Monday, June 22, 2009
Friday, June 19, 2009
Firefighter Friday: Jessica Locke on Runaway Engine 13 (part two)
(Boston Globe)
ENGINE 13 REPORT DEFIES COMMON SENSE
Recently released video of the investigation into Engine 13 casts serious doubt on the report issued by Jack Laine of AJL Associates, which claimed human error on the part of the driver. The accident – which took place on May 15, 2007 – severely injured Lt. Rich Geary when the truck took off under its own power, running him over.
The report by AJL states: “{Engine 13} was indeed in the “Road position” otherwise the truck under discussion, also known as engine #13 would not have moved. In our opinion, human error is the major underlining factor in this accident.”
However, there is no explanation of the “human error” in the report.
Though Laine never comes out and says it, the crucial point of his conclusion centers around the green indicator lights in the cab: Did the driver put the pump shift lever into the correct position, which turns the lights on…or not?
The video clearly shows the truck malfunctioning. With the pump shift lever in the correct position, the green lights illuminate even though the truck transmission fails to “lock up” to produce water pressure. This is what the driver stated happened the night of the accident, and what was witnessed by Lt. Rich Geary prior to the accident. In addition, State Police photos taken the night of the accident show that the pump shift lever is in the correct position.
(The Police Report erroneously stated that the green light was a warning sign to the driver that he was in the wrong gear, and blamed the driver for ignoring it, thus their conclusion of “human error”.)
In an interview after the reports came out, Laine was asked directly what the driver did. Laine replied, “He made a mistake.” When asked what that mistake was, he said, “I don’t know what he did.” In another interview with a TAB reporter, Laine said, “He had a lapse of judgment.” Laine offered no further information as to the driver’s actions.
In the video, Laine is shown agreeing with Ralph Craven (the investigator hired by the Newton Firefighters Association), that there were numerous mechanical problems with the apparatus. Laine goes so far as to say in reference to Engine 13, “it did not make the shift” and “there is an issue with the system”. There is no reference to driver error.
On camera, Laine suggests the possibility the gear malfunctions were caused by the towing of the rig out from the embankment after the night of the accident. However, he is immediately refuted by Mr. Craven , who informed Laine that the apparatus suffered the same mechanical defects prior to the incident and were reported by two separate drivers. Laine responds: “I haven’t talked to anybody at the scene with any of that information.”
Laine never interviewed the driver. Further, according to Ralph Craven, Laine never did any of his own tests on the pump transmission. Witnesses at the scene of the investigation stated that Mr. Craven was “running the show”.
Laine said in an interview with the TAB that he stood by the cab while Mr. Craven was underneath the engine. However, in that same interview he said that he did not see anyone, including Craven, conduct an inspection to verify the unaligned gears.
This is an erroneous statement, as Mr. Craven was not only taking measurements of the unaligned gears, but Laine referenced Mr. Craven’s measurements in his own report.
Laine’s report indicated that Engine 13 should have been taken out of service because of mechanical issues. It also recommended that the vehicle be decommissioned, because it did not meet applicable National Fire Protection Association Standards.
Laine was paid $1855.95 by the City of Newton for his investigation.
(Jessica Locke is Executive Director of the Firefighters Fund (www.firefightersfund.org) an organization that provides assistance to FDNY firefighters suffering from exposure to Ground Zero, and author of Rescue at Engine 32, a memoir about her volunteer work with these firefighters after 9/11.)
Firefighter Friday: Jessica Locke on Runaway Engine 13 (part one)
The Newton Police report claims that the driver, Joe Yerardi, failed to note “warning signs” that the vehicle was not in “pump gear” mode. According to the police, green indicator lights in the cab and on the outside panel serve as this warning.
In fact, the green indicator lights are the signal that the driver is in “pump mode” and is “okay to pump”.
Police are not qualified to assess mechanical problems of fire apparatus pump operation. Based on testimony of witnesses and facts presented in a video of the investigation, the Police report coming to a conclusion of “human error” was clearly outside their area of expertise.
The Police report (PD) states:
“”We have determined that Engine 13 was not in pump gear position. Furthermore, the operator failed to appreciate the warning signs that the engine was not in pump gear position, but in fact in drive gear position. These warning signs are identified as the green indicator light in the front cab, the green indicator light on the side pump panel and absence of water pressure. Therefore, the operators failure to recognize these signs was a contributing factor in this accident.”
Ralph Craven, (RC) a nationally recognized emergency vehicle maintenance & safety investigator who submitted his own report [RC report] on the Engine 13 investigation on May 30, 2007, refuted this conclusion by the Newton Police. He states in a letter of 2/25/09:
“The PD report indicates that the green lights were a warning sign that the pump was not in gear. This is an incorrect statement, as green lights are indicators in a functioning apparatus that the driver is in pump gear. In the RC report several tests were performed and the lights did in fact illuminate while the pump was in the road position, which is a mechanical malfunction of this apparatus. Mr. Yeradi stated in the RC report that when he shifted in the cab, the green light illuminated and he exited the cab.”
The malfunction of the lights is verified in a video of the investigation. In addition, Lt. Geary told police he checked “the pump gear” in the cab. It was his responsibility as the officer to verify and report on any malfunction of the truck. In an interview he stated the green light was on. Photos of the cab taken by State Police Reconstruction Unit the night of the incident show that the pump lever is in the correct position.
Another error in the Police Report was in regard to water pressure.
Craven writes: “Officer Babcock stated another warning sign was a lack of water pressure. Both the AJL report [investigator hired by the City of Newton] and the RC report agree that there was a failure in the lockup for the automatic transmission. There would be no water pressure indicated on the gauge with this failure.”
Craven goes on to say in his letter that there was no way for Yerardi to know that lack of water pressure with green indicator lights on would mean he was in wrong gear unless he was a trained mechanic and had crawled under the truck to look. Other reasons why there might be lack of water pressure include a worn pump, a sticky gauge or “tank to pump valve” not open.
The Police Report also accused Yerardi of failing to follow proper reporting procedures:
“The failure by members of the Newton Fire Department in following established departmental procedures relative to identifying equipment problems and writing equipment repair request were evident in the investigation. All complaints of faulty equipment for Engine 13 were verbal and no member of the Newton Fire Department documented a written request for repair or attempted to take Engine 13 out of service. The problems in not reporting and reacting to equipment failures on Engine 13 was a contributing factor in this accident.”
Craven refuted this also:
“Mr. Yerardi stated they told the Deputy Chief of the pump problem, getting it into gear, and told him not to rely on them for water. Mr. Yerardi also informed his Captain of the pump problem. The City of Newton does not have a Formal Maintenance Program as indicated by the mechanics and Mr. Yerardi did in fact follow established procedures because he informed his Captain and Deputy Chief. It was their responsibility to take the vehicle out of service. Mr Yerardi acted within his scope of authority and responsibility.”
Craven summarizes: “The City supplied a piece of equipment that was insufficient and did not meet the standards. The vehicle was rife with mechanical failures that were reported up the channels but the City did nothing about them. Mr. Yerardi was doing his job with equipment that did not meet the standards, was broken and, not repaired and maintained according to professional standards. Mr. Yerardi simply had nothing to do with this accident other than the fact that he was assigned to be the driver the night of the accident.”
National Fire Protection Agency standards state: “The fire department assumes full liability of retaining known deficient apparatus in service. To knowingly operate or approve of the operation of a vehicle that could kill or injure the public or a firefighter severely exposes the fire department officials to liability." NFPA standards recommend that any apparatus 20 years old or older and built prior to 1991 should be removed from service permanently.
Engine 13 was 24 years old and was being used as a spare. In the past, Newton FD Chief LaCroix authorized 24 year old Ladder 4’s return to service after it injured two firefighters. The apparatus injured two more before it was finally decommissioned. LaCroix denied knowledge of the previous injuries to the media. LaCroix still continues to allow operation of 24 year old Engine 10 which is in full service at this time.
(Jessica Locke is Executive Director of the Firefighters Fund (www.firefightersfund.org) an organization that provides assistance to FDNY firefighters suffering from exposure to Ground Zero, and author of Rescue at Engine 32, a memoir about her volunteer work with these firefighters after 9/11.)
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