Firetruck parts not correct, police say
Brake chamber, pads ‘unsuitable’
A detailed police report from a recent investigation of a fatal Boston firetruck crash concludes that a Fire Department contractor installed the wrong parts on the ladder truck’s brakes several months before the crash and that firefighters who were not licensed mechanics repeatedly adjusted the brakes in violation of national safety guidelines.
The contractor replaced a brake chamber and brake pads on Ladder 26 with “unsuitable’’ parts in spring 2008, which decreased stopping power significantly, according to a copy of the report obtained by the Globe. A few months later, when firefighters working on the truck noticed the brakes not working properly, they made manual adjustments that may have masked underlying problems.
The report, prepared by Boston police homicide investigators, points to guidelines issued in 2006 by the National Transportation Safety Board that said such adjustments are “a dangerous practice that can have serious consequences.’’
The decreased braking power contributed to the massive brake failure Jan. 9, when Ladder 26 barreled down a steep hill and slammed into an apartment building, killing Lieutenant Kevin M. Kelley, the report said.
The report did not single out the faulty parts or the firefighter adjustments as primary causes. But they add to an already long list of cataclysmic errors that contributed to the crash. Last week, Suffolk District Attorney Daniel F. Conley said his investigation found poor driver training and a lack of preventive maintenance were contributing factors.
The police report, which Conley used in his investigation but did not release, adds fuel to ongoing controversy about how vehicle maintenance is handled in the Boston Fire Department, which was criticized after the crash for using firefighters instead of licensed mechanics to work on trucks and check repairs done by contractors.
Since then, the department has hired four licensed mechanics to oversee fleet maintenance and to help with repairs, but unlicensed firefighters continue to do the bulk of the work.
The report also contradicts the Fire Department’s assertions immediately after the crash that firefighters had not performed work on the brakes.
Yesterday, department spokesman Steve MacDonald said “further investigation revealed that was not the case.’’ MacDonald added that the department plans to hire more mechanics to do maintenance work.
“In the meantime, any work that’s done by firefighters is checked by the fleet safety manager, who is a licensed mechanic,’’ MacDonald said.
The 20-page police report states that the Fire Department hired Avon-based Damian Diesel Inc. to service Ladder 26 in early 2008. Damian Diesel subcontracted the job to Woodward’s Auto Spring Shop in Brockton, the report states. The shop told the police investigator that it had replaced brake shoes and pads on the ladder truck with “comparable’’ parts in March 2008, the report says.
But an examination of the truck after the crash found the pads were “insufficient,’’ providing less friction than required for the 22-ton truck, and a brake chamber that was smaller than required. Smaller brake chambers provide less braking force.
Mark Woodward, identified in the report as manager of Woodward’s Auto Spring Shop, reached by phone yesterday, said he had not seen the report and declined to comment.
The report states that Boston firefighters working in the department’s vehicle maintenance division were changing a tire on the truck on May 16, 2008, when they decided to adjust the brakes. Noticing the brakes were not working as forcefully as they should, they manually tweaked automatic slack adjusters on both rear wheels until the brakes stopped the wheels from turning, according to the report.
The slack adjusters are designed to automatically adjust brake pressure as brake pads wear down and should only be manually adjusted by qualified technicians when the part is initially installed or when it is the only way to get the vehicle to a repair shop, according to the guidelines from the NTSB. Those guidelines were also distributed in 2006 by the International Association of Fire Chiefs, which warned that manual adjustment outside those circumstances could have “deadly consequences.’’
The police report, citing Fire Department logs of maintenance work, pointed out that Boston firefighters and outside contractors performed the improper adjustments on the truck 10 times “despite clear and concise warnings to the contrary.’’
The Police Department’s findings prompted federal officials who are also investigating Boston’s crash to issue a rare safety bulletin in October warning fire departments across the nation once again about such practices. The bulletin from the Firefighter Fatality Investigation and Prevention Program at the National Institute for Occupational Safety and Health said it had learned that despite the earlier warnings, “fire departments may not fully appreciate the hazards related to manual adjustment of ASAs,’’ the automatic slack adjusters.
Robert Clarke, a consultant who specializes in large vehicle maintenance and engineering, said in an interview yesterday that the results of the Boston police investigation provide a “sad lesson.’’ He said the substandard brake pads, smaller brake chamber, and the manual adjustments by Boston firefighters would all have decreased stopping power when it was really needed: on a steep hill and with a poorly trained driver behind the wheel.
“You’ve got a bunch of things going on there at once,’’ Clarke said. “It’s a perfect storm situation.’’
Donovan Slack can be reached at firstname.lastname@example.org.