Flaws found in firefighters’ last line of defense

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."

MSNBC.com Eric R. Schmidt, former fire protection engineer for the CDC's Fire Fighter Fatality Investigation and Prevention Program

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.

CAUSE FOR ALARM Documents with this series You can read these documents online (in PDF files) to learn more about firefighter safety and the warnings that were raised: "Performance guidelines" for CDC fire protection engineer Eric Schmidt, from Dawn Castillo on Feb. 14, 2000 Eric Schmidt's termination letter at the CDC, from Dawn Castillo on June 9, 2000 Eric Schmidt's letter to the CDC's NIOSH director, Linda Rosenstock, on Oct. 2, 2000, warning about PASS devices and other firefighter gear CDC memo on hiring of Eric Schmidt and his qualifications, Feb. 22, 1999 Eric Schmidt's "fully successful" mid-year performance review, Feb. 7, 2000 The investigative manual for the CDC's Fire Fighter Fatality Investigation and Prevention Program A warning on PASS devices from the National Fire Protection Association, Dec. 5, 2005 The new standard on PASS devices from the NFPA And follow this link to watch excerpts of the interview with Eric Schmidt, a timeline, photos of the 15 firefighters who died, and more.

"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.

CDC Dawn Castillo, CDC

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.

"We reported that the PASS did not appear to be heard," Castillo said. "Did we follow up and do additional testing? We did not. 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.

Interactive Cause for Alarm View in-depth video interviews, a photo gallery and a timeline of events, and learn more about a firefighter's protective  equipment.

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.'"

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