MERV
02-06-2007, 12:07 PM
U.S. waited 5 years to heed expert’s warning on ‘man down’ alarms
FIRST OF TWO PARTS
By Bill Dedman
Investigative reporter
An MSNBC Special Report
Updated: 11:40 a.m. ET Feb 6, 2007
Worn by a million firefighters in the U.S., the PASS device is a motion sensor that makes an awful racket if a firefighter stops moving for 30 seconds while battling a blaze. It flashes its lights and lets loose a series of ear-splitting beeps — an urgent call to help a fallen comrade.
It’s a call that hasn't always been heard. Tests by federal and independent labs show that some PASS alarms can fail to perform as intended if they get too hot or wet — a serious problem for people who rush into burning buildings with water hoses. And federal investigative reports reviewed by MSNBC.com show that 15 firefighters have died since 1998 in fires where a PASS, or Personal Alert Safety System, either didn't sound or was so quiet that rescuers weren't given a chance to find the firefighter quickly.
Documents made public under the Freedom of Information Act reveal that nine of those deaths came after the federal government blocked an investigation by its own expert into possible failures of PASS alarms and other firefighting equipment. A manager for the Centers for Disease Control and Prevention, the federal agency that is charged by Congress with investigating firefighter deaths, ordered an agency fire safety engineer on Feb. 14, 2000, to "minimize your fact gathering during investigations" and to restrict his investigations to issues relevant "for the prevention of future similar events."
On Monday, hours after the publication of MSNBC.com's report, Sen. John Kerry, D-Mass., called on the U.S. Department of Health and Human Services to investigate the "deeply troubling" information in the story. “It is completely unacceptable that our first responders don’t have the proper safety equipment, and if these allegations prove true, it’s unfathomable that the CDC would cover up something so detrimental to our firefighters’ safety,” Kerry told MSNBC.com.
On the same day that the CDC manager instructed the agency's fire safety engineer to scale back his investigation, Houston firefighter Kim Smith had become lost in a pre-dawn fire in a McDonald's restaurant.
Hearing no beeps from her PASS alarm, and seeing no flashing lights, her comrades searched for two hours before finding her body.
‘If a firefighter dies, it's a good funeral’
Nine more times, the rituals of a firefighter's funeral — a fire truck bearing the flag-draped casket; the bagpipers playing “Will Ye No Come Back Again?” — were re-enacted before the CDC took action, calling finally in April 2005 for higher standards for testing PASS alarms.
“Fire departments give good funerals," said Richard M. Duffy, the health and safety chief for the International Association of Fire Fighters.
"We never did investigations to the extent that they were needed … but we did some very, very good funerals. If a cop dies, it's a crime scene. If a firefighter dies, it's a good funeral."
After the CDC’s warning, tests quickly demonstrated that temperatures commonly encountered by firefighters could hurt the performance of at least some PASS alarms.
Tests in a convection oven at the National Institute of Standards and Technology found a problem with the two models it tested: The volume of the beeping diminished substantially at temperatures as low as 300 degrees Fahrenheit — the sort of temperatures that firefighters encounter in a room next to a fire. Researchers said they believe that all of the half-dozen or so brands of PASS alarms on the market would be similarly affected.
In addition, some PASS devices made by at least three manufacturers have had problems over the past decade with water leaking into the electronics or battery compartments, causing them to either beep continually or stop working altogether, according to interviews and documents reviewed by MSNBC.com.
Later this week, a tougher new standard for testing PASS devices in heat and water will be issued by the National Fire Protection Association. But manufacturers say it will be months before an improved device is on the market. And even when new models are available, there is no plan for recalling the old ones, so fire departments may have to bear the cost of replacing them.
Meanwhile, the approximately 1 million professional and volunteer firefighters across the nation will rely on the older PASS alarms as their last line of defense.
Precise role in fatalities is unclear
No one can say for sure that a PASS device caused any of the 15 deaths in which the alarms weren’t heard. And it's impossible to say that any firefighter would necessarily have survived if the PASS alarm had been seen and heard.
Firefighting is dangerous even when done right. But firefighter fatalities usually involve a series of mistakes: inadequate staffing or training; firefighters working alone instead of in pairs; an incident commander's mistake in evaluating the risk. The PASS device is intended to give firefighters who are injured, trapped or just lost in the smoke a chance to survive such miscues.
It is required to shriek for an hour at 95 decibels so it can be heard over the roar of the fire and the cacophony of chain saws cutting, exhaust fans blowing, glass breaking and water flowing.
"It sends a chill up your spine," Kenneth R. Willette, the fire chief in Concord, Mass., said of the alarm’s piercing cry. "You know that means someone is in trouble. So until you can locate that person, your heart is racing and all you can think about is finding that person."
The first generation of PASS alarms, which were introduced in the early 1980s, had a human problem: Annoyed when the device started beeping when they stood still on a break, many firefighters would just not turn them on.
So the National Fire Protection Association set a standard requiring that the device be armed automatically when a firefighter turns on the air supply. These so-called "integrated PASS devices" are built into the self-contained breathing apparatus. When the firefighter is motionless — usually for 30 seconds — they first sound a gentle beep, the pre-alarm signal, then ramp up to the full alarm. That's why, at a fire, bystanders will often see firefighters waggling their hips. They're not dancing. They're telling the PASS, "I'm still alive."
In exchange for that annoyance, firefighters rely on the devices to work when they need them. And they usually do. Manufacturers say that hundreds of firefighters have been saved by PASS devices.
Devices silent, or just too quiet
The stories of the 15 who were not saved are contained in reports by the CDC's Fire Fighter Fatality Investigation and Prevention Program. Each firefighter was wearing an automatic PASS alarm. In 12 of the 15 cases, nothing was heard; in three cases, the sound was muffled by the firefighter lying on the device and could be heard only when rescuers found the victim and rolled him over, according to the CDC's reports.
In November 2000 in Pensacola, Fla., firefighter Maurice Bartholomew got lost trying to leave a house fire. Firefighters searched for an hour before finding him in a kitchen at the back of the house. His PASS alarm wasn't heard or seen at all.
In March 2002 in Jefferson City, Tenn., volunteer firefighter Shane Murray was trapped in a house fire. He was found after 18 minutes just 5 feet from the door. His PASS device was beeping, but not loud enough to be heard while he was lying on it.
And in May 2002 in St. Louis, firefighter Rob Morrison's PASS alarm was not heard or seen for 20 minutes while he was injured inside a refrigeration company fire. Firefighter Derek Martin went looking for Morrison at the wrong end of the building and got lost. Both men died.
"I just can't believe that this was happening a number of times and no one was told about it," said Morrison’s widow, Laura. "I mean, Rob didn't know. None of the firemen knew."
Eric R. Schmidt didn't know for sure that PASS devices were malfunctioning, but he suspected that there was a recurring problem with the alarms.
Engineer's warning ignored
Schmidt went to work for the CDC in 1999 as the first fire protection engineer in the firefighter fatality program in Morgantown, W.Va. In 1998, Congress gave the CDC the responsibility for investigating firefighter deaths and searching for lessons that could prevent additional fatalities. The CDC's National Institute for Occupational Safety and Health, or NIOSH, was given responsibility for the program.
Documents provided by the CDC show that Schmidt was investigating a December 1999 fire in Keokuk, Iowa, where three firefighters died along with the three children they had been trying to save. The firefighters had been wearing two PASS devices apiece — one that is armed only if a firefighter turns it on, and the integrated alarm that is switched on automatically. Schmidt thought it was strange that none of the dozen other firefighters on the scene recalled hearing the alarms, so he wanted to collect the tape recordings from the dispatch center to see if the sounds could be heard there.
“I’m saying, the math here is astonishing," Schmidt told MSNBC.com, describing his conversation with his supervisors at the CDC. "The chance of having a dozen deaf firefighters is astronomical."
Schmidt also knew that in New York City in 1998, no one had heard the PASS alarms of two firefighters who died in a high-rise apartment fire. A third firefighter died in the same fire, but his PASS sounded. That information was in the CDC unit's investigative report on that fire, issued in August 1999.
"I can’t tell you I understood what the failure pattern was,” Schmidt said. “All I could tell you is, something is not adding up. This needs more attention. Let’s go back and listen to the tapes. They said, ‘We don’t want to listen to the tapes.’”
On that Valentine's Day morning in 2000, the head of the firefighter program, Dawn Castillo, gave Schmidt a memo labeled "performance guidelines."
First, she reminded Schmidt that he was still on probation as a new employee, and would need to improve his performance to keep his job.
Then she urged him to stop wasting his time asking for evidence such as dispatch tapes.
She criticized his "persistence in gathering complete autopsy reports"; just getting the cause of death by phone was sufficient, she said.
And she told Schmidt he didn't need to gather details such as the measurements of a fire hose that had burned through, or information on firefighters' protective jackets, which he thought had been recalled by the manufacturer.
‘Minimize your fact gathering’
Castillo offered four reasons for Schmidt to scale back his investigations:
# "The collection of detailed information not of likely use in an investigation is an inefficient use of your time."
# It's "a burden on those who help us in gathering the facts of the case."
# It's "a potential liability to the program if those who spend their time helping us to understand the case are upset by the absence of information that they helped provide in the summary report."gu
# Any information that is gathered could be requested from the CDC by others. The agency does not identify individuals in its reports.
"You need to minimize your fact gathering during investigations," Castillo wrote, "to those pieces of information which are needed to summarize the chain of events or that have direct implications for prevention recommendations."
The memo was hand-delivered just as fire departments around the country were lowering their flags to half staff.
Earlier that morning, in southwest Houston, 30-year-old Kim Smith had been about to end her 24-hour shift. She planned to spend the rest of Valentine's Day with her fiancé.
But at 4:33, a fire alarm awakened the crew in Fire Station 76: There was a fire at a McDonald's.
She was one of the first firefighters to rush into the restaurant. Attached to her air supply was a PASS device made by Scott Health & Safety, the U.S. market leader in self-contained breathing apparatus.
She and firefighter Lewis Mayo, 44, took a hose line into the kitchen for a "fast attack" on the fire. She'd done this many times, and had won regional competitions for her firefighting skills and endurance.
Inside the McDonald's, the heat became intense and 30-foot flames were shooting out of the roof. At 4:52 a.m., the chief ordered everyone to evacuate, but Smith and Mayo didn't emerge from the inferno. They had been buried by a ceiling collapse.
A PASS device was heard. It was Mayo's, and he was found alive, though he later died at the hospital.
But Smith's PASS was never heard, the CDC found. It took two hours to find her body in the debris, just 6 feet from the door. Police discovered later that burglars had set the fire.
Fired for ‘marginal’ performance
Four months after the double-fatality fire in Houston, Schmidt was fired by Castillo in June 2000 for "marginal" performance. Castillo wrote in his termination letter that he was not a good team player, was inefficient, and spent time gathering information "of questionable utility and necessity." She cited especially the delay waiting for the dispatch tapes in the Iowa fire. The program didn't replace him, and hasn't had a fire engineer since, she told MSNBC.com.
But Schmidt didn't drop the equipment issues. He wasn’t just an engineer, but also a former fire captain in Prince George's County, Md., with 20 years of experience in the fire service. On Oct. 2, 2000, he wrote to Dr. Linda Rosenstock, the director of the CDC's NIOSH agency.
Schmidt asked Rosenstock to look into the issues of firefighter equipment so more firefighters wouldn't die. He highlighted three instances where he was told not to investigate: the fire hose that failed; the firefighter coats that may have been recalled; and the PASS devices, which he called "another issue that warrants further investigation."
"This is but only one example," he wrote of Castillo's performance guidelines, "where the managers of this program in Morgantown repeatedly instruct staff to omit critical facts because of ‘potential liability to the program.’ These managers have shown little, if any regard, for the fact that fire fighters will continue to actually suffer injuries and death in part because NIOSH fails to document critical aspects of these incidents."
Rosenstock is no longer at the CDC. She was in her last month in government when Schmidt's letter arrived. Now the dean of the UCLA School of Public Health, she declined to be interviewed by MSNBC.com, but sent word through a spokeswoman that she doesn't remember Schmidt’s letter.
Castillo told MSNBC.com that the CDC took no action in response to the letter, because Schmidt didn't provide any new information beyond what they had already discussed.
"Although PASS devices were one issue that he addressed in his letter, in passing, that letter did not provide any additional documentation to substantiate his concerns," Castillo said.
She said no additional documentation was requested.
"No, no one acted upon it," she said, "because there was nothing substantive to act upon."
Manager: No valid areas of inquiry blocked
Castillo said she had not blocked any valid areas of inquiry, but didn't want Schmidt to get sidetracked by nonessential issues. To be able to investigate deaths with limited funds, she said, investigators had to limit themselves to the factors that led to deaths, not to follow trails on other safety issues of uncertain value.
In the Iowa fire, she said, the firefighters wouldn't have survived the extreme heat of a flashover, or sudden ignition of a room — even if their fire hose had held, or their coats had not been recalled, or the PASS alarms had been heard.
"Did we follow up and do additional testing? We did not," Castillo said. "Do we have the resources to go down every single path? We do not. Do we generally tell people not to follow up on promising leads? Absolutely not."
Citing a computer simulation of the Iowa fire, Castillo said the temperatures reached 1,100 degrees F, which she said was not survivable and in which no PASS device could be expected to operate. The national standard for PASS devices, however, has since 1998 included a flashover simulation: 1,500 to 2,100 degrees for 10 seconds.
After Schmidt was fired, the CDC released its investigative report on the Iowa fire in April 2001. One of its recommendations is curious: Instead of recommending that PASS alarms be tested, it stated that firefighters should use PASS alarms. But as another section of the report makes clear, all three firefighters were wearing their automatic alarms, and they were not heard.
Schmidt said he thinks one cause of his disagreements with Castillo was a difference in perspective. He is an engineer and a firefighter. She's an epidemiologist and specialist in child labor, who won her agency's top award in 2004. He said she just didn't respect the value of personal protective equipment, because child workers aren't allowed in jobs where such gear is used. But firefighters can't control their work environment -- they go where they're called. That's why they rely on helmets, hoods, gloves, boots, bunker pants, coats and face masks.
"She would say, 'The room flashed over. How could anybody have survived?'” he said. “I said, 'Well, firefighters have survived flashover. You're going to be in the burn ward for a period of time, but firefighters have survived flashover.'"
Other opportunities missed
As the years passed, the CDC missed other chances to look into PASS alarms.
In May 2001 in Passaic, N.J., firefighter Alberto Tirado was hunting for children in a fire. Rescuers entered the building three times trying to find him, and only when they turned him over could they hear a faint PASS alarm.
Back at the CDC lab, Tirado’s PASS device wouldn't sound its alarm, but the technician who ran the test didn’t pursue the matter, because the agency does not certify the alarms.
Nor did he send it to the Safety Equipment Institute, which does certify that the devices meet the standards set by the fire prevention association.
"The PASS device did not function," the technician wrote in the final report. "I made no attempt to determine why the device failed to activate. Because NIOSH does not test or certify PASS devices, no further testing or evaluations were conducted on the PASS unit."
One reason the CDC didn't focus on PASS alarms, Castillo told MSNBC.com, is that its mission is to focus on the factors that get firefighters into trouble — more than the factors that might help get them out of trouble. She called the PASS devices "tertiary," or of third rank or importance.
"When we are doing our investigation, we are focusing on those things that we feel — that we find, through our investigation process, have the greatest role in resulting in that firefighter's death," Castillo said. "The PASS device is a last resort."
Schmidt argues that it’s impossible to determine what's important without investigating. In agreeing to discuss his personnel file, he said, he doesn't want all the focus to be on PASS devices.
"My point for doing all this is, I want to make sure there’s a process in place to identify sentinel events, so investigators don’t have to fight tooth and nail to identify something, which may be a hunch.
"In 2000, when I wrote my letter, it was something that was odd, that I was trying to tell them. They said, ‘Don’t worry about that.’
"If you’re doing a scientific investigation," Schmidt said, "you have to write down these hunches, because if you get them two or three times, you’ve got a problem. ... Within 90 days of documenting a sentinel event, put something out to the fire service."
2003 death triggers a warning
It wasn’t until after a 2003 death, Castillo said, that the CDC concluded that PASS devices had a problem.
Even then the CDC took more than a year to issue a warning to the fire prevention association.
In the Inwood section of New York City on Dec. 16, 2003, firefighter Thomas Brick was lost in a fire in a mattress warehouse. It took 30 minutes to find him. When he was turned over, his PASS alarm emitted a very low sound of the sort associated with an electrical short.
Brick had been in the first class of recruits after the terror attacks of Sept. 11, 2001.
Brick's death, Castillo told MSNBC.com, "was the first in which our investigators had direct evidence that typical exposure to heat at the scene of a fire might adversely affect a PASS device."
Although the CDC team made its visit to the fire scene on Jan. 26, 2004 — 41 days after Brick's death — the agency waited another 450 days — until April 20, 2005 — to ask the National Fire Protection Association to consider toughening the tests for PASS alarms.
In that period, two more firefighters died in fires where rescuers couldn't find them:
Firefighter Steve Fierro died in Carthage, Mo., on Feb. 18, 2004. Unaware that Fierro was near the front of the building, the rescue team was searching at the rear. It took about 43 minutes to find him.
Firefighter Nito Guajardo died in Baytown, Texas, on Dec. 20, 2004. He was found after a 15-minute search, about 15 feet from the door.
"It was gut wrenching," said Schmidt, the former CDC engineer. "I mean it was very difficult to hear that additional firefighters were dying."
To try to figure out what was going wrong, the National Institute of Standards and Technology in Gaithersburg, Md., put two models of PASS alarms into its oven.
When heated first to room temperature, about 73 degrees F, both PASS devices beeped at about 86 decibels, roughly as loud as a Mack truck driving past at a distance of just 3 feet.
But when heated to 392 degrees, the PASS devices sounded at only 72 decibels, only as loud as a busy restaurant. (The decibel scale is logarithmic, so a drop of 14 decibels represents a substantial decrease in volume.)
"One of the tricky things is, the volume decreases, but when it cools down, it comes back," said Nelson Bryner, leader of the firefighting technology group that oversaw the tests.
"If a firefighter goes down, the noise generator may not have worked. But once the fire is out, now it's working. One is led to believe that the PASS worked the whole time."
The scientists won't reveal which companies made the two PASS devices that were tested, but in fire protection association committee meetings, manufacturers agreed that all the PASS devices now on the market use essentially the same technology to sense motion and sound the alarm.
But heat is only part of the problem.
The hair dryer treatment
Under the national standard since 1998, PASS devices must be able to withstand immersion in water for two hours, and even work after a dunk for 5 minutes with the battery compartment left open.
Since 2000, however, Dallas firefighters have been using hair dryers to dry out the battery and electronics compartments of their PASS devices, according to the department's safety officer. The water causes the devices to beep constantly, and firefighters fear that it might cause them not to sound at all when needed, a Dallas fire chief said.
"I'm embarrassed to say that's how we were addressing the problem, but the hair dryers worked," said the safety officer for Dallas Fire-Rescue, Battalion Chief Ray Reed.
He said the city is pressing the issue with the manufacturer, Scott Health & Safety, which is a division of Tyco International Ltd.
If he didn't serve on a national committee for the fire protection association, Reed said, he wouldn't have known that other departments were having similar issues.
A spokeswoman for Scott said the company is working closely with Dallas to resolve the problem, but wouldn't give any details.
A second manufacturer, Mine Safety Appliances, sent out a user advisory in November 2001 describing a problem that caused about 2 percent of its PASS devices to beep continuously. Some of those incidents were caused by water, the company said. The advisory attributed the problem to screws that have become loosened over time, and said it could be fixed by using different screws and adding waterproof glue.
Company remained mum on water leaks
No such alert was sent out by a third manufacturer, Survivair Respirators, although executives have testified that from 5 percent to 20 percent of its PASS alarms suffered from water leaks.
That information emerged in response to a lawsuit filed by the families of St. Louis firefighters Rob Morrison and Derek Martin, who died in the refrigeration company fire in 2002.
Morrison’s PASS alarm was not heard, and he was found only when a searcher stepped on him.
Martin's PASS alarm did work, but he became lost while searching for Morrison. Both firefighters were alive when they were found, but died within a day.
In the two-week trial of the Morrison family’s lawsuit in September, attorneys for Survivair disputed the claim that his PASS failed. The company argued that there were three innocent possibilities: Morrison had been moving the entire time he was lost, or for some reason he might have reset his PASS — in effect turning off the alarm — or it could have sounded but not been heard.
None of the firefighters hunting for Morrison testified that they heard his PASS alarm during the 20 minutes he was lost.
Executives of Survivair of Santa Ana, Calif., a company founded by Jacques Cousteau that is a division of the French company Bacou-Dalloz, testified that the problem of "leakers" was identified in 1997 or 1998, before its PASS device moved from preproduction to its first sale. Changes to address the problem continued at least until 2003, or a year after the St. Louis fire.
Complaints poured in from dozens of fire departments, the executives testified. About 300 out of 1,500 PASS devices sold to the Los Angeles Fire Department were returned to the company, determined to be leaking and replaced, testified James Beckstead, the company’s Western regional sales manager.
There was conflicting testimony from Survivair on the effect of the water leaks. Senior executives said that the device was designed with a fail-safe feature that would cause it to sound constantly if water got inside, making firefighters aware of the malfunction. But two company engineers testified that sometimes the devices wouldn’t sound an alarm at all if water got into the electronics.
‘We don't deem it a safety issue’
"No sound, no lights ... nothing," testified Duane Decker, the former Survivair mechanical engineer in charge of fixing the leaks. "It was determined that if water got in, sometimes they would not work."
Decker described making a series of changes: the cover was redesigned, to reduce the number of places where water could enter; a sealant was added to the cover gasket during assembly; then designers tried only the sealant with no gasket; as well as extending the coating on the circuit board to provide more protection. The company also began dunking every PASS device in water, not just a sample of them as before. But it did not call back the ones in the field for a dunking.
The St. Louis Fire Department, which bought its Survivair PASS devices in 1999, received no warning of the problem.
From the testimony of James Beckstead, the Western regional sales manager:
Q. You've said there was no recall. You've also said that there was no calling the PASS devices in for testing that were out there in the field. Was there any kind of a warning sent, a warning letter or call made, to fire departments that had the devices that were not water tested — about, "Hey," along the lines, "we've found a leakage problem, and be on the lookout," or anything like that?
A. Not that I recall.
Q. Any particular reason why not?
A. The only reason we would not do that is we don't deem it a safety issue.
Q. This is a life-saving device, isn't it?
A. It's a component of a life-saving device.
Executive: ‘The word was out there’
Survivair's senior executive, Jack Bell, testified there was no need for a warning, because firefighters knew about the water problem: "The word was out there, whether we formally told everyone — rumors or some way."
The lawyers disagreed on whether the CDC tested Morrison's PASS device, and what that test showed. The company said that the CDC tested Morrison's PASS device more than 100 times, and it worked perfectly. The CDC report on Morrison’s and Martin's death says that both PASS devices worked in a simple test, but that they were not subjected to more rigorous tests to determine if they met the national standard — again, because the CDC does not certify that equipment. Even in the simple test, the lawyer for the Morrison family argued, the video shows 3 minutes when the device failed to alarm.
And when an independent lab dunked Morrison's PASS device in water during testing to determine if it met the national standard, and then opened it in front of lawyers and a video camera, water spilled out of the electronics compartment.
"There isn't strong enough language to condemn how they handled this," the lawyer for the Morrison family, Daniel Finney Jr., of St. Louis, told MSNBC.com. "They were selling their products as lifesaving devices when they knew they were fatally flawed. They were selling them as a firefighter's lifeline, and they knew they could very well fail him in that situation, and they didn't tell anyone. It would be like selling parachutes when you know that they don't open one out of five times, and not telling anyone."
The company's vice president and general manager, Jack Bell, sent a statement to MSNBC.com in response to Finney's statement: "Survivair completely and unequivocally denies his false, factually unsupported and reckless charges. The evidence supporting Survivair’s position in this litigation is compelling. … Survivair’s equipment was not at fault."
A secret 11th-hour settlement
The jury never reached a conclusion. It was deliberating when Survivair and the Morrison family agreed to a settlement. The company admitted no fault and did not agree to make any changes or send out a warning, but it did pay an undisclosed amount to the Morrison family. A separate lawsuit by Derek Martin's family is headed to trial in April.
Meanwhile, St. Louis firefighters are still wearing the same model PASS device that Morrison wore.
Armed with the oven tests, and with testimony from the widows of Martin and Morrison, the National Fire Protection Association approved a tougher standard for PASS alarms in December. The standard, which is scheduled to be published on the association’s Web site on Friday, requires a series of tests showing the PASS alarm can withstand being heated, dunked in water, and tumbled in a dryer, according to a summary provided by the association.
The maximum temperatures the devices are required to withstand in the new test are no higher than in the old test: 500 degrees Fahrenheit for five minutes, then 1,500 to 2,100 degrees for 10 seconds in the flashover test. But it does require that the PASS device produce a sound after some of the torture tests; the old standard just required it not to melt or catch on fire.
The new standard also adds a "muffle test." The alarm will have to be more powerful so it can be heard if a firefighter falls on it.
Some manufacturers told the association that the new heat standard can't be met.
But the largest manufacturer of PASS alarms, Scott, says it will have a device to meet the new standard by this summer, when old inventory can no longer be sold.
Who will pay for replacements?
As for the more than one million U.S. firefighters with the old devices, their fire departments may have to pay for new ones, which cost about $200 apiece. It's not clear that any agency has authority to order a recall of the old ones:
# The U.S. Consumer Product Safety Commission says it doesn't have a role, because a firefighter's equipment isn't considered a consumer product.
# The National Fire Protection Association says that its standards are voluntary, that responsibility to enforce those standards rests with the Safety Equipment Institute, or SEI, another nonprofit, which certifies devices as meeting the standard.
# And SEI says that only the manufacturers can decide whether or not to recall the old devices.
"From what I understand, the manufacturer is the only one who can pull the trigger on a recall," said Stephen R. Sanders, the institute’s technical director. "We can influence whether or not a manufacturer does a recall. But they might look at us and say, ‘You're crazy.’"
The institute raised concerns several times about Survivair PASS alarms failing its random tests, but accepted the company's assurances that it was an isolated problem, or had been fixed, documents introduced in the Morrison trial show.
For Rob Morrison's widow, who comes from a firefighting family in St. Louis, the lack of accountability is baffling.
"I just couldn't figure that out," Laura Morrison said, "when firemen are giving their lives everyday to help the community and save people — and companies knew about this and never told anybody what the problem was, and let them, still today, go into a burning building not knowing if their PASS device is going to work or not."
© 2007 MSNBC Interactive© 2007 MSNBC Interactive
URL: http://www.msnbc.msn.com/id/16890732/
Part 2
CDC fields the ‘No Go Team’
Agency that examines firefighter deaths typically arrives 33 days later
SECOND OF TWO PARTS
By Bill Dedman
Investigative reporter
An MSNBC Special Report
Updated: 11:51 a.m. ET Feb 6, 2007
The CDC didn't ask for the job of investigating firefighter fatalities. That job was handed to it, after a union boss got a seat next to President Clinton on Air Force One. They were talking blue windbreakers.
After a plane or train crash, the National Transportation Safety Board dispatches its experts within two hours. The investigators in their familiar jackets take charge of the scene, secure evidence, follow leads.
The NTSB calls it the "Go Team."
That's what Harold A. Schaitberger had in mind. Now the general president of the International Association of Fire Fighters, he got an hour in the air with Clinton in the mid-1990s. The union boss told the president how the number of firefighting deaths, which had been declining sharply, was stalled at about 100 a year.
It might not have hurt their case that the firefighters had endorsed Clinton in 1992 and 1996. The president put $2.5 million in his budget for fiscal 1998 to study firefighter deaths. Congress gave the job to the Centers for Disease Control.
"We wanted to model it after the NTSB process," said Richard M. Duffy, the union's health and safety chief. "The public expects it. They expect to see those blue windbreakers every time there is such an incident.... And I think we’re getting to the point that firefighters expect that, too.”
After a decade and more than 300 investigations, how is the CDC doing?
Call it the "No Go Team."
An investigation by MSNBC.com shows that the CDC routinely takes as long as a month — and sometimes as long as nine months — to visit the scene of firefighter deaths. The CDC also:
# Doesn't investigate a death at all if the fire department or fire union raises an objection.
# Has cut back in the past three years on the number of investigations.
# Destroys information that could help identify patterns of hazards with firefighting equipment, training and tactics.
"Frankly I think the American firefighter deserves better," said Eric Schmidt, a former fire captain who was the CDC's first and only fire protection engineer before he was fired in 2000.
MSNBC.com reported Monday how documents show that Schmidt's managers in the CDC’s firefighter fatality program squelched his attempt to investigate PASS devices, the "man down alarms" that are intended to help comrades rescue an injured or immobilized firefighter. Schmidt had noticed that, in two fires in which firefighters died, the alarms weren't heard. When he kept investigating equipment problems, he was fired. Before the CDC issued a warning and recommended that the standards for PASS alarms be raised in 2005, 15 firefighters died in fires and their PASS alarm either didn't sound or wasn't loud enough to be heard, so rescuers had less chance to find them quickly.
Today, we look more broadly at the quality of CDC's investigations of firefighter deaths.
Equipment so good, it’s dangerous
Firefighting has gotten deadlier over the past decade, and one of the surprising reasons may be improved protective equipment.
With better gear, firefighters no longer surround and drown a fire — they go in. Instead of rubber coats, they have fire-resistant Kevlar. A generation ago, firefighters felt the heat and knew it was time to back out. Now, by the time they feel the heat, it may be too late to leave.
"Better protective equipment was never intended for people to get in deeper or stay in longer," said Bruce Teele, the National Fire Protection Association’s leading expert on firefighter equipment.
"Try telling that to a firefighter," countered Duffy, the union official.
Firefighters go where they're needed, sometimes ignoring the dangers even when no one is inside a burning building to be saved.
About 100 firefighters each year die on the job in the U.S. The number had been declining until the early 1990s, when it flattened out. It has stayed at 100 (not counting the 343 firefighters who died on Sept. 11, 2001), which means that the death rate per fire has climbed sharply, because fire safety efforts and smoke detectors have substantially reduced the number of fires. The number of structure fires fell by about one-eighth just in the past decade.
Last year was typical, with 104 firefighters dying in the line of duty, according to the memorial list kept by the U.S. Fire Administration.
The lack of progress in reducing fatalities is why Congress gave money to the CDC in 1998 to study firefighter deaths and make recommendations on how to avoid them. The CDC's occupational safety division was chosen because it had the experience and authority to investigate in workplaces.
Heart attacks on the job and vehicle accidents on the way to the fires account for about half of the firefighter deaths. The other half occur while fighting fires.
Why deaths per fire are increasing
Why are those deaths increasing? Studies have identified several reasons:
# Modern synthetic fabrics and furniture burn hotter than older furnishings. Americans have more electronic gear and other possessions in their homes, additional fuel for a fire.
# Lightweight wooden trusses in modern roofs collapse more easily than older beams, trapping more firefighters.
# Fire crews have been reduced and fire stations closed to hold down local tax bills. That means response times are up, and fires are burning longer before fewer firefighters arrive to attack them.
# A final irony: With fewer fires, there's less practice for firefighters and fire chiefs, so bad decisions may be more likely.
Before the CDC got involved, only a small number of fatalities were investigated, first by the National Fire Protection Association, and then by the U.S. Fire Administration. The Fire Administration reports were more thoroughly documented than the reports now done by CDC; they included timelines; dispatch communications; a description of the firefighters' protective equipment; and a description of changes made by the fire department after the fatalities. And they were more frank in describing errors in judgment by firefighters and incident commanders. Sometimes those investigative reports angered the fire union; sometimes they angered the fire departments; sometimes both.
When the CDC got the task, it assigned it to a small group in the National Institute for Occupational Safety and Health, or NIOSH, in Morgantown, W.Va., which had previously been investigating farm accidents, construction accidents — even deaths by industrial robots. Now it added the Fire Fighter Fatality Investigation and Prevention Program.
The firefighter fatality program isn’t a regulatory program — it doesn't enforce federal safety standards like OSHA does. Instead, it is supposed to make recommendations based on good science.
MSNBC.com found that the CDC delays sending investigators to the scene of firefighter fatalities. Although its investigation manual calls for a site visit within three weeks, the typical or median delay is actually 33 days, according to investigative reports studied by MSNBC.com. The longest delay was 266 days, or just about nine months.
The program does not have a 24-hour telephone line so that it can be notified of fatalities. "We do have a voice mail," said program manager Dawn Castillo. "If the call comes in on the weekends, we check it on Monday."
A month or more after a fatal fire, witness recollections are no longer fresh. It's often too late to secure the evidence or take measurements at the fire scene. So the CDC's investigators are left to work largely with secondhand information gathered by the fire department, the union, the state fire marshal.
In St. Louis, after two firefighters died on May 3, 2002, the CDC team traveled from Morgantown on June 24, a delay of 52 days.
"The building had already been torn down" by that time, said Laura Morrison, whose husband, Rob, was one of two firefighters who died that night. Other firefighters who were hunting for him said they never heard Rob Morrison’s PASS alarm.
"When they came to investigate, I was really excited about that," Laura Morrison said, because it was "the federal government and they were going to give me the answers I needed. And this was like 40 days later after the fire.
"But I thought they would really investigate, talk to firemen … find out exactly what happened to him, why firemen didn't hear his PASS device.
"When I got the report ... it said nothing about anything except certain things about what other firemen did or didn't do. It didn't go to the reason why Rob died."
Even in Worcester, Mass., where six firefighters died on Dec. 3, 1999, the CDC managers didn't want to send anyone immediately to investigate, said Schmidt, the former CDC fire prevention engineer. He said he called a CDC manager at home.
"And his comment to me was, ‘Well, that's not what we do. We'll get up there in a couple of weeks,’” Schmidt said. “But the next day, I see that they'd all left to go up there."
Castillo confirmed that the CDC went to Worcester immediately, only because the firefighter union called. Duffy, the union official, says he had the home number of Linda Rosenstock, the director of NIOSH.
"We called and said, ‘You guys have to be here,’” he said. “… I believed it was important for them to be there. There's a brand new branch to investigate firefighter fatalities, and we have six firefighters down.”
The CDC sent three people to Worcester the next day. Castillo, the manager of the program, said she wasn't sure whom Duffy called but confirmed his basic account. Rosenstock, who has since left the CDC, declined a request for an interview.
Then the CDC went right back to taking a month or longer to visit fire scenes, according to the CDC records reviewed by MSNBC.com.
Castillo said that a delay in visiting the scenes of deadly fires doesn’t mean the agency isn’t investigating. Members of her unit quickly begin making phone calls to line up the visit and gather information, she said. And she said taking time is more respectful to the family and the fire department, to allow time for funerals before investigators arrive.
Monday-Friday, 9-5
Although firefighters can and do die at any time of any day of the week, the CDC doesn't do much investigating on nights or weekends. The firefighter program reports indicate that while 43 firefighters died on weekends from 1998 through 2006, the CDC unit started only six site visits on Saturday or Sunday.
The CDC manual also urges investigators to limit their work days in the field to an eight-hour day.
By contrast, the NTSB manual encourages the investigators to leave within two hours and to work the case vigorously, with meetings from 7:30 a.m. to as late as necessary.
Fewer cases
At its measured pace, the CDC doesn't investigate every firefighter death. And last summer, it proposed reducing the number of cases that it does examine.
But without notice, it already had done so.
MSNBC.com combed through the Fire Administration's list of line-of-duty deaths from 1998 through 2006, to eliminate heart attacks and vehicle accidents and to make sure that every remaining death was one that the CDC would hear about. Then it compared that list against the CDC unit's investigations database and fatality reports, and asked the agency to update the database with any investigations in progress.
The results:
# From 1998 through 2003, the CDC investigated 89 percent of the fire scene fatalities, or 73 out of 82.
# From 2004 through 2006, the CDC investigated only 70 percent of the deaths, or 23 out of 33.
The firefighters union contends that Congress wanted every death investigated.
"Our belief is the congressional intent was that they go to every one, but Congress didn't give them the money," Duffy said.
NTSB comparison called invalid
Castillo said CDC has neither the money nor the mission to look into every death. “We did not get specific guidance, nor do we have the resources, to investigate every single firefighter death," she said. She said the CDC's $2.5 million budget for firefighter investigations is dwarfed by the $75 million that Congress gives to the NTSB each year.
Besides, the CDC has said, the conclusions of its investigations have become repetitive. Last summer, when it proposed scaling back, the agency stated that investigators "are finding similar contributory factors, and consequently repeating prevention recommendations made in previous investigations."
The CDC sought public comment last summer on a proposed change: investigating fewer specific incidents, freeing it to focus more time on databases and topical reports, such as firefighters who die of heart attacks, vehicle accidents, training accidents, and risk-vs.-reward decisions when fighting fires.
After encountering strong opposition at a public meeting to the idea of fewer investigations, the CDC abandoned the idea, Castillo told MSNBC.com. She said that the agency now plans to keep the investigations at the current level.
At that public meeting, a prominent fire chief and author of a text on firefighting encouraged the CDC to take a more scientific approach. Edward Hartin, a battalion chief in Gresham, Ore., said the investigations have been of substantial benefit to firefighters, but "there are some gaps in the information provided by these reports." He said he would like to see more information about the environment that the firefighters were working in — the building, the fire, the smoke, the heat — so better lessons could be learned about whether the firefighters made good decisions.
Only with cooperation
Unlike the NTSB, the CDC says it goes only where it's invited.
If the fire department or the union objects to having the deaths studied, the CDC backs off.
"There are times," Castillo said, "that we go out to do an investigation, we do not get cooperation. When that happens, we do not do the investigation. We have never pushed to do an investigation in that situation. ... The NTSB has specific authority to secure a site, to subpoena witnesses. ... We don't have that. We are relying on cooperation with the fire department. We have found it to be pretty successful. It's not a common event that they refuse cooperation.
"We were provided with funding for the firefighter initiative. We were not provided with statutory authority like other agencies such as the National Transportation Safety Board," Castillo said. "For example, we don't have statutory authority to enter and inspect a site, to obtain records, to perform tests, or order or obtain an autopsy for the purposes of investigation. What we do is we work with the fire department. ... We can only go when we have the cooperation from the parties that are involved."
At first, Castillo told MSNBC.com that the CDC doesn't have the right of entry to a death scene and hasn't sought it. Then she said she wasn't sure and would have to ask the CDC lawyers. In any case, she said, if the CDC has that right, it wouldn't use it very often.
"From our perspective and the feedback we are receiving from the majority of our stakeholders, our sense is that we are doing a good job, that the fire service is finding our investigations valuable for them," Castillo said. "Even if we have the authority, the agency as a whole uses it very judiciously."
Some deaths go unexamined
The CDC doesn't say which firefighter deaths it takes a pass on.
So MSNBC.com compiled its own list and found 19 firefighters from January 1999 through November 2006 whose deaths fighting fires were not investigated.
Duffy, the union safety chief, said the CDC should list every fatality on its Web site and say which ones it's not investigating.
That would be a major shift for the CDC, which doesn't identify the community or the firefighters in its reports. Confidentiality is a valued tradition in medical research, so it lists the deaths only by state and date.
But firefighter deaths are highly public events, so when the CDC reports six career firefighters were killed in a cold-storage and warehouse building fire in Massachusetts, every member of the fire service and many other citizens know that is code for "Worcester."
Shredding files
When the CDC finally acted in 2005 on the problem of PASS devices, the “man-down” alarms, it sent its public investigative reports to the National Fire Protection Association, urging it to consider raising standards.
Although the CDC told the association of five firefighter deaths that occurred where PASS alarms weren't heard, MSNBC.com found 15 in its review of the agency’s reports.
The CDC didn't identify the manufacturers, say when the alarms were made, or how they were maintained.
The CDC didn't say, because it didn't know.
The CDC investigators don't collect the same information in every fire about firefighter equipment or clothing. Castillo said it is left to individual investigators to judge which information to collect on each case.
And once the information is collected, the CDC often destroys it.
Castillo confirmed that the program keeps only the information in the reports it issues on firefighter deaths and the information in the CDC's investigations database. But MSNBC.com found that neither of those repositories has information on the make or model of PASS devices, or boots, hose lines, fire engines or any other gear that firefighters rely on — except for air supplies, for which the CDC is the certifying agency.
For PASS devices, Castillo said, "at the time that we did the investigation, we knew who made them. We do not have a record of those manufacturers. The issues that we helped uncover are not specific to an individual manufacturer; they speak to the standard the manufacturer was tested against, across a variety."
But how would CDC know if a problem was limited to a specific make or model or year if it doesn't keep that information?
"When they publish a report, they shred all the backup information," said Schmidt, the former CDC fire protection engineer. "They keep no files. You can't go back and look at past incidents. If we get a FOIA (Freedom of Information Act request), all we want to be able to do is to put the report in an envelope.
"… A comment that I heard from one of the managers at the time was, 'We don't want any widows' attorneys coming and looking at our information to build a case.' I was really offended by that. If there’s some firefighter’s widow, they deserve to hear the truth."
Castillo didn't deny that managers had said that, or something similar, but she said that concern about protecting fire departments or manufacturers from lawsuits is "not driving our investigations."
Autopsy? No thanks
In "performance guidelines" given to Schmidt in 2000, Castillo urged him to "minimize your fact gathering during investigations" and to focus only on the information necessary to explain the events that led to a death.
She scolded Schmidt for "your persistence in gathering complete autopsy reports, rather than simply getting information from the report on the cause of death." She pointed out that a manager of the program was more skilled and was able to make a phone call to get the cause of death without getting the report.
Fire departments have been told repeatedly to request an autopsy in every firefighter death, so lessons might emerge that could improve safety. That's been the advice from the International Association of Fire Chiefs, the National Fire Protection Association, the U.S. Fire Administration — and the CDC itself.
Schmidt said he had wanted autopsies so he could see, for example, whether the victim’s hands were burned, which would indicate that the firefighter took his gloves off. An autopsy also could show whether the firefighter was hampered by an underlying medical condition.
Castillo said it's still optional for her investigators to gather autopsy records, because they might not always be useful. In writing to Schmidt, she tied the limitation to privacy concerns: "Given limits on NIOSH's ability to protect information that is provided to us during the course of investigations, efforts are made to minimize information in our files with direct identifiers of individuals."
Neglected database
The CDC has boasted on its Web site about its investigations database, which Congress required it to set up. The CDC called it "a valuable tool to identify trends and analyze risk factors among line-of-duty injury deaths."
But MSNBC.com found that the database was riddled with errors that contradicted the official reports on incidents, and that it had been updated infrequently in recent years. The fire that killed Rob Morrison and fellow firefighter Derek Martin in St. Louis isn't in the database.
When the CDC was asked to cite any instances when the database had been used to identify trends or analyze risk factors, the agency removed any mention of the database from its Web site.
"We have recognized," Castillo said, "that the database has not lived up to its potential, and we are in the process of doing a critical evaluation of it."
In its present form, the database has no place to record the training that incident commanders have undergone, and no place to record information on equipment — aside from the air supplies, which the CDC certifies as meeting the national standard.
"If you were a reporter and you were doing a story on an airplane crash," Schmidt said, "you could call up the FAA (Federal Aviation Administration) or the NTSB and say, how many times has this engine been involved, and someone would say, ‘We’ve had four previous crashes.’ If you would do the same thing, can you tell me how many PASS devices had failed, they couldn’t do that."
Collecting the facts
Since Schmidt was fired in 2000, the CDC program has not hired another fire safety engineer. It has safety and occupational health specialists performing the firefighter investigations. Several do have experience and training as firefighters.
Schmidt said the underlying problem is that in 1998, Congress handed the CDC a role it hadn't asked for and may not have been trained for.
"They would spend a lot of time talking to the firefighters … and then they would write the report," he said. "… They would come back to the office, and say, ‘Which firefighter do you think was the most credible one there?’ — and benchmark everything against what that firefighter said.
"… So I would try — and this is where we were having a lot of disagreement — let's take a look at that hose, let's measure the burn mark on it, so it will tell us what position the hose was in, and that would tell us how far the firefighter got into the room. They would say, they told you. But how do you know they're right?"
Schmidt said that when he wanted to point out how inadequate a fire department's training budget was, "I had to literally argue my point, go into the office of the deputy director. They would say, 'You can’t talk about it, because you’ll be upsetting the local community. It’s a local decision.'
"That was troubling and perplexing, and to have managers say, don't follow up on that, don't look at the equipment, don't look at fire hoses that have failed, don't listen to the audiotapes — it creates a situation where the investigators don't know what to say or write because they don't understand what the managers are looking for. Because on one hand you have a procedure, and on one hand you have what the managers are telling you to say and not to say."
Castillo said her guidance to Schmidt to "minimize" investigations was directed particularly at an inefficient employee and does not reflect her general orders for the staff.
Castillo told MSNBC.com the CDC doesn't need another fire protection engineer.
"This is not an expertise that we have a need for consistently," she said. "When we don't think we have the expertise that's needed, we consult with external experts as warranted."
Both union and management want more
Last summer the a leader of the International Association of Fire Chiefs, I. David Daniels, asked the CDC to do more: investigate more of the firefighter deaths each year, especially deaths from trauma at fires; and add more information to the investigative reports, particularly on the culture in the fire department on risks vs. rewards.
The firefighters have a similar wish list. The firefighters union has long had issues with the way deaths are investigated. Now it has more friends in high places in the new Democratic-led Congress.
Duffy said the union will push this year for lawmakers to give the CDC additional funding to investigate every firefighter death; give notice if it decides not to investigate a death; institute a follow-up program to determine if fire departments implement safety recommendations; identify departments and individuals in its reports, and pay more attention to the forensic aspects of fire-scene investigations — "evidence gathering, mapping where the evidence is, chain of custody, examination or testing of the tools.”
But Castillo said the feedback she has heard leads her to believe that members of the fire service are pleased with the way the CDC is investigating firefighter deaths now.
"We have a tremendous amount of pride about the firefighter program," she said. "We think this is a flagship program and that we have made important contributions to firefighter safety."
© 2007 MSNBC Interactive© 2007 MSNBC Interactive
URL: http://www.msnbc.msn.com/id/16991877/
FIRST OF TWO PARTS
By Bill Dedman
Investigative reporter
An MSNBC Special Report
Updated: 11:40 a.m. ET Feb 6, 2007
Worn by a million firefighters in the U.S., the PASS device is a motion sensor that makes an awful racket if a firefighter stops moving for 30 seconds while battling a blaze. It flashes its lights and lets loose a series of ear-splitting beeps — an urgent call to help a fallen comrade.
It’s a call that hasn't always been heard. Tests by federal and independent labs show that some PASS alarms can fail to perform as intended if they get too hot or wet — a serious problem for people who rush into burning buildings with water hoses. And federal investigative reports reviewed by MSNBC.com show that 15 firefighters have died since 1998 in fires where a PASS, or Personal Alert Safety System, either didn't sound or was so quiet that rescuers weren't given a chance to find the firefighter quickly.
Documents made public under the Freedom of Information Act reveal that nine of those deaths came after the federal government blocked an investigation by its own expert into possible failures of PASS alarms and other firefighting equipment. A manager for the Centers for Disease Control and Prevention, the federal agency that is charged by Congress with investigating firefighter deaths, ordered an agency fire safety engineer on Feb. 14, 2000, to "minimize your fact gathering during investigations" and to restrict his investigations to issues relevant "for the prevention of future similar events."
On Monday, hours after the publication of MSNBC.com's report, Sen. John Kerry, D-Mass., called on the U.S. Department of Health and Human Services to investigate the "deeply troubling" information in the story. “It is completely unacceptable that our first responders don’t have the proper safety equipment, and if these allegations prove true, it’s unfathomable that the CDC would cover up something so detrimental to our firefighters’ safety,” Kerry told MSNBC.com.
On the same day that the CDC manager instructed the agency's fire safety engineer to scale back his investigation, Houston firefighter Kim Smith had become lost in a pre-dawn fire in a McDonald's restaurant.
Hearing no beeps from her PASS alarm, and seeing no flashing lights, her comrades searched for two hours before finding her body.
‘If a firefighter dies, it's a good funeral’
Nine more times, the rituals of a firefighter's funeral — a fire truck bearing the flag-draped casket; the bagpipers playing “Will Ye No Come Back Again?” — were re-enacted before the CDC took action, calling finally in April 2005 for higher standards for testing PASS alarms.
“Fire departments give good funerals," said Richard M. Duffy, the health and safety chief for the International Association of Fire Fighters.
"We never did investigations to the extent that they were needed … but we did some very, very good funerals. If a cop dies, it's a crime scene. If a firefighter dies, it's a good funeral."
After the CDC’s warning, tests quickly demonstrated that temperatures commonly encountered by firefighters could hurt the performance of at least some PASS alarms.
Tests in a convection oven at the National Institute of Standards and Technology found a problem with the two models it tested: The volume of the beeping diminished substantially at temperatures as low as 300 degrees Fahrenheit — the sort of temperatures that firefighters encounter in a room next to a fire. Researchers said they believe that all of the half-dozen or so brands of PASS alarms on the market would be similarly affected.
In addition, some PASS devices made by at least three manufacturers have had problems over the past decade with water leaking into the electronics or battery compartments, causing them to either beep continually or stop working altogether, according to interviews and documents reviewed by MSNBC.com.
Later this week, a tougher new standard for testing PASS devices in heat and water will be issued by the National Fire Protection Association. But manufacturers say it will be months before an improved device is on the market. And even when new models are available, there is no plan for recalling the old ones, so fire departments may have to bear the cost of replacing them.
Meanwhile, the approximately 1 million professional and volunteer firefighters across the nation will rely on the older PASS alarms as their last line of defense.
Precise role in fatalities is unclear
No one can say for sure that a PASS device caused any of the 15 deaths in which the alarms weren’t heard. And it's impossible to say that any firefighter would necessarily have survived if the PASS alarm had been seen and heard.
Firefighting is dangerous even when done right. But firefighter fatalities usually involve a series of mistakes: inadequate staffing or training; firefighters working alone instead of in pairs; an incident commander's mistake in evaluating the risk. The PASS device is intended to give firefighters who are injured, trapped or just lost in the smoke a chance to survive such miscues.
It is required to shriek for an hour at 95 decibels so it can be heard over the roar of the fire and the cacophony of chain saws cutting, exhaust fans blowing, glass breaking and water flowing.
"It sends a chill up your spine," Kenneth R. Willette, the fire chief in Concord, Mass., said of the alarm’s piercing cry. "You know that means someone is in trouble. So until you can locate that person, your heart is racing and all you can think about is finding that person."
The first generation of PASS alarms, which were introduced in the early 1980s, had a human problem: Annoyed when the device started beeping when they stood still on a break, many firefighters would just not turn them on.
So the National Fire Protection Association set a standard requiring that the device be armed automatically when a firefighter turns on the air supply. These so-called "integrated PASS devices" are built into the self-contained breathing apparatus. When the firefighter is motionless — usually for 30 seconds — they first sound a gentle beep, the pre-alarm signal, then ramp up to the full alarm. That's why, at a fire, bystanders will often see firefighters waggling their hips. They're not dancing. They're telling the PASS, "I'm still alive."
In exchange for that annoyance, firefighters rely on the devices to work when they need them. And they usually do. Manufacturers say that hundreds of firefighters have been saved by PASS devices.
Devices silent, or just too quiet
The stories of the 15 who were not saved are contained in reports by the CDC's Fire Fighter Fatality Investigation and Prevention Program. Each firefighter was wearing an automatic PASS alarm. In 12 of the 15 cases, nothing was heard; in three cases, the sound was muffled by the firefighter lying on the device and could be heard only when rescuers found the victim and rolled him over, according to the CDC's reports.
In November 2000 in Pensacola, Fla., firefighter Maurice Bartholomew got lost trying to leave a house fire. Firefighters searched for an hour before finding him in a kitchen at the back of the house. His PASS alarm wasn't heard or seen at all.
In March 2002 in Jefferson City, Tenn., volunteer firefighter Shane Murray was trapped in a house fire. He was found after 18 minutes just 5 feet from the door. His PASS device was beeping, but not loud enough to be heard while he was lying on it.
And in May 2002 in St. Louis, firefighter Rob Morrison's PASS alarm was not heard or seen for 20 minutes while he was injured inside a refrigeration company fire. Firefighter Derek Martin went looking for Morrison at the wrong end of the building and got lost. Both men died.
"I just can't believe that this was happening a number of times and no one was told about it," said Morrison’s widow, Laura. "I mean, Rob didn't know. None of the firemen knew."
Eric R. Schmidt didn't know for sure that PASS devices were malfunctioning, but he suspected that there was a recurring problem with the alarms.
Engineer's warning ignored
Schmidt went to work for the CDC in 1999 as the first fire protection engineer in the firefighter fatality program in Morgantown, W.Va. In 1998, Congress gave the CDC the responsibility for investigating firefighter deaths and searching for lessons that could prevent additional fatalities. The CDC's National Institute for Occupational Safety and Health, or NIOSH, was given responsibility for the program.
Documents provided by the CDC show that Schmidt was investigating a December 1999 fire in Keokuk, Iowa, where three firefighters died along with the three children they had been trying to save. The firefighters had been wearing two PASS devices apiece — one that is armed only if a firefighter turns it on, and the integrated alarm that is switched on automatically. Schmidt thought it was strange that none of the dozen other firefighters on the scene recalled hearing the alarms, so he wanted to collect the tape recordings from the dispatch center to see if the sounds could be heard there.
“I’m saying, the math here is astonishing," Schmidt told MSNBC.com, describing his conversation with his supervisors at the CDC. "The chance of having a dozen deaf firefighters is astronomical."
Schmidt also knew that in New York City in 1998, no one had heard the PASS alarms of two firefighters who died in a high-rise apartment fire. A third firefighter died in the same fire, but his PASS sounded. That information was in the CDC unit's investigative report on that fire, issued in August 1999.
"I can’t tell you I understood what the failure pattern was,” Schmidt said. “All I could tell you is, something is not adding up. This needs more attention. Let’s go back and listen to the tapes. They said, ‘We don’t want to listen to the tapes.’”
On that Valentine's Day morning in 2000, the head of the firefighter program, Dawn Castillo, gave Schmidt a memo labeled "performance guidelines."
First, she reminded Schmidt that he was still on probation as a new employee, and would need to improve his performance to keep his job.
Then she urged him to stop wasting his time asking for evidence such as dispatch tapes.
She criticized his "persistence in gathering complete autopsy reports"; just getting the cause of death by phone was sufficient, she said.
And she told Schmidt he didn't need to gather details such as the measurements of a fire hose that had burned through, or information on firefighters' protective jackets, which he thought had been recalled by the manufacturer.
‘Minimize your fact gathering’
Castillo offered four reasons for Schmidt to scale back his investigations:
# "The collection of detailed information not of likely use in an investigation is an inefficient use of your time."
# It's "a burden on those who help us in gathering the facts of the case."
# It's "a potential liability to the program if those who spend their time helping us to understand the case are upset by the absence of information that they helped provide in the summary report."gu
# Any information that is gathered could be requested from the CDC by others. The agency does not identify individuals in its reports.
"You need to minimize your fact gathering during investigations," Castillo wrote, "to those pieces of information which are needed to summarize the chain of events or that have direct implications for prevention recommendations."
The memo was hand-delivered just as fire departments around the country were lowering their flags to half staff.
Earlier that morning, in southwest Houston, 30-year-old Kim Smith had been about to end her 24-hour shift. She planned to spend the rest of Valentine's Day with her fiancé.
But at 4:33, a fire alarm awakened the crew in Fire Station 76: There was a fire at a McDonald's.
She was one of the first firefighters to rush into the restaurant. Attached to her air supply was a PASS device made by Scott Health & Safety, the U.S. market leader in self-contained breathing apparatus.
She and firefighter Lewis Mayo, 44, took a hose line into the kitchen for a "fast attack" on the fire. She'd done this many times, and had won regional competitions for her firefighting skills and endurance.
Inside the McDonald's, the heat became intense and 30-foot flames were shooting out of the roof. At 4:52 a.m., the chief ordered everyone to evacuate, but Smith and Mayo didn't emerge from the inferno. They had been buried by a ceiling collapse.
A PASS device was heard. It was Mayo's, and he was found alive, though he later died at the hospital.
But Smith's PASS was never heard, the CDC found. It took two hours to find her body in the debris, just 6 feet from the door. Police discovered later that burglars had set the fire.
Fired for ‘marginal’ performance
Four months after the double-fatality fire in Houston, Schmidt was fired by Castillo in June 2000 for "marginal" performance. Castillo wrote in his termination letter that he was not a good team player, was inefficient, and spent time gathering information "of questionable utility and necessity." She cited especially the delay waiting for the dispatch tapes in the Iowa fire. The program didn't replace him, and hasn't had a fire engineer since, she told MSNBC.com.
But Schmidt didn't drop the equipment issues. He wasn’t just an engineer, but also a former fire captain in Prince George's County, Md., with 20 years of experience in the fire service. On Oct. 2, 2000, he wrote to Dr. Linda Rosenstock, the director of the CDC's NIOSH agency.
Schmidt asked Rosenstock to look into the issues of firefighter equipment so more firefighters wouldn't die. He highlighted three instances where he was told not to investigate: the fire hose that failed; the firefighter coats that may have been recalled; and the PASS devices, which he called "another issue that warrants further investigation."
"This is but only one example," he wrote of Castillo's performance guidelines, "where the managers of this program in Morgantown repeatedly instruct staff to omit critical facts because of ‘potential liability to the program.’ These managers have shown little, if any regard, for the fact that fire fighters will continue to actually suffer injuries and death in part because NIOSH fails to document critical aspects of these incidents."
Rosenstock is no longer at the CDC. She was in her last month in government when Schmidt's letter arrived. Now the dean of the UCLA School of Public Health, she declined to be interviewed by MSNBC.com, but sent word through a spokeswoman that she doesn't remember Schmidt’s letter.
Castillo told MSNBC.com that the CDC took no action in response to the letter, because Schmidt didn't provide any new information beyond what they had already discussed.
"Although PASS devices were one issue that he addressed in his letter, in passing, that letter did not provide any additional documentation to substantiate his concerns," Castillo said.
She said no additional documentation was requested.
"No, no one acted upon it," she said, "because there was nothing substantive to act upon."
Manager: No valid areas of inquiry blocked
Castillo said she had not blocked any valid areas of inquiry, but didn't want Schmidt to get sidetracked by nonessential issues. To be able to investigate deaths with limited funds, she said, investigators had to limit themselves to the factors that led to deaths, not to follow trails on other safety issues of uncertain value.
In the Iowa fire, she said, the firefighters wouldn't have survived the extreme heat of a flashover, or sudden ignition of a room — even if their fire hose had held, or their coats had not been recalled, or the PASS alarms had been heard.
"Did we follow up and do additional testing? We did not," Castillo said. "Do we have the resources to go down every single path? We do not. Do we generally tell people not to follow up on promising leads? Absolutely not."
Citing a computer simulation of the Iowa fire, Castillo said the temperatures reached 1,100 degrees F, which she said was not survivable and in which no PASS device could be expected to operate. The national standard for PASS devices, however, has since 1998 included a flashover simulation: 1,500 to 2,100 degrees for 10 seconds.
After Schmidt was fired, the CDC released its investigative report on the Iowa fire in April 2001. One of its recommendations is curious: Instead of recommending that PASS alarms be tested, it stated that firefighters should use PASS alarms. But as another section of the report makes clear, all three firefighters were wearing their automatic alarms, and they were not heard.
Schmidt said he thinks one cause of his disagreements with Castillo was a difference in perspective. He is an engineer and a firefighter. She's an epidemiologist and specialist in child labor, who won her agency's top award in 2004. He said she just didn't respect the value of personal protective equipment, because child workers aren't allowed in jobs where such gear is used. But firefighters can't control their work environment -- they go where they're called. That's why they rely on helmets, hoods, gloves, boots, bunker pants, coats and face masks.
"She would say, 'The room flashed over. How could anybody have survived?'” he said. “I said, 'Well, firefighters have survived flashover. You're going to be in the burn ward for a period of time, but firefighters have survived flashover.'"
Other opportunities missed
As the years passed, the CDC missed other chances to look into PASS alarms.
In May 2001 in Passaic, N.J., firefighter Alberto Tirado was hunting for children in a fire. Rescuers entered the building three times trying to find him, and only when they turned him over could they hear a faint PASS alarm.
Back at the CDC lab, Tirado’s PASS device wouldn't sound its alarm, but the technician who ran the test didn’t pursue the matter, because the agency does not certify the alarms.
Nor did he send it to the Safety Equipment Institute, which does certify that the devices meet the standards set by the fire prevention association.
"The PASS device did not function," the technician wrote in the final report. "I made no attempt to determine why the device failed to activate. Because NIOSH does not test or certify PASS devices, no further testing or evaluations were conducted on the PASS unit."
One reason the CDC didn't focus on PASS alarms, Castillo told MSNBC.com, is that its mission is to focus on the factors that get firefighters into trouble — more than the factors that might help get them out of trouble. She called the PASS devices "tertiary," or of third rank or importance.
"When we are doing our investigation, we are focusing on those things that we feel — that we find, through our investigation process, have the greatest role in resulting in that firefighter's death," Castillo said. "The PASS device is a last resort."
Schmidt argues that it’s impossible to determine what's important without investigating. In agreeing to discuss his personnel file, he said, he doesn't want all the focus to be on PASS devices.
"My point for doing all this is, I want to make sure there’s a process in place to identify sentinel events, so investigators don’t have to fight tooth and nail to identify something, which may be a hunch.
"In 2000, when I wrote my letter, it was something that was odd, that I was trying to tell them. They said, ‘Don’t worry about that.’
"If you’re doing a scientific investigation," Schmidt said, "you have to write down these hunches, because if you get them two or three times, you’ve got a problem. ... Within 90 days of documenting a sentinel event, put something out to the fire service."
2003 death triggers a warning
It wasn’t until after a 2003 death, Castillo said, that the CDC concluded that PASS devices had a problem.
Even then the CDC took more than a year to issue a warning to the fire prevention association.
In the Inwood section of New York City on Dec. 16, 2003, firefighter Thomas Brick was lost in a fire in a mattress warehouse. It took 30 minutes to find him. When he was turned over, his PASS alarm emitted a very low sound of the sort associated with an electrical short.
Brick had been in the first class of recruits after the terror attacks of Sept. 11, 2001.
Brick's death, Castillo told MSNBC.com, "was the first in which our investigators had direct evidence that typical exposure to heat at the scene of a fire might adversely affect a PASS device."
Although the CDC team made its visit to the fire scene on Jan. 26, 2004 — 41 days after Brick's death — the agency waited another 450 days — until April 20, 2005 — to ask the National Fire Protection Association to consider toughening the tests for PASS alarms.
In that period, two more firefighters died in fires where rescuers couldn't find them:
Firefighter Steve Fierro died in Carthage, Mo., on Feb. 18, 2004. Unaware that Fierro was near the front of the building, the rescue team was searching at the rear. It took about 43 minutes to find him.
Firefighter Nito Guajardo died in Baytown, Texas, on Dec. 20, 2004. He was found after a 15-minute search, about 15 feet from the door.
"It was gut wrenching," said Schmidt, the former CDC engineer. "I mean it was very difficult to hear that additional firefighters were dying."
To try to figure out what was going wrong, the National Institute of Standards and Technology in Gaithersburg, Md., put two models of PASS alarms into its oven.
When heated first to room temperature, about 73 degrees F, both PASS devices beeped at about 86 decibels, roughly as loud as a Mack truck driving past at a distance of just 3 feet.
But when heated to 392 degrees, the PASS devices sounded at only 72 decibels, only as loud as a busy restaurant. (The decibel scale is logarithmic, so a drop of 14 decibels represents a substantial decrease in volume.)
"One of the tricky things is, the volume decreases, but when it cools down, it comes back," said Nelson Bryner, leader of the firefighting technology group that oversaw the tests.
"If a firefighter goes down, the noise generator may not have worked. But once the fire is out, now it's working. One is led to believe that the PASS worked the whole time."
The scientists won't reveal which companies made the two PASS devices that were tested, but in fire protection association committee meetings, manufacturers agreed that all the PASS devices now on the market use essentially the same technology to sense motion and sound the alarm.
But heat is only part of the problem.
The hair dryer treatment
Under the national standard since 1998, PASS devices must be able to withstand immersion in water for two hours, and even work after a dunk for 5 minutes with the battery compartment left open.
Since 2000, however, Dallas firefighters have been using hair dryers to dry out the battery and electronics compartments of their PASS devices, according to the department's safety officer. The water causes the devices to beep constantly, and firefighters fear that it might cause them not to sound at all when needed, a Dallas fire chief said.
"I'm embarrassed to say that's how we were addressing the problem, but the hair dryers worked," said the safety officer for Dallas Fire-Rescue, Battalion Chief Ray Reed.
He said the city is pressing the issue with the manufacturer, Scott Health & Safety, which is a division of Tyco International Ltd.
If he didn't serve on a national committee for the fire protection association, Reed said, he wouldn't have known that other departments were having similar issues.
A spokeswoman for Scott said the company is working closely with Dallas to resolve the problem, but wouldn't give any details.
A second manufacturer, Mine Safety Appliances, sent out a user advisory in November 2001 describing a problem that caused about 2 percent of its PASS devices to beep continuously. Some of those incidents were caused by water, the company said. The advisory attributed the problem to screws that have become loosened over time, and said it could be fixed by using different screws and adding waterproof glue.
Company remained mum on water leaks
No such alert was sent out by a third manufacturer, Survivair Respirators, although executives have testified that from 5 percent to 20 percent of its PASS alarms suffered from water leaks.
That information emerged in response to a lawsuit filed by the families of St. Louis firefighters Rob Morrison and Derek Martin, who died in the refrigeration company fire in 2002.
Morrison’s PASS alarm was not heard, and he was found only when a searcher stepped on him.
Martin's PASS alarm did work, but he became lost while searching for Morrison. Both firefighters were alive when they were found, but died within a day.
In the two-week trial of the Morrison family’s lawsuit in September, attorneys for Survivair disputed the claim that his PASS failed. The company argued that there were three innocent possibilities: Morrison had been moving the entire time he was lost, or for some reason he might have reset his PASS — in effect turning off the alarm — or it could have sounded but not been heard.
None of the firefighters hunting for Morrison testified that they heard his PASS alarm during the 20 minutes he was lost.
Executives of Survivair of Santa Ana, Calif., a company founded by Jacques Cousteau that is a division of the French company Bacou-Dalloz, testified that the problem of "leakers" was identified in 1997 or 1998, before its PASS device moved from preproduction to its first sale. Changes to address the problem continued at least until 2003, or a year after the St. Louis fire.
Complaints poured in from dozens of fire departments, the executives testified. About 300 out of 1,500 PASS devices sold to the Los Angeles Fire Department were returned to the company, determined to be leaking and replaced, testified James Beckstead, the company’s Western regional sales manager.
There was conflicting testimony from Survivair on the effect of the water leaks. Senior executives said that the device was designed with a fail-safe feature that would cause it to sound constantly if water got inside, making firefighters aware of the malfunction. But two company engineers testified that sometimes the devices wouldn’t sound an alarm at all if water got into the electronics.
‘We don't deem it a safety issue’
"No sound, no lights ... nothing," testified Duane Decker, the former Survivair mechanical engineer in charge of fixing the leaks. "It was determined that if water got in, sometimes they would not work."
Decker described making a series of changes: the cover was redesigned, to reduce the number of places where water could enter; a sealant was added to the cover gasket during assembly; then designers tried only the sealant with no gasket; as well as extending the coating on the circuit board to provide more protection. The company also began dunking every PASS device in water, not just a sample of them as before. But it did not call back the ones in the field for a dunking.
The St. Louis Fire Department, which bought its Survivair PASS devices in 1999, received no warning of the problem.
From the testimony of James Beckstead, the Western regional sales manager:
Q. You've said there was no recall. You've also said that there was no calling the PASS devices in for testing that were out there in the field. Was there any kind of a warning sent, a warning letter or call made, to fire departments that had the devices that were not water tested — about, "Hey," along the lines, "we've found a leakage problem, and be on the lookout," or anything like that?
A. Not that I recall.
Q. Any particular reason why not?
A. The only reason we would not do that is we don't deem it a safety issue.
Q. This is a life-saving device, isn't it?
A. It's a component of a life-saving device.
Executive: ‘The word was out there’
Survivair's senior executive, Jack Bell, testified there was no need for a warning, because firefighters knew about the water problem: "The word was out there, whether we formally told everyone — rumors or some way."
The lawyers disagreed on whether the CDC tested Morrison's PASS device, and what that test showed. The company said that the CDC tested Morrison's PASS device more than 100 times, and it worked perfectly. The CDC report on Morrison’s and Martin's death says that both PASS devices worked in a simple test, but that they were not subjected to more rigorous tests to determine if they met the national standard — again, because the CDC does not certify that equipment. Even in the simple test, the lawyer for the Morrison family argued, the video shows 3 minutes when the device failed to alarm.
And when an independent lab dunked Morrison's PASS device in water during testing to determine if it met the national standard, and then opened it in front of lawyers and a video camera, water spilled out of the electronics compartment.
"There isn't strong enough language to condemn how they handled this," the lawyer for the Morrison family, Daniel Finney Jr., of St. Louis, told MSNBC.com. "They were selling their products as lifesaving devices when they knew they were fatally flawed. They were selling them as a firefighter's lifeline, and they knew they could very well fail him in that situation, and they didn't tell anyone. It would be like selling parachutes when you know that they don't open one out of five times, and not telling anyone."
The company's vice president and general manager, Jack Bell, sent a statement to MSNBC.com in response to Finney's statement: "Survivair completely and unequivocally denies his false, factually unsupported and reckless charges. The evidence supporting Survivair’s position in this litigation is compelling. … Survivair’s equipment was not at fault."
A secret 11th-hour settlement
The jury never reached a conclusion. It was deliberating when Survivair and the Morrison family agreed to a settlement. The company admitted no fault and did not agree to make any changes or send out a warning, but it did pay an undisclosed amount to the Morrison family. A separate lawsuit by Derek Martin's family is headed to trial in April.
Meanwhile, St. Louis firefighters are still wearing the same model PASS device that Morrison wore.
Armed with the oven tests, and with testimony from the widows of Martin and Morrison, the National Fire Protection Association approved a tougher standard for PASS alarms in December. The standard, which is scheduled to be published on the association’s Web site on Friday, requires a series of tests showing the PASS alarm can withstand being heated, dunked in water, and tumbled in a dryer, according to a summary provided by the association.
The maximum temperatures the devices are required to withstand in the new test are no higher than in the old test: 500 degrees Fahrenheit for five minutes, then 1,500 to 2,100 degrees for 10 seconds in the flashover test. But it does require that the PASS device produce a sound after some of the torture tests; the old standard just required it not to melt or catch on fire.
The new standard also adds a "muffle test." The alarm will have to be more powerful so it can be heard if a firefighter falls on it.
Some manufacturers told the association that the new heat standard can't be met.
But the largest manufacturer of PASS alarms, Scott, says it will have a device to meet the new standard by this summer, when old inventory can no longer be sold.
Who will pay for replacements?
As for the more than one million U.S. firefighters with the old devices, their fire departments may have to pay for new ones, which cost about $200 apiece. It's not clear that any agency has authority to order a recall of the old ones:
# The U.S. Consumer Product Safety Commission says it doesn't have a role, because a firefighter's equipment isn't considered a consumer product.
# The National Fire Protection Association says that its standards are voluntary, that responsibility to enforce those standards rests with the Safety Equipment Institute, or SEI, another nonprofit, which certifies devices as meeting the standard.
# And SEI says that only the manufacturers can decide whether or not to recall the old devices.
"From what I understand, the manufacturer is the only one who can pull the trigger on a recall," said Stephen R. Sanders, the institute’s technical director. "We can influence whether or not a manufacturer does a recall. But they might look at us and say, ‘You're crazy.’"
The institute raised concerns several times about Survivair PASS alarms failing its random tests, but accepted the company's assurances that it was an isolated problem, or had been fixed, documents introduced in the Morrison trial show.
For Rob Morrison's widow, who comes from a firefighting family in St. Louis, the lack of accountability is baffling.
"I just couldn't figure that out," Laura Morrison said, "when firemen are giving their lives everyday to help the community and save people — and companies knew about this and never told anybody what the problem was, and let them, still today, go into a burning building not knowing if their PASS device is going to work or not."
© 2007 MSNBC Interactive© 2007 MSNBC Interactive
URL: http://www.msnbc.msn.com/id/16890732/
Part 2
CDC fields the ‘No Go Team’
Agency that examines firefighter deaths typically arrives 33 days later
SECOND OF TWO PARTS
By Bill Dedman
Investigative reporter
An MSNBC Special Report
Updated: 11:51 a.m. ET Feb 6, 2007
The CDC didn't ask for the job of investigating firefighter fatalities. That job was handed to it, after a union boss got a seat next to President Clinton on Air Force One. They were talking blue windbreakers.
After a plane or train crash, the National Transportation Safety Board dispatches its experts within two hours. The investigators in their familiar jackets take charge of the scene, secure evidence, follow leads.
The NTSB calls it the "Go Team."
That's what Harold A. Schaitberger had in mind. Now the general president of the International Association of Fire Fighters, he got an hour in the air with Clinton in the mid-1990s. The union boss told the president how the number of firefighting deaths, which had been declining sharply, was stalled at about 100 a year.
It might not have hurt their case that the firefighters had endorsed Clinton in 1992 and 1996. The president put $2.5 million in his budget for fiscal 1998 to study firefighter deaths. Congress gave the job to the Centers for Disease Control.
"We wanted to model it after the NTSB process," said Richard M. Duffy, the union's health and safety chief. "The public expects it. They expect to see those blue windbreakers every time there is such an incident.... And I think we’re getting to the point that firefighters expect that, too.”
After a decade and more than 300 investigations, how is the CDC doing?
Call it the "No Go Team."
An investigation by MSNBC.com shows that the CDC routinely takes as long as a month — and sometimes as long as nine months — to visit the scene of firefighter deaths. The CDC also:
# Doesn't investigate a death at all if the fire department or fire union raises an objection.
# Has cut back in the past three years on the number of investigations.
# Destroys information that could help identify patterns of hazards with firefighting equipment, training and tactics.
"Frankly I think the American firefighter deserves better," said Eric Schmidt, a former fire captain who was the CDC's first and only fire protection engineer before he was fired in 2000.
MSNBC.com reported Monday how documents show that Schmidt's managers in the CDC’s firefighter fatality program squelched his attempt to investigate PASS devices, the "man down alarms" that are intended to help comrades rescue an injured or immobilized firefighter. Schmidt had noticed that, in two fires in which firefighters died, the alarms weren't heard. When he kept investigating equipment problems, he was fired. Before the CDC issued a warning and recommended that the standards for PASS alarms be raised in 2005, 15 firefighters died in fires and their PASS alarm either didn't sound or wasn't loud enough to be heard, so rescuers had less chance to find them quickly.
Today, we look more broadly at the quality of CDC's investigations of firefighter deaths.
Equipment so good, it’s dangerous
Firefighting has gotten deadlier over the past decade, and one of the surprising reasons may be improved protective equipment.
With better gear, firefighters no longer surround and drown a fire — they go in. Instead of rubber coats, they have fire-resistant Kevlar. A generation ago, firefighters felt the heat and knew it was time to back out. Now, by the time they feel the heat, it may be too late to leave.
"Better protective equipment was never intended for people to get in deeper or stay in longer," said Bruce Teele, the National Fire Protection Association’s leading expert on firefighter equipment.
"Try telling that to a firefighter," countered Duffy, the union official.
Firefighters go where they're needed, sometimes ignoring the dangers even when no one is inside a burning building to be saved.
About 100 firefighters each year die on the job in the U.S. The number had been declining until the early 1990s, when it flattened out. It has stayed at 100 (not counting the 343 firefighters who died on Sept. 11, 2001), which means that the death rate per fire has climbed sharply, because fire safety efforts and smoke detectors have substantially reduced the number of fires. The number of structure fires fell by about one-eighth just in the past decade.
Last year was typical, with 104 firefighters dying in the line of duty, according to the memorial list kept by the U.S. Fire Administration.
The lack of progress in reducing fatalities is why Congress gave money to the CDC in 1998 to study firefighter deaths and make recommendations on how to avoid them. The CDC's occupational safety division was chosen because it had the experience and authority to investigate in workplaces.
Heart attacks on the job and vehicle accidents on the way to the fires account for about half of the firefighter deaths. The other half occur while fighting fires.
Why deaths per fire are increasing
Why are those deaths increasing? Studies have identified several reasons:
# Modern synthetic fabrics and furniture burn hotter than older furnishings. Americans have more electronic gear and other possessions in their homes, additional fuel for a fire.
# Lightweight wooden trusses in modern roofs collapse more easily than older beams, trapping more firefighters.
# Fire crews have been reduced and fire stations closed to hold down local tax bills. That means response times are up, and fires are burning longer before fewer firefighters arrive to attack them.
# A final irony: With fewer fires, there's less practice for firefighters and fire chiefs, so bad decisions may be more likely.
Before the CDC got involved, only a small number of fatalities were investigated, first by the National Fire Protection Association, and then by the U.S. Fire Administration. The Fire Administration reports were more thoroughly documented than the reports now done by CDC; they included timelines; dispatch communications; a description of the firefighters' protective equipment; and a description of changes made by the fire department after the fatalities. And they were more frank in describing errors in judgment by firefighters and incident commanders. Sometimes those investigative reports angered the fire union; sometimes they angered the fire departments; sometimes both.
When the CDC got the task, it assigned it to a small group in the National Institute for Occupational Safety and Health, or NIOSH, in Morgantown, W.Va., which had previously been investigating farm accidents, construction accidents — even deaths by industrial robots. Now it added the Fire Fighter Fatality Investigation and Prevention Program.
The firefighter fatality program isn’t a regulatory program — it doesn't enforce federal safety standards like OSHA does. Instead, it is supposed to make recommendations based on good science.
MSNBC.com found that the CDC delays sending investigators to the scene of firefighter fatalities. Although its investigation manual calls for a site visit within three weeks, the typical or median delay is actually 33 days, according to investigative reports studied by MSNBC.com. The longest delay was 266 days, or just about nine months.
The program does not have a 24-hour telephone line so that it can be notified of fatalities. "We do have a voice mail," said program manager Dawn Castillo. "If the call comes in on the weekends, we check it on Monday."
A month or more after a fatal fire, witness recollections are no longer fresh. It's often too late to secure the evidence or take measurements at the fire scene. So the CDC's investigators are left to work largely with secondhand information gathered by the fire department, the union, the state fire marshal.
In St. Louis, after two firefighters died on May 3, 2002, the CDC team traveled from Morgantown on June 24, a delay of 52 days.
"The building had already been torn down" by that time, said Laura Morrison, whose husband, Rob, was one of two firefighters who died that night. Other firefighters who were hunting for him said they never heard Rob Morrison’s PASS alarm.
"When they came to investigate, I was really excited about that," Laura Morrison said, because it was "the federal government and they were going to give me the answers I needed. And this was like 40 days later after the fire.
"But I thought they would really investigate, talk to firemen … find out exactly what happened to him, why firemen didn't hear his PASS device.
"When I got the report ... it said nothing about anything except certain things about what other firemen did or didn't do. It didn't go to the reason why Rob died."
Even in Worcester, Mass., where six firefighters died on Dec. 3, 1999, the CDC managers didn't want to send anyone immediately to investigate, said Schmidt, the former CDC fire prevention engineer. He said he called a CDC manager at home.
"And his comment to me was, ‘Well, that's not what we do. We'll get up there in a couple of weeks,’” Schmidt said. “But the next day, I see that they'd all left to go up there."
Castillo confirmed that the CDC went to Worcester immediately, only because the firefighter union called. Duffy, the union official, says he had the home number of Linda Rosenstock, the director of NIOSH.
"We called and said, ‘You guys have to be here,’” he said. “… I believed it was important for them to be there. There's a brand new branch to investigate firefighter fatalities, and we have six firefighters down.”
The CDC sent three people to Worcester the next day. Castillo, the manager of the program, said she wasn't sure whom Duffy called but confirmed his basic account. Rosenstock, who has since left the CDC, declined a request for an interview.
Then the CDC went right back to taking a month or longer to visit fire scenes, according to the CDC records reviewed by MSNBC.com.
Castillo said that a delay in visiting the scenes of deadly fires doesn’t mean the agency isn’t investigating. Members of her unit quickly begin making phone calls to line up the visit and gather information, she said. And she said taking time is more respectful to the family and the fire department, to allow time for funerals before investigators arrive.
Monday-Friday, 9-5
Although firefighters can and do die at any time of any day of the week, the CDC doesn't do much investigating on nights or weekends. The firefighter program reports indicate that while 43 firefighters died on weekends from 1998 through 2006, the CDC unit started only six site visits on Saturday or Sunday.
The CDC manual also urges investigators to limit their work days in the field to an eight-hour day.
By contrast, the NTSB manual encourages the investigators to leave within two hours and to work the case vigorously, with meetings from 7:30 a.m. to as late as necessary.
Fewer cases
At its measured pace, the CDC doesn't investigate every firefighter death. And last summer, it proposed reducing the number of cases that it does examine.
But without notice, it already had done so.
MSNBC.com combed through the Fire Administration's list of line-of-duty deaths from 1998 through 2006, to eliminate heart attacks and vehicle accidents and to make sure that every remaining death was one that the CDC would hear about. Then it compared that list against the CDC unit's investigations database and fatality reports, and asked the agency to update the database with any investigations in progress.
The results:
# From 1998 through 2003, the CDC investigated 89 percent of the fire scene fatalities, or 73 out of 82.
# From 2004 through 2006, the CDC investigated only 70 percent of the deaths, or 23 out of 33.
The firefighters union contends that Congress wanted every death investigated.
"Our belief is the congressional intent was that they go to every one, but Congress didn't give them the money," Duffy said.
NTSB comparison called invalid
Castillo said CDC has neither the money nor the mission to look into every death. “We did not get specific guidance, nor do we have the resources, to investigate every single firefighter death," she said. She said the CDC's $2.5 million budget for firefighter investigations is dwarfed by the $75 million that Congress gives to the NTSB each year.
Besides, the CDC has said, the conclusions of its investigations have become repetitive. Last summer, when it proposed scaling back, the agency stated that investigators "are finding similar contributory factors, and consequently repeating prevention recommendations made in previous investigations."
The CDC sought public comment last summer on a proposed change: investigating fewer specific incidents, freeing it to focus more time on databases and topical reports, such as firefighters who die of heart attacks, vehicle accidents, training accidents, and risk-vs.-reward decisions when fighting fires.
After encountering strong opposition at a public meeting to the idea of fewer investigations, the CDC abandoned the idea, Castillo told MSNBC.com. She said that the agency now plans to keep the investigations at the current level.
At that public meeting, a prominent fire chief and author of a text on firefighting encouraged the CDC to take a more scientific approach. Edward Hartin, a battalion chief in Gresham, Ore., said the investigations have been of substantial benefit to firefighters, but "there are some gaps in the information provided by these reports." He said he would like to see more information about the environment that the firefighters were working in — the building, the fire, the smoke, the heat — so better lessons could be learned about whether the firefighters made good decisions.
Only with cooperation
Unlike the NTSB, the CDC says it goes only where it's invited.
If the fire department or the union objects to having the deaths studied, the CDC backs off.
"There are times," Castillo said, "that we go out to do an investigation, we do not get cooperation. When that happens, we do not do the investigation. We have never pushed to do an investigation in that situation. ... The NTSB has specific authority to secure a site, to subpoena witnesses. ... We don't have that. We are relying on cooperation with the fire department. We have found it to be pretty successful. It's not a common event that they refuse cooperation.
"We were provided with funding for the firefighter initiative. We were not provided with statutory authority like other agencies such as the National Transportation Safety Board," Castillo said. "For example, we don't have statutory authority to enter and inspect a site, to obtain records, to perform tests, or order or obtain an autopsy for the purposes of investigation. What we do is we work with the fire department. ... We can only go when we have the cooperation from the parties that are involved."
At first, Castillo told MSNBC.com that the CDC doesn't have the right of entry to a death scene and hasn't sought it. Then she said she wasn't sure and would have to ask the CDC lawyers. In any case, she said, if the CDC has that right, it wouldn't use it very often.
"From our perspective and the feedback we are receiving from the majority of our stakeholders, our sense is that we are doing a good job, that the fire service is finding our investigations valuable for them," Castillo said. "Even if we have the authority, the agency as a whole uses it very judiciously."
Some deaths go unexamined
The CDC doesn't say which firefighter deaths it takes a pass on.
So MSNBC.com compiled its own list and found 19 firefighters from January 1999 through November 2006 whose deaths fighting fires were not investigated.
Duffy, the union safety chief, said the CDC should list every fatality on its Web site and say which ones it's not investigating.
That would be a major shift for the CDC, which doesn't identify the community or the firefighters in its reports. Confidentiality is a valued tradition in medical research, so it lists the deaths only by state and date.
But firefighter deaths are highly public events, so when the CDC reports six career firefighters were killed in a cold-storage and warehouse building fire in Massachusetts, every member of the fire service and many other citizens know that is code for "Worcester."
Shredding files
When the CDC finally acted in 2005 on the problem of PASS devices, the “man-down” alarms, it sent its public investigative reports to the National Fire Protection Association, urging it to consider raising standards.
Although the CDC told the association of five firefighter deaths that occurred where PASS alarms weren't heard, MSNBC.com found 15 in its review of the agency’s reports.
The CDC didn't identify the manufacturers, say when the alarms were made, or how they were maintained.
The CDC didn't say, because it didn't know.
The CDC investigators don't collect the same information in every fire about firefighter equipment or clothing. Castillo said it is left to individual investigators to judge which information to collect on each case.
And once the information is collected, the CDC often destroys it.
Castillo confirmed that the program keeps only the information in the reports it issues on firefighter deaths and the information in the CDC's investigations database. But MSNBC.com found that neither of those repositories has information on the make or model of PASS devices, or boots, hose lines, fire engines or any other gear that firefighters rely on — except for air supplies, for which the CDC is the certifying agency.
For PASS devices, Castillo said, "at the time that we did the investigation, we knew who made them. We do not have a record of those manufacturers. The issues that we helped uncover are not specific to an individual manufacturer; they speak to the standard the manufacturer was tested against, across a variety."
But how would CDC know if a problem was limited to a specific make or model or year if it doesn't keep that information?
"When they publish a report, they shred all the backup information," said Schmidt, the former CDC fire protection engineer. "They keep no files. You can't go back and look at past incidents. If we get a FOIA (Freedom of Information Act request), all we want to be able to do is to put the report in an envelope.
"… A comment that I heard from one of the managers at the time was, 'We don't want any widows' attorneys coming and looking at our information to build a case.' I was really offended by that. If there’s some firefighter’s widow, they deserve to hear the truth."
Castillo didn't deny that managers had said that, or something similar, but she said that concern about protecting fire departments or manufacturers from lawsuits is "not driving our investigations."
Autopsy? No thanks
In "performance guidelines" given to Schmidt in 2000, Castillo urged him to "minimize your fact gathering during investigations" and to focus only on the information necessary to explain the events that led to a death.
She scolded Schmidt for "your persistence in gathering complete autopsy reports, rather than simply getting information from the report on the cause of death." She pointed out that a manager of the program was more skilled and was able to make a phone call to get the cause of death without getting the report.
Fire departments have been told repeatedly to request an autopsy in every firefighter death, so lessons might emerge that could improve safety. That's been the advice from the International Association of Fire Chiefs, the National Fire Protection Association, the U.S. Fire Administration — and the CDC itself.
Schmidt said he had wanted autopsies so he could see, for example, whether the victim’s hands were burned, which would indicate that the firefighter took his gloves off. An autopsy also could show whether the firefighter was hampered by an underlying medical condition.
Castillo said it's still optional for her investigators to gather autopsy records, because they might not always be useful. In writing to Schmidt, she tied the limitation to privacy concerns: "Given limits on NIOSH's ability to protect information that is provided to us during the course of investigations, efforts are made to minimize information in our files with direct identifiers of individuals."
Neglected database
The CDC has boasted on its Web site about its investigations database, which Congress required it to set up. The CDC called it "a valuable tool to identify trends and analyze risk factors among line-of-duty injury deaths."
But MSNBC.com found that the database was riddled with errors that contradicted the official reports on incidents, and that it had been updated infrequently in recent years. The fire that killed Rob Morrison and fellow firefighter Derek Martin in St. Louis isn't in the database.
When the CDC was asked to cite any instances when the database had been used to identify trends or analyze risk factors, the agency removed any mention of the database from its Web site.
"We have recognized," Castillo said, "that the database has not lived up to its potential, and we are in the process of doing a critical evaluation of it."
In its present form, the database has no place to record the training that incident commanders have undergone, and no place to record information on equipment — aside from the air supplies, which the CDC certifies as meeting the national standard.
"If you were a reporter and you were doing a story on an airplane crash," Schmidt said, "you could call up the FAA (Federal Aviation Administration) or the NTSB and say, how many times has this engine been involved, and someone would say, ‘We’ve had four previous crashes.’ If you would do the same thing, can you tell me how many PASS devices had failed, they couldn’t do that."
Collecting the facts
Since Schmidt was fired in 2000, the CDC program has not hired another fire safety engineer. It has safety and occupational health specialists performing the firefighter investigations. Several do have experience and training as firefighters.
Schmidt said the underlying problem is that in 1998, Congress handed the CDC a role it hadn't asked for and may not have been trained for.
"They would spend a lot of time talking to the firefighters … and then they would write the report," he said. "… They would come back to the office, and say, ‘Which firefighter do you think was the most credible one there?’ — and benchmark everything against what that firefighter said.
"… So I would try — and this is where we were having a lot of disagreement — let's take a look at that hose, let's measure the burn mark on it, so it will tell us what position the hose was in, and that would tell us how far the firefighter got into the room. They would say, they told you. But how do you know they're right?"
Schmidt said that when he wanted to point out how inadequate a fire department's training budget was, "I had to literally argue my point, go into the office of the deputy director. They would say, 'You can’t talk about it, because you’ll be upsetting the local community. It’s a local decision.'
"That was troubling and perplexing, and to have managers say, don't follow up on that, don't look at the equipment, don't look at fire hoses that have failed, don't listen to the audiotapes — it creates a situation where the investigators don't know what to say or write because they don't understand what the managers are looking for. Because on one hand you have a procedure, and on one hand you have what the managers are telling you to say and not to say."
Castillo said her guidance to Schmidt to "minimize" investigations was directed particularly at an inefficient employee and does not reflect her general orders for the staff.
Castillo told MSNBC.com the CDC doesn't need another fire protection engineer.
"This is not an expertise that we have a need for consistently," she said. "When we don't think we have the expertise that's needed, we consult with external experts as warranted."
Both union and management want more
Last summer the a leader of the International Association of Fire Chiefs, I. David Daniels, asked the CDC to do more: investigate more of the firefighter deaths each year, especially deaths from trauma at fires; and add more information to the investigative reports, particularly on the culture in the fire department on risks vs. rewards.
The firefighters have a similar wish list. The firefighters union has long had issues with the way deaths are investigated. Now it has more friends in high places in the new Democratic-led Congress.
Duffy said the union will push this year for lawmakers to give the CDC additional funding to investigate every firefighter death; give notice if it decides not to investigate a death; institute a follow-up program to determine if fire departments implement safety recommendations; identify departments and individuals in its reports, and pay more attention to the forensic aspects of fire-scene investigations — "evidence gathering, mapping where the evidence is, chain of custody, examination or testing of the tools.”
But Castillo said the feedback she has heard leads her to believe that members of the fire service are pleased with the way the CDC is investigating firefighter deaths now.
"We have a tremendous amount of pride about the firefighter program," she said. "We think this is a flagship program and that we have made important contributions to firefighter safety."
© 2007 MSNBC Interactive© 2007 MSNBC Interactive
URL: http://www.msnbc.msn.com/id/16991877/