Report Details Shoddy Maintenance In Boston

Poorly-trained mechanics, firefighters reluctant to report apparatus problems due to lack of preventive maintenance, bad record-keeping. Those are among a range of deficiencies found by a consultant hired to examine the Boston Fire Department’s maintenance division following a fatal accident early this year.

The Death Of Lt. Kelley

The maintenance shortcomings became personal on Jan. 9, when Lt. Kevin Kelley was killed after Ladder 26 crashed into a building, reportedly after the brakes failed. A review determined that the truck’s brakes had not been inspected since March 2008, despite the manufacturer’s recommendation that they be inspected quarterly.

The fatality prompted Boston Fire Commissioner Roderick Fraser to hire Mercury Associates Inc. of Gaithersburg, Md., a fleet management consultant, to assess the department’s vehicle maintenance practices. Mercury’s report was issued last month.

“It is important to note that our assessment was not intended to investigate the direct or indirect causes of the crash of Ladder 26 or to ascertain whether any other pieces of apparatus in the BFD fleet are in danger of being involved in similar accidents,” the consultants wrote. “Rather it was to examine the department’s general approach to apparatus maintenance and repair in recognition of the fact that no organization can have confidence in the safety of its fleet if it lacks confidence in the soundness of its fleet maintenance and repair practices.”

The report, from Fraser’s perspective, revealed an inspection and preventive maintenance program that was ineffective. There was no system to check the work of outside vendors who do the larger repairs. There was no sign of any processes or procedures for opening or tracking work orders. And, he said, the people assigned to maintenance didn’t have the knowledge, skills or abilities to do the job.

“It’s been this way for at least 30 years,” he said. “There’s no mechanics or emergency vehicle technicians. When I came here, I thought it odd that we have no mechanics or technicians working maintenance. The people assigned to do all the maintenance were firefighters. I attempted to negotiate with firefighters’ union to change that and replace firefighters with mechanics, and [at the time] they were opposed to that.”

One of the recommendations from Mercury Associates was to replace the firefighters in the maintenance department with professional mechanics and technicians. Fraser said that process is underway.

Need For Improvement

“We’re also trying to bargain with the union, and I think the union now realizes it’s more important than they originally thought,” he said. “This isn’t something that happened overnight, it happened over a long period of time. I’m not trying to point fingers; it’s not anyone’s fault. But the process has failed, and we need a new and improved process.”

Fraser said Kelley’s death opened the department’s eyes to the need for an outsider to take a closer look at the department’s vehicle maintenance and inspection procedures.

“One of the things we were faced with was the culture that there’s nothing wrong,” Fraser said. “Everything’s been fine for 50 years with the system as it is, so why do we need to change it? Having an outside consultant come in and write this report lays bare all the facts, so now there can be no argument about what the problems are and what needs to be done on either side.”

Hire A Consultant

Fraser recommends that fire officials anywhere who want a fresh look at their vehicle maintenance practices hire an outside consultant.

“I could have asked our public works garage to come over, but in some ways that’s not independent,” he said. “If you bring in a recognized expert like we did and say, ‘Hey, report what’s wrong and what we need to do,’ then no one can really contest what the report says.”

Fraser said removing any possible sign of bias is the key to change. “Sometimes one or both sides are reluctant to change,” he said. “Having an independent report from an expert means both sides have to come together independently, and agree to move forward to make the system work.”

Mercury Associates said the core of the problems with Boston’s fleet maintenance division was its use of firefighters. “The principal implication of relying primarily on firefighters rather than civilian managers and technicians to oversee the management and maintenance of the fleet is that BFD has been reluctant to invest in the development of in-house fleet management expertise,” the consultant’s report said. “We believe this is the primary reason that the department’s fleet management practices are deficient in many areas.”

One of those deficiencies cited in the report is that the department has no organized system to handle work orders and maintenance requests by firefighters. Another problem, according to the report, was that apparatus problems were not reported.

“Many firefighters reportedly are reluctant to report problems with their vehicles out of fear that they may be taken out of service for an extended period of time in order to address a back log of defects that has developed due to poor preventive maintenance practices and – no surprise – the repeated failure to report little problems that eventually snowball into bigger problems,” the report said. “Various anecdotes were shared with us during our visit about vehicles with obvious safety problems such as bad brakes and broken windows and mirrors being driven by firefighters.”

When Fraser started as commissioner two years ago, he said the maintenance people didn’t have e-mail, computers or the means to use fleet management software.

“So now every firehouse is up and running on the city’s fiber optic network, everyone is on e-mail and we have a process where you can report everything to maintenance,” Fraser said.”Now we are looking at bringing in maintenance professionals that have experience with fleet management software and put in place a process where we can report and track problems more effectively.”

He said Boston officials are looking at the popular Firehouse brand of software for fleet management, but he’s not convinced that it’s robust enough for the large department’s needs.

Getting the rank-and-file behind the changes will be difficult, Fraser said, but he’s already seeing signs of acceptance.

“You have to get them to understand the importance of it. I think that they do. We have a lot more things being reported today than before the accident and hopefully that will continue,” he said. “We just need to make it part of the culture, a culture of daily checks and proper training that emphasizes the importance of this.”

But what about smaller fire departments that may not be able to afford pricey consultants, fleet management software and full-time professional mechanics? Fraser said there are ways they can take a closer look at their maintenance procedures.

“Take the [National Fire Protection Association 1911] standard and use it as a checklist, which is what our consultant kind of did anyway,” he said. “He took the NFPA standard and went through it step-by-step and looked at all these different things to see if we were doing it.”

Fraser also recommended that fire officials in other towns and cities learn from Boston’s mistakes by reading the entire consultant’s report, posted on line at

He said, “a good way to learn on the cheap is to find out what other people have learned.” “If you read the report and you say, ‘Hmm, I’ve never heard of this, do we do that,’ you have yourself a question to start with. The report also mentions some things we are doing [to fix the problems], so you can look at those things and say, ‘Do I do that?'”

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