By Jamie Thompson
FireRescue1 Editor
BOSTON —Fifteen “causative factors” have been outlined in a report in the death of a Boston firefighter in a ladder truck crash in January last year.
The fire department’s board of inquiry report released this month outlines a range of issues including funding for preventative maintenance, insufficient manpower in the department’s maintenance division and the installation of improper parts by outside vendors.
Many of the findings mirror those found in a report compiled by an outside consultant that was released about two months after the incident that killed Lt. Kevin Kelley. The 52-year-old died when the brakes failed on Ladder 26 and it crashed into a building.
A second report in December, this time from police investigators, concluded that a department contractor installed brake parts on the vehicle that may have contributed to the accident.
It said the contractor replaced a brake chamber and pads on the ladder truck with “unsuitable” parts in spring 2008, which decreased stopping power significantly.
The latest report from the fire department’s board of inquiry goes into even more depth — 137 pages in total — into the reasons and factors behind the crash. “It is The Board of Inquiry’s opinion that it is of vital importance that the recommendations arising from this Report be implemented in a timely manner to prevent further accidents of this nature from occurring in the future,” the report said.
The “causative factors” it lists are:
1. An aging fleet of apparatus
2. Need for certified mechanics to perform major repairs
3. Installation of improper parts by outside vendors dating back to January 15, 1999
4. Lack of adequate funding for preventive maintenance
5. No employee assigned the specific responsibility of overseeing a
preventive maintenance program
6. Inadequate preventive maintenance program that did not meet the
Manufacturer’s recommendations
7. Insufficient manpower in the Maintenance Division
8. Antiquated record keeping
9. Lack of a system to communicate apparatus related safety bulletins
10. An inadequate driver’s training program
11. Lack of a comprehensive daily apparatus inspection program
12. Failure to drain apparatus air tanks on a daily basis
13. Lack of a periodic, thorough and objective safety audit based on NFPA 1500
14. Insufficient maintenance of L-26’s air supply, air compressor and air reservoir tanks, according to manufacturer’s recommendations
15. Severely reduced braking force due to improper brake adjustment of both front brakes and the right rear brake, and nonexistent brake force at the left rear brake
Among the areas of concern outlined on the report is “hiring practices” over the past few years. Historically, the Boston Fire Department positions of Superintendent of Maintenance and Assistant Superintendent of Maintenance have, almost exclusively, been reserved for appointment through the political process, the report said.
“There is credible evidence that some of these political appointments have been filled not at the discretion of the Fire Commissioner, but at the direction of City Hall,” the report said. “There is equally credible evidence that most of the people appointed to these positions have worked tirelessly in an attempt to carry out the responsibilities of their respective positions, albeit to varying degrees of success.
“The problem is that these appointments have been made exclusively as political rewards, with little or no consideration to the professional qualifications or aptitude of the individuals selected to fill these positions.”
Since January 10, 2009, the department has taken steps to appoint people who reportedly have proper credentials for the apparatus maintenance positions for which they are being hired, the report added.