GAO 

United States Government Accountability Office

Report to Congressional Requesters

HUMANE METHODS 

OF SLAUGHTER ACT 

Actions Are Needed to 

Strengthen 

Enforcement 

February 2010 

GAO-10-203 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

February 2010

HUMANE METHODS OF SLAUGHTER ACT 

Actions Are Needed to Strengthen Enforcement 

Highlights of GAO-10-203, a report to 

congressional requesters 

Concerns about the humane 

handling and slaughter of livestock 

have grown; for example, a 2009 

video showed employees at a 

Vermont slaughter plant skinning 

and decapitating conscious 1-week 

old veal calves. The Humane 

Methods of Slaughter Act of 1978, 

as amended (HMSA) prohibits the 

inhumane treatment of livestock in 

connection with slaughter and 

requires that animals be rendered 

insensible to pain before being 

slaughtered. The U.S. Department 

of Agriculture’s (USDA) Food 

Safety and Inspection Service 

(FSIS) is responsible for HMSA. 

GAO was asked to (1) evaluate 

FSIS’s efforts to enforce HMSA, 

(2) identify the extent to which 

FSIS tracks recent trends in 

resources for HMSA enforcement, 

and (3) evaluate FSIS’s efforts to 

develop a strategy to guide HMSA 

enforcement. Among other things, 

GAO received survey responses 

from inspectors at 235 plants and 

examined a sample of FSIS 

noncompliance reports and 

suspension data for fiscal years 

2005 through 2009. 

What GAO Recommends

GAO is making recommendations 

to strengthen HMSA enforcement 

by, for example, establishing 

specific guidance on actions to 

take for HMSA violations. In 

commenting on a draft of this 

report, USDA did not state whether 

it agreed or disagreed with GAO’s 

findings or recommendations. 

However, it stated that it plans to 

use them in improving efforts to 

enforce HMSA. 

GAO’s survey results and analysis of FSIS data suggest that inspectors have 

not taken consistent actions to enforce HMSA. Survey results indicate 

differences in the enforcement actions that inspectors would take when faced 

with a humane handling violation, such as when an animal was not rendered 

insensible through an acceptable stunning procedure by forcefully striking the 

animal on the forehead with a bolt gun or properly placing electrical shocks. 

Specifically, as shown below, 23 percent of inspectors reported they would 

suspend operations for multiple unsuccessful stuns with a captive bolt gun

whereas 27 percent reported that they would submit a noncompliance report. 

GAO’s review of noncompliance reports also identified incidents in which 

inspectors did not suspend plant operations or take regulatory actions when 

they appeared warranted. The lack of consistency in enforcement may be due 

in part to the lack of clarity in current FSIS guidance and inadequate training. 

The guidance does not clearly indicate when certain enforcement actions 

should be taken for an egregious act—one that is cruel to animals or a 

condition that is ignored and leads to the harming of animals. A noted humane 

handling expert has stated that FSIS inspectors need clear directives to 

improve consistency of HMSA enforcement. According to GAO’s survey, 

FSIS’s training may be insufficient. For example, inspectors at half of the 

plants did not correctly answer basic facts about signs of sensibility. Some 

private sector companies use additional tools to assess humane handling and 

improve performance. 

Percentage of Inspectors Identifying Enforcement Actions for Stunning 

Source: GAO analysis of survey results.

Multiple unsuccessful captive bolt stuns Multiple misplaced electrical stuns

37%

34%

17% 7%

27%

38%

23%

7%

None of these

5% Don’t know 4% Don’t know

None of these

Noncompliance

report only

Regulatory control

action

Suspension

Noncompliance

report only

Regulatory control

action

Suspension

FSIS cannot fully identify trends in its inspection funding and staffing for 

HMSA, in part because it cannot track HMSA inspection funds separately from 

the inspection funds spent on food safety activities. FSIS also does not have a 

current workforce planning strategy for allocating limited staff to inspection 

activities, including HMSA enforcement. FSIS has strategic, operational, and 

performance plans for its inspection activities but does not clearly outline 

goals, needed resources, time frames, or performance metrics and does not 

have a comprehensive strategy to guide HMSA enforcement.

View GAO-10-203 or key components.

To view survey results online click on 

GAO-10-244SP. For more information, 

contact Lisa Shames at (202) 512-3841 or 

shamesl@gao.gov. 
Page i GAO-10-203 

Contents 

Letter 1

Background 4 

Weaknesses Persist in FSIS’s Enforcement, Training and Guidance, 

and Data Management 12 

FSIS Cannot Fully Identify and Plan Resource Needs for HMSA 

Enforcement 31 

FSIS Does Not Have a Comprehensive Strategy for Enforcing 

HMSA 35 

Conclusions 37 

Recommendations for Executive Action 38 

Agency Comments and Our Evaluation 39 

Appendix I Objectives, Scope, and Methodology 41 

Appendix II Location of Inspectors Observing HMSA Compliance 

 at Typical Mid-Sized Plant 45 

Appendix III HMSA Suspensions for FSIS Districts 46 

Appendix IV Comments from the U.S. Department of Agriculture 47 

Appendix V GAO Contact and Staff Acknowledgments 60

Tables 

Table 1: Total Specified in Annual Appropriations for FSIS 

Inspections, Estimated Amount FSIS Dedicated for 

Humane Handling Enforcement, and Estimated Percentage 

of FSIS Annual Inspection Appropriation for Humane 

Handling, Fiscal Years 2005 through 2008 32 

Table 2: Minimum Number of FTEs Required by Congress for 

Humane Handling Compared with the FTEs Reported by 

FSIS, Fiscal Years 2005 through 2009 34 

Table 3: Universe of Plants and Sample Description 42 

Humane Slaughter
Figures 

Figure 1: States and Territories Covered by FSIS District Offices 5 

Figure 2: Stunning Methods Consistent with HMSA 6 

Figure 3: Key FSIS Inspection Personnel Involved in HMSA 

Enforcement 10 

Figure 4: Percentage of Inspectors Identifying Which Enforcement 

Action They Would Take for Electrical Prodding 13 

Figure 5: Percentage of Inspectors Identifying Which Enforcement 

Action They Would Take for Stunning 16 

Figure 6: Percentage of Inspectors Identifying Which Enforcement 

Action They Would Take for Other Violations 18 

Figure 7: Percentage of Inspectors-in-Charge Identifying 

Suspension as the Appropriate Enforcement Action, by 

Plant Size 19 

Figure 8: Number of Plant Suspensions Nationwide, Calendar Years 

2005 through August 2009 21 

Figure 9: Inspectors Identified the Need for Additional Guidance 

and/or Training in Seven Key Areas of Humane Handling 

Enforcement 23 

Figure 10: Percentage of Inspectors-in-Charge Reporting Video 

Surveillance as Very or Moderately Useful in Five Plant 

Areas 29 

Figure 11: Location of Inspectors Observing Compliance with the 

HMSA at a Typical Mid-Sized Plant 45 

Figure 12: Percentage of Suspensions by District, Calendar Year 

2008 46 

Page ii GAO-10-203 Humane Slaughter
Abbreviations 

DVMS district veterinary medical specialist 

FSIS Food Safety and Inspection Service 

FTE full-time equivalent 

HMSA Humane Methods of Slaughter Act of 1978 

USDA U.S. Department of Agriculture 

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Page iii GAO-10-203 Humane Slaughter
Page 1 GAO-10-203 

United States Government Accountability Office

Washington, DC 20548 

 

February 19, 2010 

The Honorable Darrell E. Issa 

Ranking Member 

Committee on Oversight and Government Reform 

House of Representatives 

The Honorable Dennis J. Kucinich 

Chairman 

Subcommittee on Domestic Policy 

Committee on Oversight and Government Reform 

House of Representatives 

Concerns about the humane handling and slaughter of livestock have 

increased in recent years, particularly after a widely publicized video in 

2008 of actions at a slaughter plant in California. The 2008 video showed 

employees at the plant delivering electric shocks to nonambulatory cows, 

spraying them with high-pressure water hoses, and ramming them with a 

forklift to force them to rise for slaughter. The U.S. Department of 

Agriculture (USDA) suspended operations at the California plant, citing 

the egregious nature of its actions and its failure to maintain and 

implement controls to prevent the inhumane handling and slaughter of 

nonambulatory cows at the facility. More recently, in October 2009, USDA 

received a video recording of employees at a Vermont slaughter plant that 

shows employees skinning and decapitating conscious veal calves, which 

are about 1-week old. USDA and the state of Vermont suspended the 

operating licenses for this plant, effectively shutting down operations, 

pending the results of an ongoing investigation. Such actions may violate 

the Humane Methods of Slaughter Act of 1978, as amended (HMSA). 

HMSA prohibits the inhumane treatment of livestock in slaughter plants 

and generally requires that animals be rendered insensible—typically 

referred to as stunning—before proceeding with slaughter. 

USDA’s Food Safety and Inspection Service (FSIS) is responsible for 

ensuring the safety of meat and other products in the United States, as 

well as for enforcing HMSA. Since 2002, Congress has urged USDA to fully 

enforce HMSA, directed it to enhance staffing for HMSA-related 

inspections and enforcement, and designated funding to develop and 

maintain a system for tracking the amount of time that inspectors spend 

on HMSA enforcement. 

Humane Slaughter
 

We have previously reported on weaknesses in FSIS’s management of 

HMSA, particularly its reporting of violations and use of inconsistent 

criteria for enforcement.1

 In 2004, we recommended that FSIS take several 

actions to improve HMSA oversight, including providing informative data 

on HMSA violations and assessing whether FSIS resources are sufficient to 

effectively enforce the act. In 2008, USDA’s Office of Inspector General 

reported that FSIS management controls over preslaughter activities could 

be strengthened to minimize the possibility of egregious humane handling 

events.2

In this context, you asked us to (1) evaluate FSIS’s efforts to enforce 

HMSA, (2) identify the extent to which FSIS tracks recent trends in FSIS 

inspection resources for enforcing HMSA, and (3) evaluate FSIS’s efforts 

to develop a strategy to guide HMSA enforcement. 

To evaluate FSIS’s efforts to enforce HMSA, we examined a sample of 

FSIS noncompliance reports, suspension data, and district veterinary 

medical specialist reports in all 15 of FSIS’s district offices for fiscal years 

2005 through 2009. To assess the reliability of these data, we examined the 

data for obvious errors in completeness and accuracy, reviewed existing 

documentation about the systems that produced the data, and questioned 

knowledgeable officials about the data and systems. We determined that 

the data were sufficiently reliable for the purposes of this report, with any 

limitations noted in the text. From May 2009 through July 2009, we also 

surveyed inspectors-in-charge—those responsible for reporting on 

humane handling enforcement in the plants—from a random sample of 

inspectors-in-charge at 257 livestock slaughter plants. We selected the 

sample of 257 plants, stratified by size, from a universe of 782 plants, and 

then surveyed inspectors-in-charge at the sample plants. Our sample 

allows us to make estimates about the observations and opinions of all 

inspectors-in-charge at U.S. slaughter plants. We obtained an overall 

 

1

GAO, Humane Methods of Slaughter Act: USDA Has Addressed Some Problems but Still 

Faces Enforcement Challenges, GAO-04-247 (Washington, D.C.: Jan. 30, 2004). Also, see 

GAO, Humane Methods of Handling and Slaughter: Public Reporting on Violations Can 

Identify Enforcement Challenges and Enhance Transparency, GAO-08-686T (Washington, 

D.C.: Apr. 17, 2008). 

2

U.S. Department of Agriculture, Office of Inspector General, Great Plains Region, Audit 

Report: Evaluation of FSIS Management Controls Over Pre-Slaughter Activities, Report 

No. 24601-0007KC (November 2008). 

Page 2 GAO-10-203 Humane Slaughter
 

survey response rate of 93 percent.3 This report does not contain all of the 

results from our survey. The survey can be viewed at GAO-10-244SP. We 

also met with key officials from FSIS’s Office of Field Operations who are 

responsible for implementing HMSA at the headquarters level. To 

understand district officials’ perspectives on HMSA enforcement, we 

conducted semistructured interviews with each of FSIS’s 15 district 

veterinary medical specialists (DVMS) and 15 district managers. We also 

obtained the views of experts in humane handling to understand key 

principles of humane handling techniques and enforcement. In particular, 

we consulted with Dr. Temple Grandin, a world-renowned expert on 

animal welfare, who provided her expert opinion on particular humane 

handling incidents we identified as possible HMSA violations.4

 To identify 

the extent to which FSIS tracks recent trends in inspection resources for 

enforcing HMSA, we reviewed FSIS funding and staffing data for each 

district. We also conducted semi-structured interviews with resource 

management analysts in each of FSIS’s 15 district offices and interviewed 

key officials in the Resource Management and Planning Office within the 

Office of Field Operations. To assess FSIS’s efforts to develop a strategy to 

enforce HMSA, we reviewed relevant FSIS strategies, including the most 

recent FSIS Strategic Plan FY 2008 through FY 2013, the Office of Field 

Operations’ Workforce Plan, and other relevant planning documents. A 

more detailed description of our objectives, scope, and methodology is 

presented in appendix I. 

We conducted this performance audit from October 2008 to February 

2010, in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives. 

 

3

All full sample percentage estimates from the survey have margins of error at the 95 

percent confidence level of plus or minus 7 percentage points or less, unless otherwise 

noted. Percentage estimates by plant size have margins of error at the 95 percent 

confidence level of plus or minus 10 percentage points or less, unless otherwise noted. 

4

Dr. Grandin has served as a consultant to industry and FSIS, written extensively on 

modern methods of livestock handling, and has designed slaughter facilities that have 

helped improve animal welfare in the United States. 

Page 3 GAO-10-203 Humane Slaughter
 

In 2008, the most recently available data, more than 153 million cattle, 

sheep, hogs, and other animals ultimately destined to provide meat for 

human consumption were slaughtered at about 800 slaughter plants 

throughout the United States that engage in interstate commerce. Under 

federal law, meat-processing facilities that engage in interstate commerce 

must have federal inspectors on site. FSIS classifies plants according to 

size and the number of employees. Specifically, large plants have 500 or 

more employees; small plants have from 10 to 499 employees; and very 

small plants have fewer than 10 employees, or annual sales of less than 

$2.5 million. Under HMSA, FSIS inspectors are to ensure that animals are 

humanely treated from the moment they arrive at a plant until they are 

slaughtered. FSIS deploys these inspectors from 15 district offices 

nationwide. Figure 1 shows the states and territories in each FSIS district. 

Background 

Page 4 GAO-10-203 Humane Slaughter
 

Figure 1: States and Territories Covered by FSIS District Offices 

Fla. P.R.

Guam

Northern

Mariana

Islands Vir. Islands

La.

Miss. Ga. Ala.

S.C.

Ark.

Tex.

N.C.

Tenn.

N. Mex. Okla. Ariz.

Ky.

Va.

Md.

Del.

Kan. Mo.

W.Va.

Colo.

N.J.

Ind. Ohio

Nev.

Utah Calif.

R.I.

Conn.

Pa.

Ill.

Mass.

Neb.

Iowa

Wyo. N.Y.

Vt.

N.H.

Mich.

S. Dak.

Ore.

Wis.

N. Dak. Maine

Idaho

Mont.

Wash.

Minn.

D.C.

Alameda

District

Atlanta

District

Atlanta District cont.

Beltsville

District

Raleigh

District

Raleigh

District cont.

Des Moines

District

Madison

Minneapolis District 

District

Lawrence

District

Chicago

District

Jackson

District

Springdale

District

Dallas

District

Denver

District

Denver District cont.

Albany

District

Philadelphia

District

Hawaii

Alaska

Amer. 

Samoa

Sources: GAO analysis of FSIS data; Map Resources (map).

After livestock arrive at a slaughter plant, plant employees monitor their 

movements as they are unloaded from trucks to holding pens and 

eventually led into the stunning chute. Plant employees typically restrain 

an animal in the chute and stun it by using one of several devices—carbon 

dioxide gas, an electrical current, a captive bolt gun,5

 or a gunshot—that, 

as required by HMSA regulations, is rapid and effective in rendering the 

 

5

A captive bolt gun contains a steel bolt—powered by either compressed air or a blank 

cartridge—that is driven into an animal’s brain and then retracted into the gun, which 

resets the bolt for the next animal. This gun has the same effect as a gun with live bullets 

but is safer than a firearm. 

Page 5 GAO-10-203 Humane Slaughter
 

animal insensible. (See fig. 2.) Under HMSA, animals must be rendered 

insensible—that is, unable to feel pain—on the first stun before being 

shackled, hoisted on the bleed rail, thrown, cast, or cut. According to the 

expert we consulted, animals on the bleed rail that exhibit any of the 

following signs are considered sensible and would therefore be need to be 

restunned: 

• natural blinking, 

• lifting head straight up and keeping it up (righting reflex), 

• rhythmic breathing, and 

• vocalizing. 

Figure 2 shows stunning methods consistent with HMSA. 

Figure 2: Stunning Methods Consistent with HMSA 

Carbon dioxide gas Electrical current

Source: FSIS “Humane Handling Basics.”

Captive bolt gun Gunshot

Once the animals are considered stunned, they are shackled and hoisted 

onto a processing line, where their throats are cut, and they are fully bled 

before processing continues. HMSA exempts only ritual slaughter, such as 

kosher and halal slaughter, from the HMSA requirement that animals be 

rendered insensible on the first blow. See appendix II for a more detailed 

description of the movement of livestock through the plant. 

FSIS has issued a variety of regulations and directives instructing FSIS 

inspectors on how to enforce HMSA. Overall, the regulations emphasize 

the minimization of “excitement and discomfort” to the animals and 

require that they are effectively stunned before being slaughtered. In 2003, 

FSIS guidance on humane handling enforcement stated that inspectors 

Page 6 GAO-10-203 Humane Slaughter
 

were to determine whether a humane handling incident does, or will 

immediately lead to, an injured animal or inhumane treatment. The 

guidance also specified the types of actions inspectors should take when 

these situations occur. Also in 2003, FSIS began providing “humane 

interactive knowledge exchange” scenarios as an educational tool to 

enhance inspectors’ understanding of appropriate enforcement actions. 

These eight written scenarios, available on FSIS’s Web site, provide 

examples of inhumane incidents and suggest enforcement actions. 

In 2005, the agency issued additional guidance specifying egregious 

humane handling situations.6

 This guidance defines egregious as any act 

that is cruel to animals or a condition that is ignored and leads to the 

harming of animals. The guidance provided the following examples of 

egregious acts: 

• making cuts on or skinning conscious animals, 

• excessively beating or prodding ambulatory or nonambulatory disabled 

animals, 

• dragging conscious animals, 

• driving animals off semitrailers over a drop-off without providing adequate 

unloading facilities so that animals fall to the ground, 

• running equipment over animals, 

• stunning animals and then allowing them to regain consciousness, 

• leaving disabled livestock exposed to adverse climate conditions while 

awaiting disposition, or 

• otherwise intentionally causing unnecessary pain and suffering to animals. 

If inspectors determine that an egregious humane handling incident has 

occurred, they may suspend inspection at the plant immediately, 

effectively shutting down the plant’s entire operation, and determine 

corrective actions with plant management and the district office. 

 

6

U.S. Department of Agriculture, Food Safety and Inspection Service, FSIS Notice 12-05, 

Documentation of Humane Handling Activities (Feb. 18, 2005). 

Page 7 GAO-10-203 Humane Slaughter
 

In 2008, after the reported inhumane handling incident in California, which 

was at the Westland/Hallmark plant, FSIS expanded its guidance to 

include two more examples of egregious actions for which inspectors may 

suspend a plant: (1) multiple failed stuns, especially in the absence of 

corrective actions, and (2) dismemberment of live animals. 

According to FSIS guidance, when FSIS inspectors observe a violation of 

HMSA or its implementing regulations and determine that animals are 

being injured or treated inhumanely, they are to take both of the following 

enforcement actions, which may restrict a facility’s ability to operate: 

• Issue a noncompliance report. This report documents the humane 

handling violation and the actions needed to correct the deficiency in 

cases where the animal may be injured or harmed. Inspectors are also 

directed to notify plant management when issuing a noncompliance 

report. 

• Issue a regulatory control action. Inspectors place a regulatory control 

action or a reject tag on a piece of equipment or an area of the plant that 

was involved in harming or inhumanely treating an animal. This tag is used 

to alert plant management to the need to quickly respond to violations that 

they can readily address. The tag prohibits the use of a particular piece of 

equipment or area of the facility until the equipment is made acceptable to 

the inspector. 

When inspectors determine that an egregious humane handling incident 

has occurred, in addition to issuing a noncompliance report and regulatory 

control action, FSIS may also take the following actions: 

• Suspend plant operations. An on-site FSIS supervisor—known as an 

inspector-in-charge—can initiate an action to suspend plant operations 

when an inspector observes egregious abuse to the animals. The inspector 

must document the facts that serve as the basis of the suspension action in 

a written memorandum of interview and promptly provide that 

information electronically to district officials. Ultimately, district officials 

assess the facts supporting the suspension, take any final action, and 

notify officials in headquarters. 

• Withdraw the plant’s grant of inspection. If the plant fails to respond to 

FSIS’s concerns about repeated and/or serious violations, the district 

offices may decide to withdraw all inspectors. Without FSIS inspectors on 

site, the plant’s products cannot enter interstate or foreign commerce. The 

FSIS Administrator may file a complaint to withdraw the plant’s grant of 

inspection and if the grant of inspection is withdrawn, the plant must then 

Page 8 GAO-10-203 Humane Slaughter
 

reapply for and be awarded a grant of inspection before it may resume 

operations. 

FSIS employs inspectors at plants and in FSIS districts to help enforce 

HMSA and its food safety inspections. In the plant, FSIS employs 

inspectors-in-charge, online and offline inspectors, and relief inspectors. 

Inspectors-in-charge are the chief inspectors in the plant and may or may 

not be veterinarians. These inspectors are responsible for reporting 

humane handling activities for each shift, as well as carrying out food 

safety responsibilities, and making enforcement decisions in consultation 

with district officials when necessary. Online inspectors are typically 

assigned specific duties on the slaughter line, such as inspecting carcasses 

and animal heads; however, they may also perform some humane handling 

inspection duties as well. Offline inspectors conduct a variety of 

inspection activities throughout the plant and may also perform some 

humane handling inspection activities. FSIS also employs permanent relief 

inspectors, who step in for plant inspectors who are absent for a period of 

time, and may also observe humane handling. The plant inspectors and the 

inspectors-in-charge are supervised by frontline supervisors, who oversee 

multiple plants. Each plant has at least one FSIS veterinarian who is 

responsible for examining livestock prior to slaughter and performing 

humane handling activities. Some plants may require two veterinarians, 

depending on the volume of animals slaughtered at the plant and the 

number of operating shifts. Figure 3 provides an overview of FSIS 

personnel involved in the enforcement of HMSA. 

Page 9 GAO-10-203 Humane Slaughter
 

Figure 3: Key FSIS Inspection Personnel Involved in HMSA Enforcement 

a

FSIS has a total of 15 district offices. 

b

Patrol veterinarians typically perform veterinarian duties at small and very small plants that do not 

have veterinarians. 

c

Three plants are shown for illustrative purposes only. A frontline supervisor may supervise more than 

one plant. According to FSIS documents, a very small plant has fewer than 10 employees; a small 

plant has 10 to 499 employees; and a large plant has 500 or more employees. 

Source: GAO analysis of FSIS data.

Office of the FSIS

Administrator

Office of Program 

Evaluation, Enforcement 

and Review 

Office of Field 

Operations

Office of Policy, Program 

and Employee 

Development

District officea

-District manager

-Deputy district manager

-District veterinary medical specialist

-Resource management analyst

Very small plantc

-Inspector-in-charge

-Relief inspectors

Frontline supervisor

Patrol veterinarianb

Small plantc

-Inspector-in-charge

-Veterinarian

-Online/offline inspectors

-Relief inspectors

Large plantc

-Inspector-in-charge

-Veterinarian

-Online/offline inspectors

-Relief inspectors

Office of Regulatory 

Operations

Page 10 GAO-10-203 Humane Slaughter
 

Although FSIS does not require inspectors to observe the entire handling 

and slaughter process during a shift, it requires inspectors-in-charge to 

record the amount of time that the FSIS inspectors collectively devoted to 

observing humane handling during one shift. The inspectors-in-charge 

enter this information into a data tracking system known as the Humane 

Activities Tracking System. 

At the district level, the DVMS in each of FSIS’s 15 districts serves as the 

liaison between the district office and headquarters on all humane 

handling matters. These employees are directed to visit each plant within 

their district over a 12- to 18-month period and review the humane 

handling practices at each plant. DVMSs may also coordinate the 

verification of humane handling activities and educate plant inspectors on 

relevant humane handling information in directives, notices, and other 

information from headquarters through the district office to inspectors in 

the field. 

Industry groups and animal welfare organizations have recently 

recommended actions to improve HMSA enforcement. As an expert 

witness, in 2008 testimony, Dr. Grandin proposed that FSIS guidance on 

humane handling be clearer—especially in determining when humane 

handling incidents at slaughter plants should be considered egregious 

violations of the HMSA.7

 She has also suggested that FSIS adopt a 

numerical scoring system—which has been adopted by the American Meat 

Institute—to determine how well animals were being stunned and handled 

at the plants. The system has different standards for different species of 

animal and can be adjusted to fit plants that slaughter fewer animals. 

Overall, the system seeks to reduce the subjective nature of inspections by 

using objective measures to help slaughter plants improve their humane 

handling performance. In addition, the Humane Society of the United 

States has proposed a variety of reforms to strengthen HMSA 

enforcement, including requiring FSIS inspectors to observe the entire 

humane handling and slaughter process during a shift. 

 

7

Dr. Temple Grandin, testimony before the Domestic Policy Subcommittee, House 

Committee on Oversight and Government Reform, “After the Beef Recall: Exploring 

Greater Transparency in the Meat Industry” (Washington, D.C: Apr. 17, 2008). 

Page 11 GAO-10-203 Humane Slaughter
 

According to our survey results and analysis of FSIS data, inspectors have 

not taken consistent actions to enforce HMSA once they have identified a 

violation. These inconsistencies may be due, in part, to weaknesses in 

FSIS’s guidance and training for key inspection staff. While FSIS expects 

its inspectors to use their professional judgment based on the guidance in 

deciding enforcement actions, industry and others are using other tools to 

assist their efforts to improve humane handling performance. 

Furthermore, although FSIS has taken steps to correct data weaknesses in 

HMSA reporting that we noted in 2004, it has not used these data to 

analyze HMSA enforcement across districts and plants to identify 

inconsistent enforcement. For these reasons, FSIS cannot ensure that it is 

preventing the abuse of livestock at slaughter plants or that it is meeting 

its responsibility to fully enforce HMSA. 

Weaknesses Persist in 

FSIS’s Enforcement, 

Training and 

Guidance, and Data 

Management 

GAO Survey Results and 

FSIS Data Indicate 

Inconsistent Enforcement 

According to FSIS officials, inspectors are to use their judgment in 

deciding whether to suspend a plant’s operations or take the less stringent 

enforcement action (that is, issue a noncompliance report and a regulatory 

control action) when a humane handling violation occurs. For example, 

FSIS guidance is unclear on what constitutes excessive electrical 

prodding, such as the number of times an animal can be prodded before 

the inspector should consider the prodding to be excessive and therefore 

egregious. According to FSIS’s guidance, if the inspector determines that 

the action was egregious, the inspector may also choose to suspend plant 

operations but is not required to do so. 

U.S. meat industry representatives have expressed concerns in interviews 

about the inconsistency of HMSA enforcement across districts. For 

example, according to American Meat Institute officials, the inconsistency 

in HMSA enforcement is the single most critical issue for the industry; 

furthermore, one official noted that a number of the differences in 

interpretation of HMSA compliance are related to determining whether or 

not an animal is sensible after stunning. In addition, the expert we 

consulted testified in April 2008 that FSIS inspectors need better training 

and clear directives to improve consistency of HMSA enforcement.8

 

8

Dr. Temple Grandin, testimony before the Domestic Policy Subcommittee, House 

Committee on Oversight and Government Reform, “After the Beef Recall: Exploring 

Greater Transparency in the Meat Industry” (Washington, D.C. Apr. 17, 2008). 

Page 12 GAO-10-203 Humane Slaughter
 

Our survey results indicate differences in the enforcement actions that 

inspectors reported they would take when faced with a humane handling 

violation. In our survey, we asked inspectors their views on electrically 

prodding over 50 out of 100 animals. Figure 4 shows the inspectors’ 

responses to questions concerning electrical prodding. Under FSIS’s 

guidance, inspectors are directed to issue a noncompliance report and 

take a regulatory control action in cases of excessive electrical prodding, 

but suspension is not required. However, the expert we consulted told us 

that she considers these cases to be egregious humane handling violations 

that should result in suspensions. In addition, according to an FSIS 

training scenario, electrical prods are never to be used on the anus, eyes, 

or other sensitive parts of the animal. 

Figure 4: Percentage of Inspectors Identifying Which Enforcement Action They 

Would Take for Electrical Prodding 

Source: GAO analysis of survey results.

Electrically prodding most animals Electrically prodding in the rectal area

35%

40%

9%

32%

7%

23%

6%

22%

23%

Don’t know

None of these

Noncompliance

report only

Regulatory

control

action

Suspension

None of these

Noncompliance

report only

Regulatory

control

action

Suspension

3% Don’t know

Notes: This figure is based on the following survey question: “Do you believe that each of the 

following factors alone generally indicates that an establishment’s action should result in a (1) 

suspension, (2) regulatory control action, (3) noncompliance report, or (4) none of these?” These 

factors included electrically prodding over 50 of 100 animals within acceptable voltage and electrically 

prodding one animal deliberately in the rectal area. 

Percentages may not total 100 percent due to rounding. 

As figure 4 shows, 49 percent of the inspectors surveyed reported that they 

would either take a regulatory control action, such as placing a reject tag 

on a piece of equipment or suspending a plant’s operations for electrical 

prodding of most animals, and 29 percent reported that they would take 

none of these actions or did not know what action to take for electrical 

prodding most animals. Furthermore, 67 percent of the inspectors 

Page 13 GAO-10-203 Humane Slaughter
 

surveyed reported that they would either take a regulatory control action 

or suspend operations for electrical prodding in the rectal area, and 10 

percent reported that they would take none of these actions or did not 

know what action to take for electrical prodding in the rectal area. FSIS 

regulations prohibit electrical prodding that the inspector considers to be 

excessive.9

 FSIS guidance also states that excessive beating or prodding of 

ambulatory or nonambulatory disabled animals is egregious abuse—and 

may therefore warrant suspension of plant operations. From inspectors’ 

compliance reports, we identified several specific incidents in which 

inspectors did not either take a regulatory control action or suspend plant 

operations. For example: 

• In 2008, in the Denver district, the FSIS inspector reported observing a 

plant employee excessively using an electrical prod as his primary method 

to move the cattle—using the prod approximately 55 times to move about 

46 head of cattle into the stun box. Cattle vocalized at least 15 times, 

which the inspector believed indicated a high level of stress. The FSIS 

inspector stated that this incident constituted excessive use of the 

electrical prod. As stated in FSIS guidance, excessive use of an electrical 

prod is an egregious violation that calls for the issuance of both a 

noncompliance report and a regulatory control action and for which an 

inspector may suspend plant operations. In this instance, the inspector 

stated that he had issued a noncompliance report. The inspector did not 

state that he took a regulatory control action and did not suspend 

operations at the plant, as the guidance allows. In the opinion of the expert 

we consulted, this was an egregious instance that should have resulted in a 

suspension. 

• In 2007, in the Minneapolis district, an FSIS inspector reported observing 

plant employees using the electrical prods excessively to move hogs into 

the stunning chute. The animals became excited, jumping on top of one 

another, and vocalizing excessively. From the noncompliance report, it is 

unclear what, if any, regulatory actions were taken. According to FSIS 

regulations, electrical prods are to be used as little as possible in order to 

minimize excitement and injury; any use of such implements that an 

inspector considers excessive is prohibited. 

• In 2008, in the Dallas district, the FSIS inspector reported that a plant 

employee used an electrical prod to repeatedly shock cows in the face and 

neck in an effort to turn them around in an overcrowded area. The 

 

9

C.F.R. § 313.2(b). 

Page 14 GAO-10-203 Humane Slaughter
 

inspector deemed the use of the electrical prod excessive, but the report 

does not indicate whether any regulatory control action was taken. 

With regard to stunning, our survey results and review of noncompliance 

records also show inconsistent enforcement actions when humane 

handling violations occurred. As figure 5 shows, 23 percent of inspectors 

reported they would suspend operations, while 38 percent would issue a 

regulatory control action for multiple unsuccessful captive bolt gun stuns. 

Similarly, 17 percent reported they would suspend operations for multiple 

misplaced electrical stuns, and 37 percent would issue a regulatory control 

action. According to FSIS guidance, egregious abuses that could result in a 

plant suspension include stunning animals and allowing them to regain 

consciousness and multiple attempts to stun an animal, especially in the 

absence of immediate corrective measures. However, it is unclear when a 

suspension is warranted, even if the acts are deemed to be egregious. 

FSIS’s guidance simply states that an inspector-in-charge may immediately 

suspend the plant if there is an egregious humane handling violation—

however, there is no clear directive to do so in guidance. In the opinion of 

the expert we consulted, if over 10 percent of the animals require a second 

shot or if over 5 percent of pigs had experienced an improperly placed 

electrical stun,10 plant operations should be suspended. FSIS agreed that 

these incidents are troubling, and possibly egregious, but did not comment 

further. Figure 5 shows our survey results on stunning. 

 

10Electrical stuns must be properly placed on the animal to ensure effective stunning; that 

is, the current must go through the brain. 

Page 15 GAO-10-203 Humane Slaughter
 

Figure 5: Percentage of Inspectors Identifying Which Enforcement Action They 

Would Take for Stunning 

Notes: This figure is based on survey question 11: “Do you believe that each of the following factors 

alone generally indicates that an establishment’s action should result in a (1) suspension, (2) 

regulatory control action, (3) noncompliance report, or (4) none of these?”

Percentages may not total 100 percent due to rounding. 

We also identified several incidents in FSIS’s noncompliance reports in 

which inspectors did not suspend plant operations or take a regulatory 

control action. For example, 

Source: GAO analysis of survey results.

Multiple unsuccessful captive bolt stuns Multiple misplaced electrical stuns

37%

34%

7% 17%

27%

38%

23%

7%

None of these

5% Don’t know 4% Don’t know

None of these

Noncompliance

report only

Regulatory

control

action

Suspension

Noncompliance

report only

Regulatory

control

action

Suspension

• In 2009, in the Raleigh district, a plant employee stunned a bull twice in 

the head with a captive bolt, but the bull remained sensible. Instead of 

restunning the animal with the captive bolt gun, the employee then drove a 

steel instrument used to sharpen knives into the open hole in the bull’s 

head in an attempt to make the animal insensible. The bull rose to its feet 

and vocalized in apparent pain until it was eventually rendered insensible 

with a bullet to the head. FSIS regulations do not recognize this steel 

instrument as an acceptable stunning method.11 However the inspector 

placed a reject tag on the stun box and cited the incident as egregious in 

 

11See 9 C.F.R. §§ 313.5, 313.15, 313.16, 313.30. 

Page 16 GAO-10-203 Humane Slaughter
 

the noncompliance report but did not suspend operations. In the opinion 

of the expert we consulted, this incident was an example of an egregious 

HMSA violation that should have resulted in a suspension. 

• In 2008, in the Denver district, the inspector reported that the first attempt 

to stun a bull with a captive bolt stunner appeared to misfire, resulting in 

smoke and the smell of powder and no response by the bull.12 A second 

stunning attempt appeared to render the bull unconscious in the stun box. 

However, it was followed by a third stunning attempt while the bull was 

still in the stun box. The employee then allowed the bull to roll out into the 

pit for shackling. The bull appeared unconscious but still was breathing 

rhythmically, indicating that the animal was still sensible. The employee 

then entered the pit and stunned the bull again and started conversing 

with another employee. The bull once again started breathing rhythmically 

while being shackled, a sign that the bull still had not been rendered 

insensible to pain as the law requires. In response, the DVMS asked the 

employee to stun the bull again, and this stun rendered the bull 

unconscious and no longer breathing rhythmically. According to the 

report, the plant received a noncompliance report, but no regulatory 

control action was taken, as called for by guidance. In the opinion of our 

expert consultant, a regulatory control action should have been taken in 

this case because of multiple stuns that left the animal breathing 

rhythmically. 

We also identified several other types of humane handling violations for 

which inspectors took inconsistent enforcement actions. For example, 

according to FSIS’s regulations, animals are not to be moved from one 

area to another faster than a normal walking speed, with minimum 

excitement and discomfort. A faster speed could result in animals being 

driven over each other. Furthermore, animals in a holding pen are to have 

access to water and, if held longer than 24 hours, access to food. 

According to the expert we consulted, deliberately driving animals over 

the top of other others and failing to provide water for animals held over a 

weekend are egregious humane handling violations and, in her opinion, 

these actions should result in plant suspensions. However, as figure 6 

shows, although most inspectors would take an enforcement action, 

including a regulatory control action, for these violations, 40 percent of 

inspectors surveyed would suspend plant operations for driving animals 

 

12The inspector’s report did not indicate whether the original captive bolt stun gun was 

functioning properly. 

Page 17 GAO-10-203 Humane Slaughter
 

over each other, and 55 percent would suspend plant operations for failing 

to provide water over a weekend. 

Figure 6: Percentage of Inspectors Identifying Which Enforcement Action They 

Would Take for Other Violations 

Notes: This figure is based on survey question 11: “Do you believe that each of the following factors 

alone generally indicates that an establishment’s action should result in a (1) suspension, (2) 

regulatory control action, (3) noncompliance report, or (4) none of these?”

Percentages may not total 100 due to rounding. 

The lack of consistency in enforcement actions is highlighted by 

inspectors’ responses to our question about when they would suspend 

plant operations. According to our survey results, less than one-third of 

the inspectors-in-charge in the very small and small plants reported that 

they would be likely to suspend plant operations for multiple incorrect 

placements of electrical stunners and electrical prodding of most animals. 

Inspectors-in-charge at large plants with more frequently reported plant 

suspensions had more stringent views on enforcement actions than those 

at very small plants. For example, inspectors-in-charge at large plants 

more frequently reported suspensions as the enforcement actions that 

should be taken compared with inspectors-in-charge at very small plants. 

Figure 7 illustrates three humane handling scenarios in which significant 

differences were observed between large and very small plants. For 

example, large plants were more likely than very small plants to suspend 

plant operations for multiple incorrect electrical stuns, driving animals 

over the top of others, and electrically prodding most animals. 

Source: GAO analysis of survey results.

Driving animals on top of others No water over a weekend

55%

36%

9%

50%

40%

9%

1% Don’t know

1%

None of these

Noncompliance

report only

Regulatory

control

action

Suspension

1% Don’t know

1%

None of these

Noncompliance

report only

Regulatory

control

action

Suspension

Page 18 GAO-10-203 Humane Slaughter
 

Figure 7: Percentage of Inspectors-in-Charge Identifying Suspension as the 

Appropriate Enforcement Action, by Plant Size 

Notes: Inspectors-in-charge at large plants more frequently reported suspensions than inspectors-incharge at very small plants for 6 out of the 14 humane handling scenarios presented in our survey. 

Estimates by plant size have a margin of error of less than 15 percentage points. 

This figure is based on survey question 11: “Do you believe that each of the following factors alone 

generally indicates that an establishment’s action should result in a (1) suspension, (2) regulatory 

control action, (3) noncompliance report, or (4) none of these?”

We found similar indications of inconsistent enforcement across districts. 

According to our analysis of FSIS data, from calendar years 2005 through 

2007, 10 districts of 15 FSIS districts—responsible for overseeing 44 

percent of all animals slaughtered nationwide—suspended 35 plants for 

HMSA violations. The remaining 5 districts—responsible for overseeing 56 

percent of all livestock slaughtered nationwide—did not suspend any 

plants.13 For example, the Des Moines and the Chicago districts, which 

0

10

20

30

40

50

60

Large plants

Small plants

Very small plants

Electrically prodding

most animals

Driving animals

over the top

of others

Multiple misplaced

electrical stuns

Plant size

Percentage

Source: GAO analysis of survey results.

 

13These five FSIS districts are Albany, Beltsville, Chicago, Des Moines, and Lawrence. 

Page 19 GAO-10-203 Humane Slaughter
 

oversee the first and second highest volume of livestock slaughtered 

nationwide, respectively, were among the 5 districts that had never issued 

a suspension until February 2008, according to our analysis. 

Before 2008, these five districts issued noncompliance reports, sometimes 

with regulatory control actions, such as a reject tag on a piece of 

equipment, rather than suspending an entire plant’s operations. For 

example, in 2007, in the Lawrence district, a hog was observed walking 

around the stunning chute grunting and bleeding from the mouth and 

forehead. The animal had been stunned improperly, and plant personnel 

stated that both stun guns were not working and were being repaired. 

Because the plant did not have an operable stun device, the animal 

suffered for at least 10 minutes while the plant repaired the gun. The FSIS 

inspector applied a reject tag to the stunning box; stunning operations in 

the area were halted until the plant had taken corrective actions, but the 

record did not state the amount of time that stunning was stopped. 

According to FSIS’s guidance, however, stunning animals and then 

allowing them to regain consciousness is considered egregious. 

Suspensions increased overall following the February 2008 

Westland/Hallmark incident in California. For calendar years 2007 and 

2008, more than three-quarters of all suspensions were for stun-related 

violations for all districts. In the 10 districts that suspended operations for 

calendar years 2005 and 2006, over 40 percent of those suspensions were 

for stunning violations. (See app. III for detailed information on the 

number of HMSA enforcement actions over the period we reviewed.) 

Furthermore, following that incident, FSIS directed the inspectors to 

increase the amount of time they devoted to humane handling by 50 to 100 

percent for March through May 2008. FSIS found that, when the amount of 

time spent on humane handling was increased, the number of 

noncompliance reports increased as well. 

The Westland/Hallmark incident highlighted the problems that could occur 

when inspection staff inconsistently apply their discretion in determining 

which enforcement actions to take for humane handling violations. 

According to the USDA Inspector General’s 2008 report that followed the 

Westland/Hallmark incident, between December 2004 and February 2008, 

FSIS inspectors did not write any noncompliance reports or suspend 

operations for humane handling violations at the Westland/Hallmark plant. 

Nevertheless, FSIS personnel acknowledged that at least two incidents of 

humane handling violations had occurred at the Westland/Hallmark plant 

during this period, both of which involved active abuse of animals. Instead 

of taking an enforcement action, the inspectors verbally instructed plant 

Page 20 GAO-10-203 Humane Slaughter
 

personnel to discontinue the action or practice in question. The report also 

stated that Westland/Hallmark had an unusual lack of noncompliance 

reports and that inspectors did not believe they should write a 

noncompliance report if an observed violation was immediately resolved. 

Finally, our analysis of FSIS enforcement data for calendar years 2005 

through August 2009 shows that suspensions were not consistently used to 

enforce HMSA. Figure 8 shows the total number of suspensions over the 

period and reveals that suspensions spiked from a low of 9 in calendar 

year 2005 to a high of 98 in 2008—a nearly 11-fold increase overall—and, 

as of August 2009, FSIS had suspended operations at 50 plants. Based on 

our review of the suspension records, it appears that this spike followed 

the February 2008 Westland/Hallmark incident. Also, more than threequarters of these suspensions resulted from failure to render at least one 

animal insensible on the first stun. From calendar year 2005 through 2008, 

the number of noncompliance reports issued for humane handling 

decreased overall, while the number of animals slaughtered increased 

from about 128 million in 2004 to about 153 million in 2008. 

Figure 8: Number of Plant Suspensions Nationwide, Calendar Years 2005 through 

August 2009 

a

Calendar year 2009 data are as of August 2009. 

0

20

40

60

80

100

2009a 2005 2006 2007 2008

Number of suspensions

Calendar year

Source: GAO analysis of FSIS data.

Page 21 GAO-10-203 Humane Slaughter
 

While we cannot determine the extent to which HMSA violations were 

overlooked from FSIS data and inspection reports, we attempted to 

determine whether a much higher rate of enforcement actions were taken 

on the days that DVMSs conducted their audits for humane handling. 

However, according to FSIS officials, the records of DVMS audit visits are 

incomplete, and we were therefore unable to conduct a complete analysis. 

As a result, we could not fully determine how often DVMSs conducted 

humane handling audit visits nor whether there is a higher rate of 

enforcement actions on the days that DVMSs conducted their audits for 

humane handling. Furthermore, our survey found that 85 to 95 percent of 

inspectors-in-charge who had taken some type of enforcement action 

reported that their immediate supervisor, the DVMS, and other district 

management personnel were moderately or very supportive of their 

actions. 

Weaknesses in Guidance 

and Training May 

Contribute to Inconsistent 

Enforcement 

We found that incomplete guidance and inadequate training may 

contribute to the inconsistent enforcement of HMSA. Specifically, 

according to our survey results, inspectors at the plants we surveyed 

would like more guidance and training in seven key areas, as figure 9 

shows. 

Page 22 GAO-10-203 Humane Slaughter
 

Figure 9: Inspectors Identified the Need for Additional Guidance and/or Training in 

Seven Key Areas of Humane Handling Enforcement 

0

10

20

30

40

50

60

Slips and

falls

Electrical

stunning

failure

Electrical

prodding

Beating

Double

stunning

Sensible animal

on bleed rail

Animal

sensibility

Source: GAO analysis of survey results.

Percentage of responses

Note: This figure is based on survey question 12: “Would additional guidance and/or training be 

helpful in the following areas? (1) determining when an animal is sensible or returning to sensibility; 

(2) determining what, if any, action to take for a sensible animal on the rail; (3) determining what, if 

any, action to take for double stunning; (4) determining when the use of a driving instrument or tool 

becomes beating; (5) determining whether a specific incidence of electric prodding requires a 

suspension, regulatory control action, or noncompliance report; (6) determining whether electrical 

stunning of an animal fails to render and maintain insensibility; and (7) assessing situations involving 

slipping and falling.”

Furthermore, an estimated 457 inspectors-in-charge, or those at more than 

half the plants surveyed, reported that additional FSIS guidance or training 

is needed on whether a specific incident of electrical prodding requires an 

enforcement action. In addition, of the 80 inspectors who provided 

detailed responses to our survey, 15 noted the need for additional 

guidance, including clarification on what actions constitute egregious 

actions. Similarly, 25 of the 80 inspectors who provided written comments 

identified a need for additional training in several key areas. 

With respect to guidance, in 2004, we had recommended that FSIS 

establish additional clear, specific, and consistent criteria for district 

offices to use when considering whether to take enforcement actions 

Page 23 GAO-10-203 Humane Slaughter
 

because of repeat violations.14 FSIS agreed with this recommendation and 

delegated to the districts the responsibility for determining how many 

repeat violations should result in a suspension. However, incidents such as 

those at the Bushway Packing plant in Vermont suggest that this 

delegation was not successful. To date, FSIS has not issued additional 

guidance. 

Operations at this Vermont plant were suspended three times in May, 

June, and July 2009 for egregious humane handling violations. Two of the 

suspensions were for dragging nonambulatory conscious veal calves that 

were about 1-week old. According to a document describing the third 

incident, an employee threw a calf from the second tier of a truck to the 

first so that the calf landed on its head and side. FSIS has not issued any 

guidance to the district offices on how many suspensions should result in 

a request for a withdrawal of a grant of inspection. If specific guidance had 

been available on when to request a withdrawal of grant of inspection, the 

district office might have decided to request such a withdrawal before the 

October 2009 incident. If FSIS ultimately withdrew the grant, it would have 

required the plant to reapply for, and be awarded, a grant of inspection 

license before it could resume operations. 

Regarding training, FSIS relies primarily on “on-the-job” training by 

DVMSs—who are directed to visit each plant within their district over a 12-

to 18-month period. In addition, supervisory veterinarians and inspectorsin-charge provide on-the-job training. FSIS officials we spoke with said 

that the on-the-job training needs to be integrated into a formal training 

program and that efforts are under way to do so. FSIS also provides some 

humane handling training electronically. For example, in February 2009, 

all inspectors assigned to slaughter plants were required to complete a 

mandatory 1-hour basic humane handling course online, which the agency 

can track centrally. FSIS officials also stated that, since 2005, incoming 

inspectors have been required to complete some humane handling training 

during orientation. According to FSIS officials we spoke with, the agency 

has asked the districts to begin entering data on the completion of other 

humane handling courses so that this information can also be tracked 

centrally. 

Our survey results suggest, however, that even inspectors-in-charge who 

had to complete mandatory humane handling training in February 2009 

 

14GAO-04-247. 

Page 24 GAO-10-203 Humane Slaughter
 

may not have been sufficiently trained. For example, an estimated 449, or 

57 percent, of the inspectors-in-charge at the plants we surveyed from May 

through July 2009, reported incorrect answers on at least one of six 

possible signs of sensibility.15 Specifically, an estimated 133, or 18 percent, 

of the inspectors–in-charge, failed to identify rhythmic breathing as a sign 

of sensibility. In addition, in 2004, we had reported that inspectors did not 

have the knowledge they needed to take enforcement actions when 

appropriate.16 At that time, most of the deputy district managers, and 

about one-half of the DVMSs, noted that an overall lack of knowledge 

among inspectors about how they should respond to an observed 

noncompliance had been a problem in enforcing the HMSA. 

 

Several outside observers have also commented on the need for better 

FSIS training.17 Specifically: 

• In November 2008, USDA’s Office of Inspector General found that FSIS 

does not have a formal, structured developmental program and system in 

place to ensure that all of its inspection and supervisory staff receive both 

formal and on-the-job training to demonstrate that they possess the 

competencies essential for FSIS’s mission-critical functions. The Inspector 

General recommended a structured training and development program 

that includes continuing education to provide the organizational control 

needed to demonstrate the competency of the inspection workforce. The 

Inspector General also stated that the workforce needs to be certified 

annually. 

• In 2009, the National Academies’ Institute of Medicine recommended 

testing and improved training, with special emphasis on the quality and 

15Our survey presented the four signs of sensibility—natural blinking, lifting head straight 

up and keeping it up (righting reflex), rhythmic breathing, and vocalizing—and added two 

that, alone, do not generally indicate sensibility—rear leg(s) kicking and tail moving. In our 

assessment, if the respondent selected at least one of the two signs that do not indicate 

sensibility or if he or she indicated that they did not know the answer, the respondent’s 

answer was considered to be incorrect in our calculation. 

16GAO-04-247. 

17In addition, we identified a set of principles to help federal agencies improve the 

effectiveness of their training efforts. See GAO, Human Capital: A Guide for Assessing 

Strategic Training and Development Efforts in the Federal Government, GAO-04-546G

(Washington, D.C.: Mar. 1, 2004). 

Page 25 GAO-10-203 Humane Slaughter
 

consistency of noncompliance reports for food safety issues.18 The 

institute noted that the decision to issue a noncompliance report is 

subjective and inspectors’ experience levels and training differ. 

Supervisory review by inspectors-in-charge may likewise be variable or 

subject to bias and, therefore, unreliable. 

• In 2009, representatives of the three major industry associations—the 

American Meat Institute, the American Association of Meat Processors, 

and the National Meat Association—told us that more training on humane 

handling is needed for FSIS inspectors. Specifically, the American Meat 

Institute identified insensibility as a critical issue in enforcement and 

noted that additional training on the signs of insensibility, such as blinking 

and the righting reflex, would be helpful. 

• In 2009, the Humane Society of the United States recommended that FSIS 

inspectors receive adequate in-person, on-the-ground training so they can 

properly assess the conditions and treatment of animals. 

FSIS officials stated that it launched a voluntary HMSA training program 

for plant employees at small slaughter plants in 2009. These plants 

represent the highest humane handling risk, according to FSIS officials, 

because plant management may not have sufficient resources to fully train 

plant employees on HMSA practices. 

FSIS Has Only Recently 

Begun to Consider Using 

Additional Tools to 

Evaluate HMSA 

Performance 

In recent years, the meat industry has adopted numerical scoring and 

video surveillance to improve plants’ humane handling performance 

overall. According to FSIS officials, the agency does not require the use of 

such objective measures or scoring to aid judgment for enforcement 

purposes because situations are highly variable, and inspectors and 

higher-level officials are to use their judgment in conjunction with FSIS 

guidance. However, in December 2009, FSIS provided DVMSs with 

guidance on what it characterized as, an objective system to facilitate 

determinations of the problems that plants in their districts need to 

address.19 Several of the DVMSs we interviewed acknowledged that they 

 

18Institute of Medicine of the National Academies, Review of the Use of Process Control 

Indicators in the FSIS Public Health Risk-Based Inspection System (Washington, D.C: 

Mar. 3, 2009). 

19U.S. Department of Agriculture, Food Safety and Inspection Service, FSIS Directive 

6910.1, Rev. 1, District Veterinary Medical Specialist Work Methods (Dec. 7, 2009). 

Page 26 GAO-10-203 Humane Slaughter
 

have been using a form of numerical scoring on their own to assist their 

efforts in evaluating HSMA enforcement at the plants. 

The numerical scoring system was developed in 1996 by Dr. Grandin to 

determine how well animals were being stunned and handled at the plants. 

The system has different standards for different species of animal and can 

be adjusted to fit plants that slaughter fewer animals. This system seeks to 

reduce the subjective nature of inspections and uses the scoring system to 

help identify areas in need of improvement. For example, in a large plant, 

if more than 5 out of 100 animals were not rendered insensible on the first 

stun, the plant would fail the evaluation. Other standards include the 

percentage rates for slips and falls and the number of animals moved by an 

electrical prod. Once the plant is aware of the weaknesses, it can consider 

its options to improve its humane handling performance, such as repairing 

equipment and floors to provide better footing for the animals and 

targeting employee training in those specific areas. 

The numerical scoring system has been adopted by industry and animal 

welfare organizations, as well as one federal agency. At the federal level, 

according to agency officials, USDA’s Agricultural Marketing Service uses 

this system to rate slaughter plants to determine whether to approve or 

deny them to provide meat to the National School Lunch Program. In 

addition, the American Meat Institute and independent audit firms 

employed by restaurant chains, such as Burger King and McDonald’s, have 

adopted this numerical scoring system to evaluate humane handling at 

their associated slaughter plants. According to industry experts, a 

publicized humane handling incident at their plants would potentially 

damage their business interests. Recently, the Canadian Food Inspection 

Agency proposed adoption of numerical scoring for federally inspected 

plants in Canada. 

FSIS officials have stated that while the numerical scoring system may be 

useful in helping plants determine their humane handling performance; it 

should not be used to assess compliance with HMSA. Because the 

numerical scoring system allows for a certain percentage of stunning 

failures, using it would be inconsistent with the HMSA requirement that all 

animals must be rendered insensible on the first blow. However, as we 

noted earlier, this requirement has not been met consistently by slaughter 

plants because of human error, equipment failures, and animal movement, 

leaving FSIS to exercise its discretion in determining which violations 

require enforcement action. 

Page 27 GAO-10-203 Humane Slaughter
 

Video surveillance is another tool being increasingly used by slaughter 

plants. Specifically, slaughter plants can hire specialized video technology 

companies to record plant operations and audit plant performance 

through remote video surveillance and the use of the American Meat 

Institute numerical scoring system to assess humane handling 

performance at the plant. These video technology companies can also 

provide slaughter plant management with continuous feedback and 

customized progress reports documenting humane handling performance 

at their plants. According to the testimony of one video surveillance 

company, this technology helps plant management provide positive 

reinforcement to the workers who are performing well and helps identify 

workers who may need further training. 

In November 2008, the Office of the Inspector General recommended that 

FSIS determine whether FSIS-controlled, in-plant video monitoring would 

be beneficial in preventing and detecting animal abuses. However, FSIS 

officials responded that FSIS-controlled video cameras would not provide 

the definitive data needed to support enforcement of humane handling 

requirements, as compared with the direct, ongoing and random 

verification of humane handling practices at the plants.20 According to the 

Humane Society of the United States, while video surveillance might serve 

as a supplemental tool, it does not negate the need for real-time 

inspectors’ observations. According to our survey results, between 52 to 66 

percent of inspectors-in-charge at large plants reported that video 

surveillance would be moderately or very useful in each of the five plant 

areas. Figure 10 illustrates our survey results on the usefulness of video 

surveillance for all plants. FSIS officials recently told us that they are 

exploring potential uses of video surveillance, but the agency had not 

released any official policy change, as of November 2009. 

 

20U.S. Department of Agriculture, Office of Inspector General, Great Plains Region, 

Evaluation of FSIS Management Controls Over Pre-Slaughter Activities, Report No. 

24601-0007KC ( November 2008). 

Page 28 GAO-10-203 Humane Slaughter
 

Figure 10: Percentage of Inspectors-in-Charge Reporting Video Surveillance as 

Very or Moderately Useful in Five Plant Areas 

0

10

20

30

40

50

60

70

Large plants

Small plants

Very small plants

Stun box Bleed rail

and restrainer

Alleyway/chute

to stun box

Truck unloading Pens

area

Plant size

Percentage

Source: GAO analysis of survey results.

Notes: This figure is based on survey question 31: “If FSIS were to issue regulations addressing the 

use of video surveillance, how useful would it be for you to have access to video of each of the 

following areas at this establishment (1) stun box and restrainer; (2) the bleed rail; (4) pens; (5) 

alleyway/chute to the stun box; and (6) area where the trucks are unloaded?”

Estimates by plant size have a margin of error of less than 9 percentage points. 

In addition, of 96 inspectors who provided written comments on the 

usefulness of video surveillance in our survey, most frequently reported 

that video surveillance would facilitate more inspections in different plant 

locations and provide a true picture of animal handling while plant staff do 

not know that the inspector is watching. Since video surveillance can 

provide continuous footage of ongoing activities in the plant, it may 

provide evidence regarding alleged violations when inspectors do not 

directly observe humane handling. For example, according to 39 percent 

of inspectors-in-charge at large plants, plant staff improved their handling 

behavior upon the inspectors’ arrival. Furthermore, 25 percent of 

inspectors-in-charge at the large plants in our survey reported that plant 

Page 29 GAO-10-203 Humane Slaughter
 

staff often, or always, alert each other about inspectors’ movements 

between areas by radio or whistle, for example. 

FSIS Has Not Fully 

Analyzed Humane 

Handling Data to 

Consistently Enforce 

HMSA 

Although FSIS collects humane handling data, we found that it is not fully 

analyzing and using these data to help ensure more consistent HMSA 

enforcement. For example, we found substantial differences in the range 

of time devoted to humane handling for large plants that slaughter market 

swine when we compared the amount of time devoted to humane handling 

activities for plants of similar size and species in an effort to determine if 

there were any inconsistencies among districts. Specifically, out of the six 

slaughter plants that kill between 700,000 to 900,000 market swine, the 

average time that a plant would devote to humane handling ranged from 

1.8 to 9.7 hours per shift in 2008. For the nine plants that slaughter 

between 2 and 3 million market swine, we found that the average amount 

of time per shift ranged from 2.7 to 5.2 hours per shift in 2008. 

In January 2004, we also reported that FSIS was not adequately analyzing 

the narrative found in noncompliance reports. As of November 2009, FSIS 

headquarters officials told us that they had not begun an effort to analyze 

the narratives in noncompliance reports. Instead, they told us, they rely on 

district officials to monitor whether plant inspectors have taken consistent 

enforcement action for each incident. Headquarters officials also stated 

that they only review the percentage of humane handling activities that are 

recorded as noncompliant in an FSIS database, known as the 

Performance-Based Inspection System. However, without analyzing the 

narrative, FSIS cannot readily provide the reasons for the noncompliance 

reports—for example, whether these reports were issued for one or two 

failed stuns, which is not uncommon, rather than three or four failed 

stuns, which might be considered an egregious violation. Thus, FSIS 

cannot easily analyze noncompliance reports across the districts to 

identify trends or patterns in plant violations or potential enforcement 

inconsistencies across districts. 

Also in 2004, we reported that FSIS was not tracking humane handling 

activities. In response to the tracking issue, FSIS created the Humane 

Activities Tracking System, a database that inspectors use to record the 

amount of time they devote to humane handling activities in each plant. 

Inspectors are directed to record the total amount of time devoted to 

humane handling activities for each plant shift in 15-minute increments. 

According to our survey results, inspectors have differing views on the 

accuracy of the amount of time recorded in the tracking system. 

Specifically, 19 percent reported that the time recorded in this system was 

Page 30 GAO-10-203 Humane Slaughter
 

slightly or not at all accurate. However, 45 percent of the inspectors 

reported that the time was very accurate, and 36 percent reported that the 

time was moderately accurate. 

Furthermore, of the 93 inspectors who provided written responses 

detailing inspectors’ views of the reasons for the tracking database’s 

inaccuracies, 56 pointed out that breaking out activities into 15-minute 

increments limited their ability to record their actual time spent, and 29 

stated that humane handling activities are concurrent with other 

inspection activities. In addition, 14 responses noted that supervisors or 

district offices had placed either a minimum or maximum on the amount 

of time that could be charged to humane handling. Also, several of the 

DVMSs we interviewed reported that the Humane Activities Tracking 

System does not readily produce the types of reports that are needed to 

oversee and manage humane handling activities in their districts. For 

example, they reported that the system lacked the capability to readily 

produce comparative analyses of similar plants to help identify trends or 

anomalies across districts. 

FSIS began analyzing data across districts from the Humane Activities 

Tracking System in 2008—4 years after it developed the system. Also in 

2008, FSIS established the Data Analysis Integration Group in 

headquarters, with staff in the regional field offices to support district 

offices’ data needs. The group began reporting quarterly on HMSA 

enforcement, including the amount of time inspectors have devoted to 

HMSA, the number of plants suspended, and the number of 

noncompliance reports issued in 2009, although FSIS has not analyzed the 

narrative in the noncompliance reports. 

FSIS cannot fully identify trends in its inspection resources—specifically, 

funding and staffing—for HMSA enforcement, in part because it cannot 

track humane handling inspection funds separately from the inspection 

funds spent on other food safety activities. Furthermore, FSIS does not 

have a current workforce planning strategy to guide its efforts to allocate 

staff to inspection activities, including humane handling. 

FSIS Cannot Fully 

Identify and Plan 

Resource Needs for 

HMSA Enforcement 

FSIS Does Not Track 

HMSA Enforcement and 

Other Inspection Funds 

Separately 

According to FSIS officials, funds for humane handling come primarily 

from two sources: (1) FSIS’s general inspection account and (2) the 

account used to support the Humane Activities Tracking System. The 

general inspection account supports all FSIS inspection activities, both 

food safety and other activities, including humane handling enforcement. 

Page 31 GAO-10-203 Humane Slaughter
 

Because the same inspectors may carry out these tasks concurrently, FSIS 

cannot track humane handling funds separately, according to FSIS 

officials. 

According to FSIS officials, for the most part, inspectors are to devote 80 

percent of their time to food safety inspection activities and 20 percent of 

their time to humane handling inspection and other activities. However, 

our analysis of resources shows that this is not the case. As table 1 shows, 

we estimated that the percentage of funds dedicated to HMSA 

enforcement has been above 1 percent of FSIS’s total annual inspection 

appropriation, although it rose slightly in 2008, the year in which 

suspensions spiked following the 2008 Westland/Hallmark incident in 

California. While FSIS does not track humane handling inspection 

activities separately, FSIS’s budget office estimates the funds needed to 

carry out these activities. Using FSIS’s budget estimate for HMSA 

enforcement for fiscal years 2005 through 2008, we estimated the 

percentage of FSIS’s total annual appropriation for its federal food safety 

inspection account that would have gone to HMSA enforcement.21

Table 1: Total Specified in Annual Appropriations for FSIS Inspections, Estimated Amount FSIS Dedicated for Humane 

Handling Enforcement, and Estimated Percentage of FSIS Annual Inspection Appropriation for Humane Handling, Fiscal 

Years 2005 through 2008

Dollars in millions 

Fiscal year 

Total amount specified for FSIS 

inspection in the agency annual 

appropriationa

Estimated amount of FSIS funds 

dedicated to humane handling 

enforcement

Percentage of FSIS annual 

appropriation for inspection devoted 

to humane handling 

2005 $742.3 $9.1 1.23%

2006 753.3 10.9 1.45%

2007 a 10.0 b 

2008 829.8 $12.1 1.46%

Sources: GAO’s analysis of the Budget of the United States and FSIS data. 

a

The FSIS inspection fund includes other activities, such as livestock slaughter, poultry slaughter, 

processing inspection, egg inspection, import inspection, in-commerce compliance, district office 

activities, and food safety enforcement activities. Congress did not designate an amount from FSIS’s 

general appropriation for federal food safety inspection in fiscal year 2007. 

b

Because Congress did not specify an amount for federal food safety inspection in fiscal year 2007, 

no percentage of total inspection activities devoted to humane handling was calculated. Appropriation 

amounts come from federal food safety inspection activities specified in FSIS annual appropriations 

and do not consider rescissions or supplemental appropriations. 

 

21Fiscal year 2008 data were the latest available at the time of our review. 

Page 32 GAO-10-203 Humane Slaughter
 

In contrast to FSIS’s inability to track humane handling in its general 

inspection fund, FSIS officials noted, the DVMSs—whose primary 

responsibility is humane handling activities—have a special activity code 

that enables FSIS to track their portion of expenses, including salaries and 

travel; however, these expenses represent only a small portion of the total 

amount FSIS spends on humane handling inspection activities. 

Although FSIS does not track funds spent on humane handling inspection 

activities separately from other inspection activities, it does track the 

funds specifically dedicated to supporting the Humane Activities Tracking 

System. For fiscal years 2005 through 2009, Congress designated a total of 

nearly $13 million specifically for the Humane Activities Tracking System, 

and FSIS has spent roughly that amount on the system, according to our 

review of FSIS budget data. For fiscal year 2005 and for fiscal year 2006, 

FSIS was required to spend the funding designated for the Humane 

Activities Tracking System within 2 years of the appropriation. However, 

beginning with fiscal year 2008, Congress folded the funding for the 

Humane Activities Tracking System into a larger FSIS information 

technology initiative, and the funding is available to FSIS until it is 

expended. As of November 2009, FSIS had not completed integrating the 

Humane Activities Tracking System into the information technology 

initiative, and FSIS officials could not provide an estimate of when the 

agency expected to do so. 

FSIS Does Not Have a 

Long-term Plan for 

Addressing HMSA Staffing 

Although FSIS cannot directly account for the funding designated for 

humane handling activities, Congress in recent years has required FSIS to 

devote a minimum amount of full-time equivalent (FTE) staff to humane 

handling.22 Accordingly, FSIS estimates the total number of FTEs devoted 

to humane handling and reports this information to Congress every year. 

FSIS develops this estimate using Humane Activities Tracking System data 

on time spent on humane handling inspection activities and average 

inspector and veterinarian salaries. Table 2 shows that FSIS has reported 

exceeding Congress’s minimum FTE requirements for humane handling 

enforcement, according to FSIS’s calculation. 

 

22An FTE generally consists of one or more employed individuals who collectively 

complete 2,080 work hours in a given year. Therefore, either one full-time employee or two 

half-time employees equal one FTE. 

Page 33 GAO-10-203 Humane Slaughter
 

Table 2: Minimum Number of FTEs Required by Congress for Humane Handling 

Compared with the FTEs Reported by FSIS, Fiscal Years 2005 through 2009 

Fiscal year 

Minimum congressionally required 

FTEs for humane handling 

FTEs reported by 

FSIS

2005 63 110

2006 63 124

2007 a 121

2008 83 157

2009 120 157

Sources: GAO’s analysis of appropriation acts and FSIS data. 

a

Congress did not specify any FTEs for humane handling enforcement in fiscal year 2007. 

For fiscal year 2010, FSIS officials told us, they planned to use $2 million 

of their inspection funds to enhance oversight of humane handling 

enforcement by hiring 24 inspectors, including both public health 

veterinarians and inspectors. FSIS officials planned to strategically place 

these additional inspectors at locations where they are most needed to 

support humane handling enforcement in addition to their other food 

safety responsibilities. FSIS officials stated that the agency determined 

staffing needs on the basis of such factors as the highest number of 

animals condemned on postmortem, the number of animals inspected and 

passed for human consumption, and the amount of time spent conducting 

humane handling inspection activities. In addition, FSIS officials stated 

that the agency intends to establish a headquarters-based humane 

handling coordinator position. This coordinator will be primarily 

responsible for consistently overseeing humane handling activities. 

While FSIS has increased its hiring, it has not done so in the context of an 

updated strategic workforce plan. Such a plan would help FSIS align its 

workforce with its mission and ensure that the agency has the right people 

in the right place performing the right work to achieve the agency’s goals. 

In February 2009, we reported that the FSIS veterinarian workforce had 

decreased by nearly 10 percent since fiscal year 2003 and that the agency 

had not been fully staffed over the past decade.23 We reported that, as of 

fiscal year 2008, FSIS had a 15 percent shortage of veterinarians and the 

majority of these veterinarians work for slaughter plants. The FSIS 2007 

 

23GAO, Veterinarian Workforce: Actions Are Needed to Ensure Sufficient Capacity for 

Protecting Public and Animal Health, GAO-09-178 (Washington, D.C.: Feb. 4, 2009). 

Page 34 GAO-10-203 Humane Slaughter
 

strategic workforce plan—the most recently available—identifies specific 

actions to help the agency address some of the gaps in recruiting and 

retaining these mission-critical occupations over time. However, it does 

not address specific workforce needs for HMSA enforcement activities. 

FSIS officials stated that workforce planning occurs at the district level 

and is determined using regulations that govern the number of inspectors 

required at each slaughter plant. According to district officials, they have 

discretion in deciding where to deploy relief inspectors. Therefore, they 

can deploy these inspectors at plants that they believe may require more 

HMSA oversight. However, more than one-third of the inspectors, who 

provided written comments in our survey, noted the need for additional 

staff or the lack of time to perform humane handling activities. 

Furthermore, inspectors at 80 percent of large plants stated that covering 

for others’ responsibilities because of leave or vacancies has reduced the 

time spent on humane handling activities in those plants. While FSIS 

officials may need flexibility at the district level to allocate inspection 

resources, without an updated strategic workforce plan, the agency cannot 

effectively determine inspection needs across districts and adjust the 

inspection workforce to reflect changes in the industry and in FSIS 

resources. 

Although the strategic workforce plan indicates that the agency performs 

this assessment annually, FSIS officials acknowledged that the agency has 

not updated its strategic workforce plan since 2007. We recommended in 

January 2004 that FSIS periodically reassess whether the level of 

inspection resources is sufficient to effectively enforce HMSA. As of 

November 2009, FSIS officials had told us that they were in the process of 

developing a workforce strategy but could not provide an estimated 

completion date. 

Our body of work on results-oriented management calls for organizations 

to identify clearly defined goals that are aligned to available resources, 

develop time frames for achieving these goals, and develop performance 

metrics for measuring progress in meeting their goals. 

We have recommended that all agencies adopt strategies that include 

these key elements. By implementing results-oriented management 

principles, agencies demonstrate their efforts to resolve long-standing 

management problems that undermine program efficiency and 

effectiveness, provide greater accountability for results, and enhance 

FSIS Does Not Have a 

Comprehensive 

Strategy for Enforcing 

HMSA 

Page 35 GAO-10-203 Humane Slaughter
 

congressional decision making by providing more objective information 

on program performance.24

Although FSIS has strategic, operational, and performance plans for its 

inspection activities, these plans do not specifically address HMSA 

enforcement. That is, they do not clearly outline the agency’s goals for 

enforcing HMSA, identify expected resource needs, specify time frames, or 

lay out performance metrics. Specifically, FSIS Strategic Plan FY 2008 

through FY 2013 provides an overview of the agency’s major strategic 

goals and the means to achieve those goals. However, this plan does not 

clearly articulate or list goals related to HMSA enforcement. Instead, the 

plan generally addresses agency goals, such as improving data collection 

and analysis, maintaining information technology infrastructure to support 

agency programs, and enhancing inspection and enforcement systems 

overall to protect public health. 

FSIS Office of Field Operations officials agreed that the plan does not 

specifically address humane handling, but they explained, the operational 

plans and policy performance plans contain the details concerning 

humane handling performance. However, as we indicate below, we did not 

find that these two plans provide a comprehensive strategy for HMSA 

enforcement: 

• Office of Field Operations’ Operational Plan identifies specific FSIS 

projects or initiatives and aligns them with the appropriate strategic goal 

identified in the FSIS Strategic Plan for FY 2008 through FY 2013. It also 

specifies the estimated dates for completion and recent information on the 

status of the project or initiative. According to our analysis of the July 2009 

version of the operational plan, the most recent version available, humane 

handling activities fall under FSIS’s first strategic goal—enhance 

inspection and enforcement systems and operations to protect public 

health. While the plan identifies tasks related to humane handling 

inspection activities, it does not identify any humane handling program 

goals linked to these tasks or explain how these tasks can be completed. 

For example, one of the plan’s listed tasks is conducting humane handling 

information outreach, but the plan neither indicates how this task aligns 

with HMSA enforcement-related goals, nor does it specify resources 

 

24See GAO, Agency Performance Plans: Examples of Practices that Can Improve 

Usefulness to Decisionmakers, GAO/GGD/AIMD-99-69 (Washington, D.C.: Feb. 26, 1999) 

and GAO, Agencies Strategic Plans Under GPRA: Key Questions to Facilitate 

Congressional Review, GAO/GGD-10.1.16 (Washington, D.C.: May 1997). 

Page 36 GAO-10-203 Humane Slaughter
 

needed. The plan also does not set priorities for proposed activities or 

identify milestones that could be used to measure progress or make 

improvements. Additionally, the document does not match the activities 

with resources needed to accomplish those tasks. According to FSIS 

officials, the Office of Field Operations’ operational plan is an evolving 

document that is continually updated throughout the course of the year. 

• Office of Policy and Program Development Strategic Plan Fiscal Years 

2008-2013 identifies policy goals that support the overall FSIS Strategic 

Plan. However, this plan does not clearly articulate or list goals related to 

HMSA enforcement. 

Furthermore, FSIS does not have a set of performance measures for 

assessing the overall performance of humane handling enforcement across 

the districts. For example, FSIS is unable to determine whether the 

districts have improved their ability to enforce humane handling or may be 

weak in their enforcement. Although FSIS officials stated that the agency 

collects information such as the number of noncompliance reports, the 

number of egregious humane handling violations, and the number of 

humane handling activities performed on a routine basis by the DVMS, 

there is no indication of how these activities demonstrate improved 

enforcement of HMSA. Collecting and analyzing this type of information 

could be useful in identifying gaps or anomalies in performance and then 

developing a strategy to address them. 

It is difficult to know whether the reported incidents of egregious animal 

handling at the slaughter plants in California and Vermont are isolated 

cases or indicative of a more widespread problem. Either way, it is evident 

from our survey results and our analysis of HMSA enforcement data that 

inspectors did not consistently identify and take enforcement action for 

humane handling violations for the period we reviewed. Furthermore, our 

survey results suggest that inspectors are not consistently applying their 

discretion as to which actions to take when egregious humane handling 

incidents occur, or when they are repeated, in part because the guidance is 

unclear. That is, the guidance states that inspectors-in-charge “may” 

suspend plant operations. Consequently, plants cited for the same type of 

humane handling incident may be subject to different enforcement 

actions. In January 2004, we recommended that FSIS establish additional 

clear, specific, and consistent criteria for enforcement actions to take 

when faced with repeat violations. FSIS responded by delegating this 

responsibility to the districts. However, incidents such as those at the 

Vermont plant suggest that this delegation has not been effective. While 

Conclusions 

Page 37 GAO-10-203 Humane Slaughter
 

FSIS has stated that inspectors require discretion in enforcement, that 

discretion needs to be informed by an agency policy that ensures a 

consistent level of enforcement within plants and across districts. Without 

consistent enforcement actions, FSIS does not clearly signal its 

commitment to fully enforce HMSA. In addition, to improve plants’ 

humane handling performance, the Agricultural Marketing Service, 

DVMSs, and others have adopted objective industry tools, such as 

numerical scoring, to help identify weaknesses. However, inspectors-incharge, who are responsible for assessing daily HMSA performance at the 

plants, are not directed to use such scoring tools. 

Effective oversight of HMSA enforcement also requires FSIS to use 

available data to effectively manage the program, including allocating 

resources. FSIS has only recently begun to do so. Until 2009, FSIS did not 

routinely track and evaluate HMSA enforcement data—by geographic 

location, species, plant size, and history of compliance across districts. 

Although these analyses will be useful, FSIS has yet to analyze the 

narratives of humane handling incidents found in noncompliance reports, 

which would also help the agency identify weaknesses and trends in 

enforcement and develop appropriate strategies. Furthermore, we 

reiterate our January 2004 recommendation, which FSIS has not yet acted 

on, to periodically reassess whether its estimates still accurately reflect 

the resources necessary to effectively enforce the act. Finally, because 

FSIS does not have a comprehensive strategy for enforcing HMSA that 

aligns the agency’s available resources with its mission and goals, and that 

identifies time frames for achieving these goals and performance metrics 

for meeting its goals, it is not well positioned to improve its ability to 

enforce HMSA. 

We are making the following four recommendations to the Secretary of 

Agriculture to strengthen the agency’s oversight of humane handling and 

slaughter methods at federally inspected facilities. 

Recommendations for 

Executive Action 

To ensure that FSIS strengthens its enforcement of the Humane Methods 

of Slaughter Act of 1978, as amended, we recommend that the Secretary of 

Agriculture direct the Administrator of FSIS to take the following three 

actions: 

• establish clear and specific criteria for when inspectors-in-charge should 

suspend plant operations for an egregious HMSA violation and when they 

should take enforcement actions because of repeat violations; 

Page 38 GAO-10-203 Humane Slaughter
 

• identify some type of objective tool, such as a numerical scoring 

mechanism, and instruct all inspectors-in-charge at plants to use this 

measure to assist them in evaluating the plants’ HMSA performance and 

determining what, if any, enforcement actions are warranted; and 

• strengthen the analysis of humane handling data by analyzing the narrative 

in noncompliance reports to identify areas that need improvement. 

To ensure that FSIS can demonstrate how efficiently and effectively it is 

enforcing HMSA, we recommend that the Secretary of Agriculture direct 

the Administrator of FSIS to develop an integrated strategy that clearly 

defines goals, identifies resources needed, and establishes time frames and 

performance metrics specifically for enforcing HMSA. 

We provided USDA with a draft of this report for review and comment. 

USDA did not state whether it agreed or disagreed with our findings and 

recommendations. However, it stated that it plans to use both our findings 

and recommendations to help improve efforts to ensure that 

establishments comply with HMSA and humane handling regulations. 

USDA also recognized the need to improve the inspectors’ ability to 

identify trends in humane handling violations and work with academia, 

industry, and others to identify practices that will achieve more consistent 

HMSA enforcement. 

Agency Comments 

and Our Evaluation 

USDA commented that the report contained some misstatements of fact 

that present a false picture of FSIS’s humane handling verification and 

enforcement program and policies. We believe that we have fairly 

described FSIS policy and guidance on HMSA enforcement. In response to 

updated information that FSIS provided, we made appropriate revisions to 

clarify certain points. For example, we revised our report by deleting the 

portion of our analysis related to suspension data that occurred on the 

days that DVMSs conducted humane handling audits because on the basis 

of new information provided we believe that FSIS records of DVMS audit 

visits are incomplete. 

USDA also questioned whether the results of our survey of FSIS inspectors 

provide evidence of systemic inconsistencies in enforcement. We believe 

they do, and would encourage USDA to consider the views of inspectors at 

the plants who are responsible for daily HMSA enforcement. Our survey 

results are based on strict adherence to GAO standards and methodology 

to ensure the most accurate results possible. Furthermore, our efforts 

were fully coordinated with FSIS before we distributed the survey. 

Page 39 GAO-10-203 Humane Slaughter
 

Specifically, we vetted all of the questions with FSIS management in 

advance to ensure that these questions elicit responses that would reveal 

whether or not inspectors-in-charge understand how to fully enforce 

HMSA. In addition, we conducted numerous pre-tests of the survey with 

inspectors to ensure that we would receive the most accurate responses 

possible. We also coordinated with several humane handling experts who 

serve as FSIS consultants on training and enforcement issues to ensure 

that our questions would elicit the most accurate responses. 

USDA also provided technical comments, which we have incorporated 

into this report as appropriate. USDA’s written comments and our 

responses are presented in appendix IV. 

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies of this report to appropriate 

congressional committees; the Secretary of Agriculture; the Director, 

Office of Management and Budget; and other interested parties. The report 

also will be available at no charge on the GAO Web site at 

http://www.gao.gov. 

If you or your staff members have any questions about this report, please 

contact me at (202) 512-3841 or shamesl@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on the 

last page of this report. Key contributors to this report are listed in 

Lisa Shames 

appendix V. 

Director, Natural Resources 

 and Environment 

Page 40 GAO-10-203 Humane Slaughter
Appendix I: Objectives, Scope, and 

Methodology 

Page 41 GAO-10-203 

Appendix I: Objectives, Scope, and 

Methodology 

This report examines (1) U.S. Department of Agriculture Food Safety and 

Inspection Service’s (FSIS) efforts to enforce the Humane Methods of 

Slaughter Act of 1978, as amended (HMSA); (2) the extent to which FSIS 

tracks recent trends in FSIS inspection resources for enforcing HMSA; and 

(3) FSIS’s efforts to develop a strategy to guide HMSA enforcement. 

To evaluate FSIS’s efforts to enforce HMSA, we interviewed officials and 

collected documents from FSIS’s Office of Field Operations; Office of 

Policy and Program Development; Office of Program Evaluation, 

Enforcement and Review; and the 15 district offices. We examined a 

nonprobability sample of FSIS noncompliance reports to provide 

illustrative examples of humane handling violations. In doing so, we 

searched for the words “prod” and “stun” in 533 noncompliance reports for 

2007 and 589 noncompliance reports for 2008. Of these 1,122 reports, 272 

reports included either the word “stun” or “prod” in reference to a 

violation. We then selected several of the reports that described violations 

appearing to be egregious and provided these reports to the expert we 

consulted for her assessment. This expert determined that the violations 

described in some of these reports were not sufficiently clear or detailed 

to determine whether they represented egregious violations, while others 

were clearly egregious in her judgment. 

We also reviewed FSIS suspension data, data from the humane handling 

tracking system and district veterinary medical specialist reports in all 15 

of FSIS’s district offices for fiscal years 2005 through 2009. To assess the 

reliability of these data, we examined them for obvious errors in 

completeness and accuracy, reviewed existing documentation about the 

systems that produced the data, and questioned knowledgeable officials 

about the data and systems. We determined that the data were sufficiently 

reliable for the purposes of our review, with any limitations noted in the 

text. We also reviewed the HMSA enforcement reports produced by FSIS’s 

Office of Data Analysis and Integration Group, as well as meeting minutes 

from the monthly district veterinary medical conferences. To understand 

FSIS policy and guidance on humane slaughter enforcement, we reviewed 

relevant regulations and FSIS instructions. From May 2009 through July 

2009, we also surveyed inspectors-in-charge—those responsible for 

reporting on humane handling enforcement in the plants—from a random 

sample of inspectors at 257 livestock slaughter plants that were stratified 

by size—very small, small, and large. We adopted FSIS definition for small, 

Humane Slaughter
Appendix I: Objectives, Scope, and 

Methodology 

very small, and large plants. We obtained an overall survey response rate 

of 93 percent.1

Table 3 shows the population and sample size distribution of slaughter 

plants by large, small and very small plant size. Each of the inspectors-incharge had a nonzero probability of being included, and that probability 

could be computed for any inspector-in-charge. Each inspector-in-charge 

was subsequently weighted in the analysis to account statistically for all 

the members of the population, including those who were not selected. 

Table 3: Universe of Plants and Sample Description 

Plant size 

Number of 

plants in 

universe 

Number of

 plants in

 sample

Number of plants with 

inspectors-incharge responding 

Percentage 

response rate

Large 63 63 56 89%

Small 188 85 75 89%

Very small 531 109 104 95%

Total 782 257 235 93%

Source: GAO analysis of survey data. 

We analyzed all responses, including the written responses that we 

received from the survey by conducting a content analysis and 

categorizing the responses accordingly. The results of our survey are 

presented in a special publication titled Humane Methods of Slaughter 

Act: USDA Inspectors’ Views on Enforcement that can be viewed at 

GAO-10-244SP. 

We met with key officials from FSIS’s Office of Field Operations who are 

responsible for implementing HMSA at the headquarters level. To 

understand district officials’ perspectives on HMSA enforcement, we 

conducted semistructured interviews with each of FSIS’s 15 district 

veterinary medical specialists (DVMS), 15 district managers, and 15 

resource management analysts. We also performed a content analysis on 

all semistructured interviews to determine the districts’ perspective on 

training, guidance, and resources available for humane handling 

 

1

All full sample percentage estimates from the survey have margins of error at the 95 

percent confidence level of plus or minus 7 percentage points or less, unless otherwise 

noted. Percentage estimates by plant size have margins of error at the 95 percent 

confidence level of plus or minus 10 percentage points or less, unless otherwise noted. 

Page 42 GAO-10-203 Humane Slaughter
Appendix I: Objectives, Scope, and 

Methodology 

enforcement. To understand the perspective of animal welfare groups and 

the meat industry, we met with representatives from the Humane Society 

of the United States, the Animal Welfare Institute, the American Meat 

Institute, the National Meat Association, and the American Association of 

Meat Processors. We reviewed these organizations’ proposed reforms for 

HMSA enforcement. We also attended the 2009 American Meat Institute 

Humane Handling Conference in Kansas City, Missouri. To gain a better 

understanding of how the industry evaluates HMSA performance, we 

attended the Professional Animal Auditor Certification Organization 

training for meat plants in Denison, Iowa, in November 2008 and visited 

pork and beef slaughter plants that use a numerical scoring system. We 

also consulted animal handling expert Dr. Temple Grandin, who is a 

world-renowned expert on animal welfare who has served as a consultant 

to industry and FSIS, written extensively on modern methods of livestock 

handling, and designed slaughter facilities that have helped improve 

animal welfare in the United States and in other countries. Dr. Grandin 

provided her expert opinion on select humane handling incidents that we 

identified as possible HMSA violations. In addition to Dr. Grandin, we also 

spoke with animal welfare and food safety consultants to understand key 

principles of humane handling techniques and enforcement. We also met 

with representatives of the U.S. Department of Agriculture’s Agricultural 

Marketing Service to understand how the agency uses numerical scoring 

to evaluate humane handling at the plants that provide meat to the 

National School Lunch Program. In order to understand FSIS training 

efforts, we attended an FSIS training seminar for small and very small 

plants held in Dallas, Texas, in February 2009, and met with FSIS officials 

at the agency’s Center for Learning in Washington, D.C., as well as with 

FSIS consultants who provide training in HMSA enforcement. 

To identify the extent to which FSIS tracks recent trends in inspection 

resources for enforcing HMSA, we reviewed FSIS funding and staffing data 

for each district. We also conducted semistructured interviews with 

resource management analysts in each of FSIS’s 15 district offices and 

interviewed key officials in the Resource Management and Planning Office 

within the Office of Field Operations. We performed a content analysis on 

all semistructured interviews to determine each districts’ perspective on 

inspection resources available for humane handling enforcement. In order 

to understand how FSIS reports its annual full-time equivalent staff for 

humane handling to Congress, we collected funding and other relevant 

data and met with key officials in FSIS’s Office of Field Operations and 

Office of Management and Office of the General Counsel, as well as the 

U.S. Department of Agriculture’s Office of Budget and Program Analysis. 

Page 43 GAO-10-203 Humane Slaughter
Appendix I: Objectives, Scope, and 

Methodology 

To assess FSIS’s efforts to develop a strategy to enforce HMSA, we 

reviewed relevant FSIS strategies, including the FSIS Strategic Plan FY 

2008 through FY 2013, and the FSIS 2007 Strategic Workforce Plan. We 

also reviewed the July 2009 version of the Office of Field Operations’ 

Operational Plan and the Office of Policy and Program Development 

Strategic Plan Fiscal Years 2008-2013. Furthermore, we reviewed 

humane handling performance data from the Office of Policy and Program 

Development. We met with representatives of the FSIS Office of 

Management on human capital issues and officials from the Office of 

Personnel Management in Washington, D.C. To identify the key elements 

of a strategic plan, we reviewed the Government Performance and Results 

Act of 1993, as well as past GAO reports. 

We conducted this performance audit for our work from October 2008 to 

February 2010, in accordance with generally accepted government 

auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our audit objectives. We 

believe that the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives. 

Page 44 GAO-10-203 Humane Slaughter
Appendix II: Lo

HMSA Comp

cation of Inspectors Observing 

liance at Typical Mid-Sized Plant 

Page 45 GAO-10-203 

Figure 11 illustrates the areas in a typical, mid-sized plant from which 

inspectors can observe HMSA compliance, although inspectors are not 

always present in all areas. 

Appendix II: Location of Inspectors 

Observing HMSA Compliance at Typical MidSized Plant 

Figure 11: Location of Inspectors Observing Compliance with the HMSA at a Typical Mid-Sized Plant 

Round forcing pen with

two revolving crowd gates

Round forcing pen with

Unloading dock

Curved holding chute

1

Trucks

Antemortem inspection

Veterinarian inspector examines

animal health in the stockyard 

areas and in the holding pens.

2 Curv

3

Stunning platform

4

Walkways allow 

the workers and 

inspectors to 

navigate freely 

through the 

chute areas.

Sources: GAO graphic based on GAO analysis of information provided by FSIS and Dr. Temple Grandin, a humane handling expert.

Photographs in this figure are used by permission of Dr. Temple Grandin.

Postmortem inspection

FSIS inspectors perform 

inspections on all 

carcasses as they are 

further processed.

IIC (inspector-in-charge) or FSIS floating

inspector monitors the entire process

from the trucks through processing and

can move back and forth along the line.

Steps 1 - 6

6

Animals are hoisted

slaughtered and bled.

5

Humane Slaughter
Appendix III: HMSA Suspensions for FSIS Appendix III: HMSA Suspensions for FSIS Districts 

Districts 

Figure 12 provides an overview of the percentage of plant suspensions for 

HMSA enforcement that occurred in each district for calendar year 2008. 

The percentages were determined based on the total number of plants in 

each districts and the number of reported suspensions. As the figure 

illustrates, the Jackson district had the highest percentage of suspensions. 

Figure 12: Percentage of Suspensions by District, Calendar Year 2008

0

10

20

30

40

50

60

Districts

Percentage of plants suspended

Source: GAO analysis of FSIS data.

Springdale, AR

Raleigh, NC

Minneapoli

Philadelphia, PA

s, MN

Madison, WI

Lawrence, KS

Jackson, MS

Des Moines, IA

Dallas, TX

Chicago, IL

Denver, CO

Beltsville, MD

Albany, NY

Atlanta, GA

Alameda, CA

Page 46 GAO-10-203 Humane Slaughter
Appendix IV: Comments from the U.S. Appendix IV: Comments from the U.S. Department of Agriculture 

Department of Agriculture 

Note: GAO comments 

supplementing those in 

the report text appear at 

the end of this appendix. 

Page 47 GAO-10-203 Humane Slaughter
Appendix IV: Comments from the U.S. 

Department of Agriculture 

See comment 1. 

See comment 2. 

See comment 3. 

See comment 4. 

Page 48 GAO-10-203 Humane Slaughter
Appendix IV: Comments from the U.S. 

Department of Agriculture 

See comment 5. 

See comment 6. 

Page 49 GAO-10-203 Humane Slaughter
Appendix IV: Comments from the U.S. 

Department of Agriculture 

See comment 7. 

See comment 8. 

See comment 8. 

See comment 9. 

See comment 9. 

Page 50 GAO-10-203 Humane Slaughter
Appendix IV: Comments from the U.S. 

Department of Agriculture 

See comment 10. 

See comment 11. 

See comment 4. 

See comment 4. 

See comment 12. 

See comment 13. 

Page 51 GAO-10-203 Humane Slaughter
Appendix IV: Comments from the U.S. 

Department of Agriculture 

See comment 14. 

See comment 15. 

See comment 3. 

See comment 16. 

See comment 17. 

Page 52 GAO-10-203 Humane Slaughter
Appendix IV: Comments from the U.S. 

Department of Agriculture 

See comment 18. 

See comment 19. 

See comment 20. 

Page 53 GAO-10-203 Humane Slaughter
Appendix IV: Comments from the U.S. 

Department of Agriculture 

Page 54 GAO-10-203 

The following are GAO’s comments on the U.S. Department of 

Agriculture’s letter dated January 22, 2010. 

1. Our report acknowledges FSIS’s efforts to increase its humane 

handling enforcement efforts since the events at Westland/Hallmark. 

However, FSIS did not provide source material for some of the data in 

its comments, making it difficult to determine the completeness and 

reliability of the data provided. Therefore we could not include in the 

report the data that FSIS provides in its comments. 

GAO Comments 

2. We believe our report provides an accurate picture of FSIS’s humane 

handling enforcement activities. However, we have modified text in 

response to FSIS’s technical comments as appropriate or have 

explained why we disagree with FSIS’s comments, as noted below. 

3. We revised the report to reflect the agency’s comments by deleting the 

portion of our analysis in our draft report that related to the 

suspension data that occurred on the days that DVMSs conducted 

humane handling audits. The report now states that the recods of 

DVMS audit visits are incomplete and that we were unable to conduct 

the complete analysis. As a result, we could not fully determine how 

often DVMSs conducted humane handling audit visits nor whether 

there is a higher rate of enforcement actions on the days that DVMSs 

conducted their audits for humane handling. Specifically, our original 

analysis of the DVMS visits was based on data that FSIS provided to us 

during the course of our review. Based on the information originally 

provided to us by FSIS during our audit, these data met all of GAO’s 

data reliability standards. In January 2010, after receiving a draft copy 

of this report for comment, FSIS provided us with revised suspension 

data and informed us that the original data it had provided were 

incomplete. However, after reviewing the January 2010 data, we 

believe the revised data contain incomplete information, and we are 

therefore unable to corroborate the DVMS humane handling audit visit 

data. 

4. We modified the report to clarify that the FSIS Administrator may file a 

complaint to withdraw a grant of federal inspection. 

5. We modified the report to clarify the difference between a withdrawal 

of inspectors and a withdrawal of the grant of inspection. We added 

that only the FSIS Administrator may file a complaint to withdraw a 

grant of federal inspection. However, the district office can still 

request such a withdrawal. In 2004, we recommended that FSIS 

Humane Slaughter
Appendix IV: Comments from the U.S. 

Department of Agriculture 

establish additional, clear, specific and consistent criteria for district 

offices to use when considering whether to take enforcement actions 

because of repeat violations.1

 We continue to believe that more 

specific guidance would be valuable to better address situations such 

as the one at the Bushway Packing plant in Vermont. It is also 

important to note that inspectors need to be trained to identify what 

actions may warrant such a request to ensure that FSIS is fully 

enforcing HMSA. 

6. Although we did not state that numerical scoring is not regulatory in 

nature, we did state that using it to measure compliance would be 

inconsistent with the HMSA requirement that animals be rendered 

insensible to pain on the first blow. However, we believe that FSIS, in 

using its enforcement discretion, should identify some type of 

objective tool, such as a numerical scoring mechanism, and instruct all 

inspectors-in-charge at plants to use this measure to assist them in 

evaluating their plants’ HMSA performance and determining what, if 

any, enforcement actions are necessary in the agency’s exercise of its 

enforcement discretion. 

7. We acknowledge in the report FSIS’s efforts to strengthen its analysis 

of humane handling data later this year. Although FSIS officials 

informed us of plans to implement the Public Health Information 

System, we found that those plans have experienced delays, and the 

system has yet to be implemented. For example, Public Health 

Information System was originally scheduled to be fully functional in 

the fall 2009—we now understand that the expected date has shifted to 

the end of 2010. Without the availability of this system, we analyzed 

the humane handling data that FSIS made available to us during the 

course of our review. 

8. FSIS questioned whether our survey results provide evidence of 

systemic inconsistencies in enforcement. Our survey results are based 

on strict adherence to GAO standards and methodology to ensure the 

most accurate results possible, as summarized in appendix I of this 

report. From May 2009 through July 2009, we surveyed inspectors-incharge—those responsible for reporting on humane handling 

enforcement in the plants—from a random sample of inspectors at 257 

 

1

GAO-04-247. 

Page 55 GAO-10-203 Humane Slaughter
Appendix IV: Comments from the U.S. 

Department of Agriculture 

livestock slaughter plants that were stratified by size—very small, 

small, and large. We obtained an overall survey response rate of 

93 percent.2

9. Concerning FSIS’s comment on two of our survey questions, our 

survey results showed that 29 percent of the inspectors reported that 

they would not take any enforcement action or did not know what 

enforcement action to take for electrical prodding of most animals. 

Ten percent of the inspectors reported that they would take no 

enforcement action or did not know what action to take for electrical 

prodding in the rectal area. These figures suggest that FSIS may not be 

fully enforcing HMSA. While FSIS states that HMSA enforcement 

requires that inspectors make qualitative judgments since each 

livestock slaughter operation is unique, we found that humane 

handling experts in academia and industry firmly believe that such 

judgments need to be based on some type of objective standards, 

regardless of the size, construction, layout and staffing at the plants. 

We appreciate FSIS’s statement that it plans to examine the GAO 

survey results as it continues to improve its enforcement training and 

policies and urge FSIS to fully use the information in the survey results 

to identify practices that may achieve more consistent enforcement of 

HMSA. 

10. We modified the report to clarify that HMSA exempts ritual slaughter 

from the requirement we discuss in the sentences immediately 

preceding the text in that section of the report—that an animal be 

rendered insensible to pain on the first blow—not to the general HMSA 

requirements. 

11. Our report is correct as stated. FSIS refers to FSIS Directive 6900.2, 

Rev. 1, section VI (A) but FSIS does not refer to section VI (B), which 

states that if an inspector determines that “a noncompliance with 

humane slaughter and handling requirements has occurred and 

animals are being injured or treated inhumanely,” the inspector is to 

take two specific actions: (1) document the noncompliance on a 

noncompliance record and (2) take a regulatory control action. FSIS’s 

misapplication of the directive may further illustrate the lack of clarity 

 

2

All full sample percentage estimates from the survey have margins of error at the 95 

percent confidence level of +/- 7 percentage points or less, unless otherwise noted. 

Percentage estimates by plant size have margins of error at the 95 percent confidence level 

of +/- 10 percentage points or less, unless otherwise noted. 

Page 56 GAO-10-203 Humane Slaughter
Appendix IV: Comments from the U.S. 

Department of Agriculture 

in FSIS policy on humane handling enforcement, which may contribute 

to the lack of a clear understanding at the inspector level. 

12. Nearly three-quarters of the inspectors-in-charge responding in our 

survey reported that they were not veterinarians. While 100 percent of 

the IICs at the large plants that we surveyed were veterinarians, 88 

percent of those at very small plants in our representative survey were 

not veterinarians, and 57 percent of IICs at small plants were not 

veterinarians. In addition, we modified the text to clarify the 

responsibility of FSIS veterinarians prior to slaughter. 

13. We modified figure 3 to show that patrol veterinarian only applies to 

some small and very small plants. 

14. On page 31 of this report, we state that “FSIS began analyzing data 

across districts from the Humane Activities Tracking System in 2008—

4 years after it developed the system.” We also recognize that the Data 

Analysis Integration Group began “reporting quarterly on HMSA 

enforcement, including the amount of time inspectors have devoted to 

HMSA, the number of plants suspended, and the number of 

noncompliance reports issued in 2009.” In reviewing these reports, 

however, we found no analysis indicating that FSIS used these data to 

evaluate HSMA enforcement across the districts and plants to identify 

inconsistent enforcement. Also, FSIS officials acknowledged in our 

final meeting in November 2009, that it has never conducted any 

analysis of the noncompliance reports to determine patterns or trends 

in HMSA enforcement. Furthermore, although FSIS provided us with 

its monthly minutes of its DVMS conference calls from March through 

September 2009, these minutes did not identify any FSIS analysis of 

HMSA enforcement across the districts and possible inconsistent 

patterns. FSIS did not grant our request to attend the monthly DVMS 

conference calls in order to better understand the nature of the DVMS 

discussion and attempt to determine if such analysis was under way. 

15. We modified the text to indicate that there is “no clear directive to do 

so in guidance.” Although regulations and policy documents describe 

when suspensions may take place, the agency has offered no clear 

directive as to when they should take place. 

16. We changed the text to state “six possible signs of sensibility” to 

clarify, as noted in footnote 17 (now footnote 15), that the list of signs 

included two that, alone, do not generally indicate sensibility. In 

addition, we re-checked the coding used in our analysis to ensure that 

the calculations were correct. We found no discrepancies or errors. 

Page 57 GAO-10-203 Humane Slaughter
Appendix IV: Comments from the U.S. 

Department of Agriculture 

Therefore, these results clearly demonstrate that inspectors-in-charge 

may not have been sufficiently trained. 

17. The National Academies’ Institute of Medicine study found 

weaknesses in the noncompliance reports, and as we stated, the 

institute recommended testing and improved training with special 

emphasis on the quality and consistency of noncompliance reports for 

food safety issues. Because FSIS’s inspection personnel are 

responsible for completing noncompliance reports for both food safety 

and humane handling violations, it is evident that improving training 

on the quality and consistency of those reports would be useful in 

supporting FSIS humane handling compliance efforts. 

18. Our analysis of similar sized plants with similar slaughter volumes 

revealed substantial differences in the amount of time devoted to 

humane handling in different districts. This information might better 

inform FSIS officials to manage resources and/or training to help 

improve performance. 

19. We disagree. We conducted this analysis in an effort to gain some 

perspective on the percent of FSIS annual appropriation for inspection 

devoted to humane handling and estimated that it has been above 1 

percent of FSIS’s total annual inspection appropriation. FSIS officials 

informed us that 80 percent of their time should be devoted to food 

safety and 20 percent to humane handling inspection and other 

activities. Because FSIS cannot track humane handling funds 

separately, the agency was unable to provide the amount of funds that 

it devotes to humane handling activities. To provide context for the 

reader, we estimated the percentage of the total annual inspection 

appropriations dedicated to HMSA enforcement. We modified the text 

to expand the definition of FSIS inspection fund to include other 

activities such as livestock slaughter, poultry slaughter, processing 

inspection, egg inspection, import inspection, in-commerce 

compliance, district office activities and food safety enforcement 

activities. However, this clarification does not change the calculation. 

20. We disagree. While the OIG report states that “events that occurred at 

Hallmark were not a systemic failure of the inspection 

processes/system as designed by FSIS,” it is important to note that its 

scope was based on observations at 10 cull cow (older and weaker) 

slaughter facilities. Nevertheless, the OIG report presented 25 

recommendations to strengthen FSIS activities, and FSIS accepted all 

of these recommendations. Specifically, OIG recommended that FSIS 

needs to “reassess the inhumane handling risks associated with cull 

Page 58 GAO-10-203 Humane Slaughter
Appendix IV: Comments from the U.S. 

Department of Agriculture 

slaughter establishments and determine if more frequent or in-depth 

reviews need to be conducted.” The report also recommended “that a 

structured training and development program, with a continuing 

education component, be developed for both its inspection and 

management resources.” Furthermore, our survey results and analysis 

of HMSA enforcement data —that inspectors did not consistently 

identify and take enforcement action for humane handling violations 

for the period we reviewed—indicate a more widespread problem. 

Therefore, we continue to believe that it is difficult to know whether 

these incidents are isolated or not, and the extent of such incidents is 

difficult to determine because FSIS does not evaluate the narrative in 

noncompliance reports. 

Page 59 GAO-10-203 Humane Slaughter
Appendix V: 

A

GAO Contact and Staff 

cknowledgments 

Page 60 GAO-10-203 

Appendix V: GAO Contact and Staff 

Acknowledgments 

Lisa Shames, (202) 512-3841, or shamesl@gao.gov

In addition to the individual named above, other key contributors to this 

report were Thomas M. Cook, Assistant Director; Nanette J. Barton; 

Michele E. Lockhart; Beverly A. Peterson; Carol Herrnstadt Shulman; and 

Tyra J. Thompson. Important contributions were also made by Kevin S. 

Bray, Michele C. Fejfar, Justin Fisher, Carol Henn, Kirsten Lauber, and 

Ying Long. 

Humane Slaughter

GAO Contact 

Staff 

Acknowledgments 

(361008) 
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