PASS systems prone to fail -- Mass. firefighters had gear in ’99 fire

Mass. firefighters who died in ’99 fire may have had faulty gear

By Jay Whearley
Sunday Telegram
Copyright 2007 Worcester Telegram & Gazette, Inc.
All Rights Reserved

WORCESTER, Mass. — Their jobs inherently dangerous, U.S. firefighters have learned that a vital piece of gear they rely on to signal others when one of them goes down can malfunction when exposed to high temperatures and water, two things routinely encountered battling fires with high-pressure hoses.

Since 1998, PASS alarms — Personal Alert Safety System devices — failed to work during fires in which at least 15 American firefighters were killed, according to government documents obtained and recently reported on by MSNBC.com. PASS devices contain motion detectors and, when activated, are designed to blare out an ear-piercing alarm when a firefighter doesn’t move for 30 seconds.

Not included on the list of the 15 killed are the six Worcester firefighters who perished the night of Dec. 3, 1999, in the abandoned Worcester Cold Storage and Warehouse building on Franklin Street. Firefighters Joseph T. McGuirk, Paul A. Brotherton and Jeremiah M. Lucey, and Lts. Timothy P. Jackson, James F. Lyons and Thomas E. Spencer were wearing PASS alarms - which have been standard issue for city firemen since the early 1980s - when they entered the maze-like building that quickly became engulfed in flames that wouldn’t be contained until the next day.

Whether their PASS alarms worked that night, however, is not, and probably never will be, known, according to District Chief Michael O. McNamee, who heads the department’s Fire Safety Unit.

What transpired after the first alarm came in at 6:13 p.m. - noxious fumes; smoke so thick it was impossible to navigate the six-story structure; temperatures well above 1,100 degrees; frantic searches, first for two homeless people believed still inside; then for fellow firefighters who couldn’t be located; and a deafening roar from myriad sources - fashioned a hellish, chaotic nightmare.

The PASS alarms worn by the six men who died may have functioned properly, said Chief McNamee, initial commander at the scene of the 1999 fire. He did say that, to his knowledge, no firefighter searching for them heard a PASS alarm coming from any of the six.

“We don’t know for sure,” he said. “I’m not sure we ever will know, or that it really even matters,” he added, pointing out that there simply was too much going on that night inside what quickly would become known as “the building from hell.”

In a lengthy report on the warehouse tragedy submitted in September 2000, the federal Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health refers to PASS alarms only once, in a section citing radio transmissions between command officers and two of the six firemen.

The following information is from the CDC-NIOSH report:

At 6:48 p.m., one of the two radioed: “We have an emergency, Command. We are two floors down from the roof. This is the rescue company. Come now, two floors down from the roof. Guys, not the top floor, one floor down ...”

A short time later, he radioed again: “We need air, we need air ... We are lost ...”

As crews tried to make their way to the presumed location of the pair, other firefighters reported at 6:54 p.m. that conditions inside the building were “deteriorating very quickly” and the fourth of what eventually would be five fire alarms was sounded.

At 6:55 p.m., a commander radioed: “Rescue 1, activate your PASS system so we can hear you. Activate your emergency alarm. Activate your PASS emergency alarm.”

“They are activated,” one of victims radioed back at 6:57 p.m.

Just 2 minutes later, however, the emergency alarms contained in portable radios carried by firefighters began sounding. There was a steady succession of the portable radio alarms blaring for more than a half-hour as searchers tried to locate the missing firefighters in the maze of small - many no more than 35 feet square - storage rooms. At 8 p.m., conditions were so perilous inside that all crews were ordered out of the building.

Practically all the nation’s estimated 1 million firefighters wear PASS alarms, usually built into the breathing apparatus they carry.

Chief McNamee pointed out that despite documented problems with the devices, they are an essential tool for firefighters.

The nation’s fire departments, he said, have long been aware of problems with the PASS alarms. Those concerns were echoed in a December 2005 bulletin issued by CDC-NIOSH Fire Fighter Fatality Investigation and Prevention Program. The alert advised that investigations into four firefighter fatalities between 2001 and 2004 confirmed that PASS alarms worn by the victims could either not be heard or were barely audible.

“Initial laboratory testing of PASS by the National Institute for Standards and Technology’s Fire Research Division has shown this sound reduction to occur at temperatures as low as 300 degrees Fahrenheit and could affect all PASS,” the bulletin advised fire departments.

The 300-degree figure raised eyebrows, Chief McNamee said, noting out that 300 degrees is low heat in a cooking oven and far less than what firefighters usually encounter battling a working fire.

Still, he said, anything that can help save a firefighter’s life is worth it. The alarms provide one of the last lines of defense for those on the front lines fighting fires.

The district chief’s sentiment is echoed by a statement issued by the National Fire Protection Association after the two-part investigative series carried on MSNBC News that detailed extensive problems with PASS alarms and the manner in which CDC-NIOSH investigated the issue.

“In spite of the problems with PASS, NFPA believes that PASS remains an important tool for firefighters and other emergency responders,” the nonprofit trade association said.

The Worcester Fire Department, Chief McNamee said, uses the Air-Pak model manufactured by Scott Health and Safety Co., a division of the Tyco International Corp., and has experienced relatively few problems. The design of the system places the PASS alarm at the base of harness supporting the air tank, which prevents the alarm from being muffled if a firefighter goes down on his back.

There are at least nine different manufacturers of the PASS alarms used in the United States.

The MSNBC reports about PASS alarms and CDC-NIOSH’s handling of concerns about the devices began airing on Feb. 9. Shortly afterward, the NFPA announced revised standards for PASS devices to improve their reliability. Those standards are to go into effect this August.

Chief McNamee said the upgrade certainly will improve the alarms, but he is worried about the additional cost. The WFD has 230 PASS devices, and the cost to improve each one is to be about $250. The Fire Department already is considering consolidating some fire companies to reduce expenses.

The MSNBC series documented accounts of 15 firefighters killed on duty. In 12 of the 15 cases, nothing was heard; in the three others the alarm was muted because the firefighters fell on the device. More troubling to many firefighters across the country was the second installment of the series, which reported that nine of those deaths came after the CDC blocked an investigation by its own fire safety engineer into possible failures of PASS alarms, and that the engineer was ordered in 2000 to “minimize your fact gathering during investigations” and to restrict his investigations to issues relevant “for the prevention of future similar events.”

The day the order to scale back the investigation was issued, MSNBC reported, a firefighter was killed in a fire at a fast food restaurant in Houston. Her PASS alarm was not heard by fellow firefighters.

Four months later, an agency engineer who had become highly suspicious of the alarms was fired by the CDC.

Sen. John F. Kerry, D-Mass., was reported to have been outraged by the news report and immediately demanded a full investigation into the situation. The senator was unavailable Friday, but his office forwarded a copy of a letter he had sent to Daniel Levinson, inspector general of the federal Department of Health and Human Services, which oversees the CDC.

“I write regarding an investigative report airing on MSNBC that accuses officials with the Centers for Disease Control (CDC) of blocking an investigation into the deaths of six firefighters whose personal safety equipment failed between 1998 and 2000 and failing to take action until nine more firefighters died under similar circumstances,” Mr. Kerry stated in the letter. “These allegations are deeply troubling and should be followed up immediately with a federal investigation.”

He questioned why the engineer had been fired “despite evidence he gathered that suggested a link between faulty PASS devices and these tragic deaths. Subsequent testing of these devices by an independent laboratory showed that they do not work properly in several conditions common in firefighting.

“We owe it to the families of the deceased firefighters, as well as the nearly 1 million firefighters who still use PASS devices, to get answers and hold the negligent parties to account,” Mr. Kerry said.

“Therefore, I request that you initiate an investigation into the CDC’s handling of its investigations and determine the veracity of these allegations.”