Flaws found in firefighters’ last line of defense

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.

New York Daily News Firefighter Thomas Brick of Ladder #36 of the Inwood section of Manhattan, who died in December 2003 while fighting a four-alarm fire. His PASS alarm appeared to have shorted out.

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:

Baytown Fire Rescue Firefighter Nito Guajardo died in 2004 in Baytown, Texas. His PASS alarm wasn't heard.

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.)

CAUSE FOR ALARM Documents with this series You can read these reports (in PDF files) on firefighter protective clothing and equipment: NIST report on tests of PASS devices in high heat, September 2005 NIST report on electronic equipment in high heat, January 2006 NIST report on radios in high heat, August 2006 And follow this link for interviews, a timeline, and more.

"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.

Martin family photo St. Louis firefighter Derek Martin died trying to find Rob Morrison, whose PASS alarm wasn't heard.

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.

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