Faster response to firefighter deaths is urged

Bill Dedman Investigative reporter • Profile • E-mail

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.

Dennis Cook / AP file Sen. John Kerry, D-Mass., called for greater oversight of the CDC investigations.

"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."

James Cheng / MSNBC.com The controls for a PASS device. Most American firefighters still have the old style, believed to fail under high heat.

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.

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