amount of the contaminant in the third bottle, it was enough to turn the litmus strip blue, and it should not have been in the Tylenol capsule.

On Friday morning, February 14
th
, John Norris was interviewed on Associated Press Radio about the latest developments in the tampering case. When asked if there were any signs that the packaging on the Tylenol bottles had been tampered with, he said, “The three seals on the tainted product were, from all external signs, intact.” The FDA had examined packaging from both the second and third bottles, and in both cases, there were no indications that the packaging had been tampered with after the bottles left the factory.

When asked to explain how the killer could have gotten poisoned capsules into the bottles while leaving no sign that the packaging had been breached, Norris pontificated, “It’s possible someone extremely skilled at tampering did it outside the factory.”

At Johnson & Johnson headquarters, Robert Kniffin said the company had no comment on how cyanide might be introduced into capsules in unopened tamper-resistant packages protected by glued flaps on the boxes. “All we have said in the past is that the packaging is tamper-resistant or tamper-evident,” said Kniffin, “We never said it is tamper-proof.” Johnson & Johnson’s dogma was far different back in 1982 when they were launching the new tamper-resistant packaging.

James Burke, along with J&J General Counsel George Frazza and J&J President David Clare, had flown in the corporate helicopter to Washington D.C. for an emergency meeting with Secretary of Health and Human Services, Richard Schweiker, and FDA Commissioner, Arthur Hull Hayes, on Thursday afternoon, November 4, 1982. In the middle of that meeting, Burke pulled out samples of the newly packaged capsules. Both Schweiker and Hayes had trouble getting the bottles open. Schweiker then turned to Burke and said, “Everybody else is going to have a package. You’ve got an armored tank.”

The “armored tank” message was not the one Johnson & Johnson wanted to convey in 1986 when they needed the public to believe that a sick criminal mastermind had removed and then replaced three layers of tamper-resistant packaging on Tylenol bottles, leaving behind no detectable signs of tampering.

Although the packaging had been torn off Elsroth’s bottle by her boyfriend, it was intact on the second and third bottles. When investigators cut open the triple-sealed packages on those bottles, the poison was there, right inside the red-and-white capsules. Even Johnson & Johnson admitted, probably in the first bottle found, and definitely in the second bottle - the original factory seals on the box, neck, and mouth of the container were still in place when taken from the store shelves.

J&J executives, FDA officials, and packaging industry experts suggested that the killer had done some elaborate and expensive tampering, involving special equipment to reseal and replace the heat-shrunk barriers. However, a J&J spokesperson said indicators such as the lettering on the shrink-ring around the neck and the tautness of the foil seal over the mouth showed no signs of even that type of tampering.

None of the three seals had been broken or showed any signs of tampering on either the second or third bottles of adulterated Tylenol capsules. The capsules themselves - as opposed to the packages – did show clear signs of tampering.

The word “Tylenol,” and the “500mg” dose printed on each capsule half, are always precisely aligned when they come out of the factory. The capsules are stamped with “Tylenol” and “500mg” labels after they are filled with acetaminophen and put together, ensuring perfect alignment. The poisoned capsules in all three contaminated bottles did not have that alignment, thus leaving the mark of the killer behind.

The FBI, in addition to inspecting the tamper-resistant seals, also closely examined the bottles themselves to determine if someone had somehow invaded them without removing the seals on the bottles. The FBI even took X-rays of the bottles, but found no sign that they had been breached. The evidence showed instead that the cyanide-laced Tylenol capsules had been put into the bottles before the bottles were packaged.

Even James Burke said, “The indication was that it [the packaging] was the original factory seal at all three points [all three layers of tamper-resistant packaging]. If this [invading the bottles undetected] was done, it was done by somebody very, very bright who has the technology.”

“It is utterly baffling,” remarked James Murray, Johnson & Johnson’s seemingly confounded spokesperson. “We just cannot understand what was done.” It is almost as if the crime were committed because it was an “exquisite challenge” to break through the tough triple seals without leaving a visible mark, said Murray.

Someone had gotten the cyanide-laced Tylenol capsules into the bottles before they were packaged, and Johnson & Johnson had nothing to support its claim that the tamperings had occurred in the retail stores. Then, right on cue, J&J got some help in the form of an article titled, “Seal on Drug Package Can Be Forged,” published in
The New York Times
on February 14
th
, one day after the second bottle of cyanide-laced Tylenol was discovered. The author, Malcolm Browne, was a prominent Pulitzer Prize-winning journalist who gave instant credibility to J&J’s suggestion that someone could have breached the packaging on the Tylenol bottles without leaving any detectable signs of tampering.

“Electric heat-sealing machines are readily available and comparatively inexpensive, and plastic or laminated-foil packaging material can be purchased from many manufacturers,” wrote Browne. “The specially shaped plastic seals that some manufacturers apply to pharmaceuticals could be reproduced with the devices some hobbyists use to form plastic parts for model airplanes and automobiles.”

 
“A terrorist bent on wrapping a tainted pill or capsule in a convincingly sealed package might accomplish the task fairly easily,” according to Browne. “Few consumers are likely to examine very carefully the sealed wrappings in which drugs are sold or to compare such wrappings with samples known to be authentic.”

Browne suggested that it was relatively easy for a run-of-the-mill hobbyist to remove and replace tamper-resistant packaging. This portrayal was far from accurate. Even J&J and the FBI said they did not know how the packaging could have been tampered with undetected. Agents at the FBI lab in Washington D.C. inspected the packaging from all three bottles of contaminated Tylenol. They found no evidence of tampering. Johnson & Johnson’s experts also said the packaging on the bottles were the original factory seals. The packaging had not been forged or penetrated, and no evidence was ever produced to suggest otherwise. Only the capsules showed signs of tampering.

 
“In any case” wrote Browne, “the security of the factories that manufacture and package drugs can probably never be guaranteed. A determined terrorist might gain access to a company’s own packaging machinery, introducing poisoned substances into properly sealed containers indistinguishable from containers used for the legitimate product.”

Browne’s simplistic solution to the problem of tampering was for consumers to be more diligent. But all the diligence in the world would not have helped Diane Elsroth, because the packaging on the bottles of poisoned Tylenol had not been tampered with.

On the day Browne’s article ran in the
New York Times
, J&J executives said they still believed that both packages of cyanide-laced Tylenol had been tampered with after they had arrived in Westchester County stores. For one thing, they noted, the two packages of 24 capsules had been produced in two different plants at different times. However, that was not entirely accurate.

As it turned out, both bottles of cyanide-laced Tylenol had been shipped though the very same distribution center. The owner of that distribution center was none other than Johnson & Johnson.

On Friday, February 14
th
, James Murray said that the two bottles of cyanide-laced Tylenol capsules were part of two separate batches received at the warehouse on Welsh Road (one of two entrances to J&J’s Montgomeryville facility). “They were essentially unloaded off of one truck and loaded onto another truck,” Murray said. He said the Tylenol in the first bottle was manufactured at the McNeil plant in Fort Washington on May 17, 1985. It arrived at the Montgomeryville warehouse on August 21, 1985, and was shipped out the next day by truck. Murray said the Tylenol in the second bottle was manufactured in Dorado, Puerto Rico, on July 17, 1985. It arrived at the Montgomeryville warehouse on September 5, 1985 and was shipped out the next day.

J&J spokesperson, Robert Kniffin, confirmed that both bottles of cyanide-laced Tylenol capsules had been shipped from a McNeil distribution center in Montgomeryville about two weeks apart in the summer of 1985. Yet during the previous three days, when describing the distribution path of the first bottle of cyanide-laced Tylenol, J&J spokespersons had said only that it was shipped from a warehouse in Montgomeryville. They had never mentioned the fact that Johnson & Johnson owned and operated that Montgomeryville warehouse.

Kniffin’s characterization of the Montgomeryville facility as a distribution center was also not completely accurate. It was actually much more than that. It was the home of several J&J operating companies, including the R. W. Johnson Pharmaceutical Research Institute and the McNeil Pharmaceutical Company. The Montgomeryville facility, located seven miles north of the McNeil Consumer Products Company in Fort Washington, did in fact ship Tylenol, but the operating company that handled that task was the Johnson & Johnson Sales & Logistics Company. In 1986, just as in 1982, the Tylenol poisoning was not really a McNeil problem – it was a Johnson & Johnson problem. J&J executives, by hiding important facts about the distribution of Tylenol, were playing the same game they had played in 1982.

The three J&J regional distribution centers that handled Tylenol in both 1982 and 1986 were located in Montgomeryville, Pennsylvania; Round Rock, Texas; and Glendale, California. Robert Kniffin said the distribution centers shipped generally, though not exclusively, to their respective regions of the nation. Thus, said Kniffin, Tylenol shipped through Montgomeryville goes to the Eastern region of the United States, which included all states east of the Mississippi River.

Carl Vergari said investigators were trying to determine if the Tylenol in the second bottle might have been made in Pennsylvania even though it had a Puerto Rican lot number. He said the discovery of the second contaminated bottle had increased “the focus of the investigation on the possibility of tampering at the plant.”

Vergari now believed that the Tylenol produced at McNeil’s plant in Puerto Rico had been shipped in bulk containers of Tylenol powder or capsules and then repackaged elsewhere, possibly at McNeil’s plant in Fort Washington. Vergari, thanks to his joint investigation with the FBI, had uncovered some of J&J’s secrets about the manufacturing and distribution of Tylenol.

Burke never addressed Vergari’s allegations, and he never once strayed from his talking points. “We still believe
it’s
local tampering, but we can’t prove it didn’t happen at the plant,” Burke said.
 
“You had two bottles produced at two separate places at two separate times. What are the chances of them going through the distribution system and ending up in the same city a block apart?” argued Burke. “The odds are something like one in a billion,” he said. We can’t even estimate it, it’s so great.”

Burke’s odds calculation of “one in a billion” was off by a factor of one billion. The probability that two bottles of Tylenol manufactured in two different plants thousands of miles apart would end up in two stores on the same city block in Bronxville, New York, were actually 100 percent. The odds were 100 percent because the Tylenol in all of the bottles shipped to stores in Bronxville, New York – no matter where that Tylenol had been manufactured - went through Johnson & Johnson’s Regional Distribution Center in Montgomeryville.

The discovery of the second bottle of poisoned Tylenol got the FBI’s full attention. The number of FBI agents working on the case in New York increased from two to about twenty, and an undisclosed number of additional agents outside of New York were also put on the case. Assistant FBI Director, William Baker, said his agency would “re-examine the whole case.” He said, “FBI Director William Webster has ordered that the highest priority be given to the poisonings, and we are looking into the matter right now.”

This case “is extremely hot,” said Chief FBI Spokesperson, Milt Ahlerich. “One little person can put cyanide in capsules and this can move mountains, literally - the media, hundreds of police officers and agents, millions of dollars,” he said.

BOOK: The Tylenol Mafia
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