Flaws found in firefighters’ last line of defense

Bill Dedman Investigative reporter • Profile • E-mail

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 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.

KPRC Kim Smith and a second firefighter, Lewis Mayo, didn't emerge from the blazing McDonald's when the evacuation order was given. She died on Feb. 14, 2000, the same day that the CDC engineer was told not to waste his time on equipment problems.

“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.

James Cheng / MSNBC.com The controls for a PASS device

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.

Pensacola Fire Department Firefighter Maurice Bartholomew, Pensacola, Fla.

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.

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