oversight

Fire Safety Planning for the Weaver Building Needs Improvement

Published by the Department of Housing and Urban Development, Office of Inspector General on 2018-06-12.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                                     MEMORANDUM
                                           June 12, 2018


To:      Suzanne Israel Tufts
         Assistant Secretary for Administration, Office of Administration, A


From:    Brian T. Pattison
         Assistant Inspector General for Evaluation, Office of Inspector General, G

Subject: Final Evaluation Report – Fire Safety Planning for the Weaver Building Needs
         Improvement (2018-OE-0002)

Please see the attached final report on our evaluation of the smoke detection and alert system
during an incident on December 21, 2017. It contains three findings and three recommendations.
The report will be posted to our website within 3 days.

In your response to our draft report, you agreed with the findings and recommendations. Your
response, along with our comments to it, are included in appendix A. Based on your response,
we consider recommendation 1 “resolved-open” and recommendations 2 and 3 “unresolved-
open.” We will contact your office within 90 days to discuss your proposed management
decisions, unless we hear from your office sooner.

We appreciate the assistance you and your staff provided throughout the evaluation. If you have
any questions, please contact Director Paul Bergstrand at (202) 402-2728.

Attachment

cc
Michael Schimmenti, Director, Facilities Management Services, AHD
Rena Holland, Director, Office of Disaster Management and National Security, AHD
Mikko Makarainen, Audit Liaison, A1
Sherise Holden, Audit Liaison, A1




                                       Office of Inspector General
                                           Office of Evaluation
                                      th
                                 451 7 Street SW, Washington, DC 20410
                                 Phone (202) 708-0430, Fax (202) 401-2505
                                             www.hudoig.gov
     U.S. Department of Housing and Urban Development

                 Office of Inspector General
                       Office of Evaluation




     Fire Safety Planning for the Weaver
         Building Needs Improvement




                     Program Evaluations Division

Washington, DC      Report Number: 2018-OE-0002     June 12, 2018
                                                                     Executive Summary
                                                        Fire Safety Planning for the Weaver
                                                               Building Needs Improvement

Report Number: 2018-OE-0002                                                                  June 12, 2018

Why We Did This                  Results of Evaluation
Evaluation
                                On December 21, 2017, smoke spread from a malfunctioning air-handling unit
The Robert C. Weaver Federal on the 11th floor to parts of many other floors. While a smoke detector in an
Building serves as              air duct functioned properly and the fire department was notified, there was no
headquarters for the U.S.       audible alarm or public announcement to notify occupants to evacuate. People
Department of Housing and       in one suite described the smoke as “heavy” and “thick.”
Urban Development (HUD).
Thousands of people occupy it HUD and the General Services Administration believe that the fire safety
daily.                          system operated as designed. To sound an audible alarm for this incident, a
                                person would have had to pull a manual alarm. However, no one did. Without
Smoke and fire alert systems    an audible alarm or public notification, confusion spread about what was
are designed to provide a       happening, how widespread the threat was, and what people should do.
reasonable level of safety from
hazards created by fire or      We found that the occupant emergency plan for the Weaver Building did not
other dangerous conditions.     accurately describe the fire safety system or how occupants were to report a
We began this evaluation after fire or other emergencies; specifically, when to use manual pull stations. The
questions surfaced about how plan did not comply with regulations that require employers to explain the
the smoke detection and alert   preferred means of reporting emergencies and to list procedures for reporting a
system of the Weaver            fire or other emergency.
Building worked and was
supposed to work during an      Additionally, on March 22, 2018, we sent a memorandum to the Assistant
incident on December 21,        Secretary for Administration to inform her that fire drills had not been
2017.                           conducted at the Weaver Building for years, which posed a danger to
                                occupants of the building. The Assistant Secretary responded to our
                                memorandum by saying that a drill was being planned. On March 28, the fire
                                drill took place. We are encouraged by the Office of Administration’s quick
                                action, but a process is needed to ensure that drills occur at least every year.

                                 Recommendations

                                 To improve fire safety planning for the Weaver Building, we make the
                                 following recommendations to the Assistant Secretary for Administration:

                                    1. update the occupant emergency plan so that it lists the ways occupants
                                       are to report fires or other emergencies,
                                    2. periodically provide training on the occupant emergency plan once it is
                                       updated, and
                                    3. create a process to help ensure that fire drills for the Weaver Building
                                       occur at least every year.
Table of Contents
Introduction ..................................................................................................................... 2
   Objectives .................................................................................................................... 2
   Background .................................................................................................................. 2
   Scope and Methodology .............................................................................................. 2
Findings........................................................................................................................... 4
   The Smoke Detection System Worked as Designed, Although No Audible Alarms
   Sounded, Creating Confusion Among Building Occupants .......................................... 4
   The Occupant Emergency Plan for the Weaver Building Needs Improvement ............ 5
   HUD Had Not Conducted Fire Drills in Years............................................................... 5
Recommendations .......................................................................................................... 7
   1. Update the Occupant Emergency Plan so That It Lists the Ways Occupants Are
   To Report Fires or Other Emergencies ........................................................................ 7
   2. Periodically Provide Training on the Occupant Emergency Plan Once It Is
   Updated ....................................................................................................................... 7
   3. Create a Process To Help Ensure That Fire Drills for the Weaver Building Occur
   Every Year ................................................................................................................... 7
Appendixes ..................................................................................................................... 8
   Appendix A – Agency Comments and OIG Response ................................................. 8
   Appendix B – OIG Memorandum About the Lack of Fire Drills .................................. 10
   Appendix C – Acknowledgements ............................................................................. 11
   Appendix D – Acronyms............................................................................................. 12
Introduction
Objectives
Our objectives were to determine how the smoke detection and alert system was supposed to
work, whether the smoke detection and alert system worked as intended during the morning of
December 21, 2017, and whether fire drills were being conducted.

Background
On December 21, 2017, smoke spread throughout parts of the Robert C. Weaver Federal
Building. No audible alarm sounded during this incident. Smoke and fire alert systems are
designed to provide a reasonable level of safety from hazards created by fire or other dangerous
conditions. We began this evaluation out of concern that the smoke detection and alert system
may not have worked properly (for example, no audible alarms) during the incident.

The Weaver Building is headquarters for the U.S. Department of Housing and Urban
Development (HUD) and is owned by the General Services Administration (GSA). Thousands
of people occupy it daily. HUD’s Office of Administration, Office of Facilities Management
Services, is responsible for facilities management, including safety and environmental health.
The Office of Administration’s Office of Disaster Management and National Security is
responsible for emergency preparedness, including fire drills. GSA is responsible for the design,
maintenance, and testing of the fire safety system.

Scope and Methodology
We completed this evaluation under the authority of the Inspector General Act of 1978 as
amended and in accordance with the Quality Standards for Inspection and Evaluation issued by
the Council of the Inspectors General on Integrity and Efficiency (January 2012).

Scope

This evaluation focused on a single incident, when smoke spread throughout parts of the Weaver
Building on December 21, 2017. We expanded our scope during fieldwork to include the
frequency of fire drills.

Methodology

We interviewed HUD officials in the Office of Administration to learn how the smoke detection
and alert system is intended to operate and how it operated on the day of the incident. We
surveyed HUD Office of Inspector General (OIG) employees to learn what they saw, smelled,
and heard during the incident. We reviewed

   •    the occupant emergency plan for the Weaver Building,
   •    schematics of the Weaver Building,


                                                2
    •   testing and maintenance records for the fire safety system of the Weaver Building, and
    •   communication from the fire safety system of the Weaver Building to a MegaCenter. 1

Finally, GSA gave us its analysis of the incident and a description of the fire safety system in the
Weaver Building.

Limitations

GSA and HUD share responsibility for the fire safety system of the Weaver Building. For
example, GSA installed, tested, and maintained the system. GSA told us that the system
functioned as designed during the incident. Because GSA is outside our jurisdiction, we did not
review the specifics of the design and functionality of the system.




1
 MegaCenters monitor alarm systems, closed-circuit television networks, and wireless dispatch communications for
Federal facilities around the Nation. They are operated by the U.S. Department of Homeland Security, Federal
Protective Service.


                                                       3
Findings
The Smoke Detection System Worked as Designed, Although No
Audible Alarms Sounded, Creating Confusion Among Building
Occupants
HUD and GSA officials told us that the smoke detection system worked as designed during the
incident on December 21, 2017. The smoke and an odor were caused by a bearing and belt
malfunction on an air-handling unit on the 11th floor of the Weaver Building in an unoccupied
mechanical area. A smoke detector in a fan duct for the air handler activated and sent a signal to
a Federal Protective Service MegaCenter at 8:05 a.m. The activation of the smoke detector
caused the supply and return of air to shut down. Emergency response personnel from the
District of Columbia Fire Department arrived and determined that there was no fire.

The air-handling unit that malfunctioned services 1/8 of the building. The smoke and odor
migrated through the air-handling unit from the 11th floor throughout the other floors serviced
by this unit. The smoke was smelled on many floors but was perhaps worst on the 8th floor in a
suite occupied by OIG employees. We surveyed OIG employees to learn what they saw,
smelled, and heard during the incident. Two people who saw the smoke in one 8th floor suite
described it as “heavy,” and others said the odor was “noxious,” “electrical,” and of “burning
rubber.” One person said that “… thick grey smoke began to come out of every HVAC [heating,
ventilation, and air conditioning] vent in sight. The room began to rapidly fill with a smoky
chemical haze.”

Despite the heavy smoke and noxious odor, no audible alarm sounded or public announcement
occurred instructing people to evacuate. Several OIG employees instructed staff to evacuate on
their own initiative. However, because the incident occurred early in the morning, starting
around 8:05 a.m., people continued to come into the affected areas as others evacuated. Without
an audible alarm or public notification, confusion spread about what was happening, how
widespread the threat was, and what people should do.

According to GSA, the smoke detection system worked as designed because a message was sent
to the MegaCenter and the fire department sent emergency response personnel. GSA said that
people in areas affected by smoke should have manually activated an audible alarm by pulling an
alarm at an alarm station.

At the time of our fieldwork, GSA was installing a new fire safety system. This system included
smoke detectors in occupied areas, which did not exist at the time of the incident. A HUD
official said that the new detectors became operational on March 28, 2018. This same official
said the new smoke detectors sound an audible alarm when activated. While the new system is
operational and the old system has been taken offline, some of the new detectors were still being
tested as late as May 9, 2018.




                                                4
The Occupant Emergency Plan for the Weaver Building Needs
Improvement
The occupant emergency plan for the Weaver Building needs to be updated so that it accurately
describes the fire safety system and how occupants are to report a fire or other emergencies. 2 As
previously discussed, the air handler that malfunctioned services 1/8 of the Weaver Building.
During the incident, smoke spread from the 11th floor to at least the 2nd floor for this 1/8 of the
building. GSA said that occupants who saw smoke should have pulled a manual alarm to sound
an alarm. GSA also said that there was no record of a manual activation of the fire alarm system.
According to our survey of OIG employees, at least 13 people saw smoke. Additionally, the
smell of smoke spread to at least the 2nd floor. Yet no one followed GSA’s suggested protocol
by pulling a manual alarm.

The U.S. Department of Labor’s Occupational Health and Safety Administration (OSHA)
requires employers to explain to each employee the preferred means of reporting emergencies,
such as manual pull box alarms, public address systems, radio, or telephones. 3 OSHA also
requires employers to list procedures for reporting a fire or other emergency in their occupational
emergency plans. 4 However, the occupant emergency plan for the Weaver Building does not
state under what circumstances employees are to activate an alarm at a manual pull station. The
plan notes that these stations are located on each floor near stairwell exit doors and that pull
boxes activate the alarm system, but it also says that the fire alarm system is activated
automatically when a smoke detector goes off. It does not say that smoke detectors would not
produce an audible sound or that there were no smoke detectors in most of the occupied spaces
of the Weaver Building. 5 Based on the actions of individuals affected by this incident and the
lack of a clear explanation to employees of the preferred method for reporting a fire, a significant
number of occupants of the Weaver Building may not know when to pull a manual alarm.

HUD Had Not Conducted Fire Drills in Years
We were unable to determine when HUD last conducted a fire drill because officials could not
produce records showing when one last occurred. One official with whom we spoke said the last
one was in 2015, and another said the last one was before the shooting at the Navy Yard, which
was in September 2013. GSA requires agencies that occupy its buildings to participate in at least
one fire drill per year. 6

Email correspondence we reviewed showed that dates for a drill in 2016 were discussed but the
drill did not occur. We asked the emergency management specialist, whose role is to help

2
  While there was no fire during this incident, for the purposes of this report, we consider that a smoke event
constitutes a “fire or other emergency.”
3
  29 CFR (Code of Federal Regulations) 1910.165(b)(4)
4
  29 CFR 1910.38(c)(1)
5
  The audible alarms in the Weaver Building at the time of the incident were those in the childcare center, the
sprinklers, and the manual pull stations. Smoke detectors in the ducts, elevators, and computer room send a signal to
a MegaCenter but would not produce an audible alarm. There were no smoke detectors in the hallways or occupied
areas for most of the building.
6
  41 CFR 102-74.360(a)


                                                         5
coordinate fire drills, why a drill did not occur in 2016. He said the drill did not take place due
to a misunderstanding of the drill’s purpose, the priority of it, and a lack of support from
management. We also saw evidence of a planning meeting in December 2016, during which an
evacuation drill was discussed for the spring of 2017, but this drill did not occur. When asked
about the potential risk of not having drills, the emergency management specialist said that the
Weaver Building is a highrise with two to three thousand people in it. If something catastrophic
happened and the people that work in the building were not prepared to react to the events, the
specialist believed it would be devastating.

On March 22, 2018, we sent a memorandum to the Assistant Secretary for Administration to
inform her that fire drills at the Weaver Building had not been conducted for years, which posed
a danger to occupants of the building. 7 The Assistant Secretary responded to our memorandum
by saying that a drill was being planned. On March 28, the fire drill took place.




7
    See appendix B for the memorandum.


                                                 6
Recommendations
On December 21, 2017, smoke spread from a malfunctioning air-handling unit on the 11th floor
to parts of many other floors. While a smoke detector in an air duct functioned properly and the
fire department was notified, there was no audible alarm or public announcement to notify
occupants to evacuate. This condition occurred because no one pulled a manual alarm.
Additionally, fire drills had not been conducted for years. To improve fire safety planning for
the Weaver Building, we make the following three recommendations to the Assistant Secretary
for Administration.

1. Update the Occupant Emergency Plan so That It Lists the Ways
   Occupants Are To Report Fires or Other Emergencies
After GSA reviewed the smoke incident, it recommended that HUD address the protocol for
manually activating the building fire alarm in its emergency action plan. While the occupant
emergency plan describes the location of pull stations and states that they activate the building
alarm system, the plan does not specify under what circumstances the use of a pull box is
preferred and should be used instead of relying on an automatic activation from a smoke
detector. It also does not state that smoke detectors do not produce an audible alarm in most
cases. The plan should be updated to state when occupants should use a manual pull station to
report a fire or other emergency.

2. Periodically Provide Training on the Occupant Emergency Plan
   Once It Is Updated
Because no one pulled the manual alarm on the day of the incident, training is needed on the
proper way to report a fire or another emergency. Additionally, OSHA requires employers to
explain to each employee the preferred means of reporting emergencies. While an updated
occupant emergency plan will be a useful reference, proactively training HUD employees on a
recurring basis will help HUD meet this requirement.

3. Create a Process To Help Ensure That Fire Drills for the Weaver
   Building Occur Every Year
We are encouraged that the Office of Administration conducted a fire drill before the issuance of
this report. Yet we identified insufficient support for fire drills in the past. A more rigorous
process is needed to ensure that fire drills occur at least every year so that this critical safety
exercise is taken seriously by HUD’s future leaders.




                                                 7
Appendixes
Appendix A – Agency Comments and OIG Response
Response From the Office of Administration

Reference to
OIG
Comments




Comment 1




Comment 2




Comment 3




                                             8
OIG’s Comments to the Office of Administration’s Response

Comment 1 The Office of Administration agreed with recommendation 1 and said it will
          augment the occupant emergency plan by June 29, 2018. This plan meets the
          intent of the recommendation. The Office of Administration should provide us
          with the revised plan when it is complete. The status of recommendation 1 is
          “resolved-open.”

Comment 2 The Office of Administration agreed with recommendation 2 and said it will hold
          annual training for all HUD employees and will conduct quarterly training for all
          HUD staff members who help execute the plan, including volunteers. The Office
          of Administration should provide us with an estimated target date for these
          trainings within 90 days of this report’s issuance so that we can reach agreement
          on its management decision. The status of recommendation 2 is “unresolved-
          open.”

Comment 3 The Office of Administration agreed with recommendation 3 and said it will plan
          and conduct fire drills in the Weaver Building annually. This plan does not meet
          the intent of the recommendation. Because fire drills within the Weaver Building
          did not occur for years, a rigorous process is needed. Such a process will help
          ensure that this critical safety exercise is taken seriously by HUD’s future leaders.
          To meet the intent of this recommendation, the Office of Administration should
          create and document a process for holding fire drills at least annually. Within 90
          days of the issuance of this report, the Office of Administration should provide us
          with a proposed management decision outlining its plan for meeting
          recommendation 3. The status of recommendation 3 is “unresolved-open.”




                                               9
Appendix B – OIG Memorandum About the Lack of Fire Drills




                               10
Appendix C – Acknowledgements
This report was prepared under the direction of Brian T. Pattison, Assistant Inspector General for
Evaluation, and Paul H. Bergstrand, Director of the Program Evaluations Division. The Office
of Evaluation staff members who contributed are recognized below.

Major Contributors

Paul H. Bergstrand, Director (team lead)
Lindsay Clarke Brubaker, Senior Evaluator
Christa Kidd, Senior Evaluator
Sonia Pena, Senior Forensic Auditor

Other Contributors

Joshua Rowell, Senior Evaluator
Mofoluso Odunuga, Evaluator




                                               11
Appendix D – Acronyms
   ACRONYM                                       DEFINITION
     GSA      General Services Administration
     HUD      U.S. Department of Housing and Urban Development
     OIG      Office of Inspector General
    OSHA      Occupational Safety and Health Administration




                                            12
The Office of Inspector General is an independent and objective oversight
 agency within the U.S. Department of Housing and Urban Development.
We conduct and supervise audits, evaluations, and investigations relating
to the Department’s programs and operations. Our mission is to promote
economy, efficiency, and effectiveness in these programs while preventing
            and detecting fraud, abuse, and mismanagement.

  Report fraud, waste, and mismanagement in HUD programs and operations by
         Completing this online form: https://www.hudoig.gov/report-fraud
         Emailing the OIG hotline: hotline@hudoig.gov
         Faxing the OIG hotline:      (202) 708-4829


                        Sending written information to
              U.S. Department of Housing and Urban Development
                    Office of Inspector General Hotline (GFI)
                         451 7th Street SW, Room 8254
                             Washington, DC 20410

                    Whistleblowers are protected by law.
         https://www.hudoig.gov/fraud-prevention/whistleblower-protection

                                       Website
                             https://www.hudoig.gov/




             Program Evaluations Division




Report number: 2018-OE-0002