CDC’s fire investigation unit: the ‘No Go Team’

Bill Dedman Investigative reporter • Profile • E-mail

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.

/ U.S. Fire Administration The decline in firefighter line-of-duty deaths in the U.S. has stalled. The number of deaths has leveled off at about 100. This chart does not include 343 firefighter deaths on Sept. 11, 2001.

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.

Bill Greenblatt / UPI St. Louis Fire Commissioner and Chief Sherman George presents an American flag to Laura Morrison, widow of St. Louis firefighter Rob Morrison, during a memorial service in St. Louis on May 11, 2002. With her are their children, Matt and Megan.

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."

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