Federal investigators should respond quickly when a firefighter is killed on the job, should spread the word promptly about equipment safety issues and may need increased legal authority to compel fire departments and unions to cooperate with investigations, according to a report this week by a federal inspector general.
The report was prompted by an MSNBC.com investigation, which revealed in February that 15 firefighters have died since 1998 in fires where a motion sensor called a PASS alarm, or Personal Alert Safety System, either didn't sound or was so quiet that rescuers couldn't find a downed firefighter quickly. Nine of those deaths came after managers at the Centers for Disease Control blocked an investigation by their own fire safety engineer into possible failures of firefighting equipment. Documents showed that the engineer was told by his manager in 2000 to "minimize your fact gathering during investigations."
The inspector general did not contradict any of MSNBC.com's findings: The CDC usually takes more than a month to send investigators to the scene of a fatality; doesn't investigate if the firefighters union or fire department refuses to cooperate; has cut back on the number of firefighter deaths it looks into, and destroys information that could help identify patterns of problems with safety equipment, training or tactics.
These problems are caused by a lack of resources and oversight, not by any wrongdoing or desire to cover up problems, said the inspector general of the U.S. Department of Health and Human Services, Daniel R. Levinson.
(Update: The International Association of Fire Chiefs has released its own recommendations for improving the CDC's investigations. See details here.)
The inspector general's report was requested by U.S. Sen. John Kerry, who said he will seek greater funding for the fire safety program — and stronger congressional oversight.
"I thank the inspector general for conducting a thorough investigation," the Massachusetts Democrat told MSNBC.com. "The IG found not a lack of willpower, but a lack of resources. It’s obvious that Congress needs to provide more funding to investigate firefighter deaths and clearly define what it expects from the CDC.
"I intend to work with my colleagues over the coming months to improve oversight of the CDC’s investigative process so that the grieving families of fallen firefighters can have no doubt that the government is doing everything it can to give them closure, and to learn from tragedy so we can prevent other families from suffering the same loss in the future."
Firefighter deaths on the job continue to occur about 100 times per year in the U.S., about half from trauma and half from heart attacks and other causes. They have been investigated since 1998 by a team in Morgantown, W.Va., working for the National Institute for Occupational Safety and Health, which is part of the CDC, a unit of Health and Human Services.
The inspector general identified four "opportunities for improvement" in the Fire Fighter Fatality Investigation Program:
- The CDC should have specific guidelines for performance. The inspector general reported that the CDC has "limited resources and lacks specific directions regarding how the program must be administered. As such, there are no standards to hold the organization accountable for how the funds are used or with which to measure the success of the program."
- The CDC should investigate more quickly. MSNBC.com found by studying the CDC's database of cases that the CDC routinely takes a month — and sometimes as long as nine months — to visit the scene. The inspector general said the CDC "should explore possible ways to initiate investigations closer to the date of the actual fatality. By delaying the investigation, memories of those at the scene may not be as fresh or complete, and in some investigations, the fire site itself has been altered or destroyed by the time NIOSH investigators arrive."
- The CDC should consider seeking increased authority from Congress. The inspector general said individuals are not required to cooperate or to be interviewed by the CDC, causing the CDC to seek "an atmosphere of collegiality," not naming names of individuals or manufacturers in its reports.
- The CDC should publicize its recommendations more quickly, particularly "when there are potential equipment safety concerns."
CDC spokesman Fred Blosser said Thursday that the agency welcomes the inspector general's report. "We will review the findings and recommendations closely, and will respond appropriately," he said. "One hallmark of the program has been the engagement of our partners and stakeholders to seek data and feedback to guide future direction of the program. We all take seriously our shared mission of preventing fatalities and injuries among firefighters."
The problem with PASS devices finally came to public attention in 2005, when the CDC took action, five years after the engineer had been told to minimize his investigation. The CDC called in March 2005 for testing of the alarms, citing five firefighter deaths from 2001 through 2004 in which PASS devices did not sound or were too quiet to be heard.
By looking at the agency's own reports, MSNBC.com found 10 other deaths in six fires from 1998 through 2002, all with PASS devices not heard.
The inspector general's report does not address the question of why the CDC did not raise questions sooner about the PASS alarms, except to note that in some cases the PASS alarms appeared to be too damaged by fire to be tested. It says the CDC "included examinations of PASS devices in its investigations, sent those devices for testing when warranted, and when evidence was sufficient, called attention to potential problems with PASS devices."
When PASS alarms were tested in 2005 in a lab at the National Institute of Standards and Technologies, a problem was found immediately: The volume of the alarm diminished substantially at temperatures as low as 300 degrees Fahrenheit — the sort of heat that firefighters routinely encounter before entering a room with a fire. The heat problem is believed to affect all models. In addition, some manufacturers have had problems with water seeping into the devices. Tougher tests for heat and water are called for in new standards from the National Fire Protection Association, issued this February.
Responding to Kerry's original request, the inspector general focused on the CDC's instructions to fire safety engineer Eric R. Schmidt to "minimize your fact gathering" in investigating the 1999 deaths of three firefighters in Iowa.
The inspector general confirmed that Schmidt received this instruction, but concluded that it merely reflected "a difference of opinion" between Schmidt and his supervisor, Dawn Castillo, over the investigative model to follow. CDC uses a public health approach, focusing more on research questions, not a traditional investigative approach that law enforcement might use, the inspector general explained.
The inspector general's report quotes unnamed CDC managers as saying that Schmidt never raised the issue of PASS devices while he worked there. He disagrees.
His personnel file, provided to MSNBC.com by the CDC, shows that Schmidt was chastised by Castillo in a "performance guidance" memo on Feb. 14, 2000, for taking too long to write the report on the Iowa fire.
Castillo cited as a negative his "persistence in gathering complete autopsy reports," his desire to measure the burned area of a fire hose, and a delay in waiting for the tape recordings of dispatch communications. PASS devices are not mentioned, but Schmidt told MSNBC.com that one reason he told his managers he wanted to listen to the dispatch tapes was to determine whether the PASS alarms could be heard.
Schmidt was fired by Castillo in June 2000, at the end of his probationary period, for "marginal" performance. Castillo wrote in Schmidt's termination letter that he had not corrected the issues raised in her earlier memo, was not a good team player, and spent time gathering information "of questionable utility and necessity."
The inspector general said that he concluded that "Mr. Schmidt's termination was not related to his desire to investigate PASS devices."
Schmidt said on Thursday that he had raised the issue of PASS devices several times, as well as other equipment issues, and that his firing didn't result from a mere difference of opinion.
"The inspector general doesn't mention that our written procedures said that we should document the personal protective equipment," Schmidt said. "When your supervisor gives you written direction not to follow the procedures, it puts investigators in a Catch-22. If you keep doing it, it's insubordination. If you don't document it, then they say, 'He didn't tell us about it.'"
The inspector general acknowledges, in a footnote, that Schmidt raised the PASS issue later, in a letter to the director of NIOSH in October 2002 after he was fired. Schmidt's letter said, "This is but only one example 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."
Castillo told MSNBC.com in February that CDC managers didn't follow up on Schmidt's letter "because there was nothing substantive to act upon."
Schmidt said the inspector general's report "is further proof that the program shouldn't be run by the CDC. We did nothing wrong, they're saying, but they're saying we've learned from our mistakes. Maybe we need to find another model."
He was the agency's first fire safety engineer, and it hasn't employed another. Castillo remains in charge of the firefighter program. Two managers under her have left the agency since the MSNBC.com report in February; one retired and the other moved to another government job, the CDC said.
Newer models of PASS alarms able to withstand higher temperatures are now coming on the market, although most of the nation's firefighters continue to rely on the older models to bring help if they are trapped or knocked unconscious in a fire.