,,~~"~l-'''VIC£S'U3.

~

'"

~

~

"ó

't-tif.l

"-lb'Vd30

DEPARTMENT OF HEALTH & HUMAN SERVICES Office of Inspector General

"AUG 1Q 2007

Washington, D.C. 20201

The Honorable John Kerr

United States Senate

Washington, DC 20510

Dear Senator Kerry:

I am writing to advise you of the results of the investigation the Office of Inspector

General (OIG) conducted in response to your request of February 5,2007. In your letter,

you expressed concern regarding allegations that offcials of the Centers for Disease

Control (CDC) may have blocked an investigation into the failure of Personal Alert

Notification System (PASS) equipment used by firefighters. A PASS device is a motion

sensor that emits a series of loud beeps if it is triggered by a firefighter or if the firefighter

stands stil for more than 30 seconds. The sound from the device allows other firefighters

to locate and assist an individual who has become disoriented or incapacitated in a fire.

In February 2007, MSNBC issued a two-part report on the deaths of firefighters allegedly

related to the failure of PASS devices and on the responsibilities of the CDC, National

Institute for Occupations Safety and Health (NIOSH) in this matter. MSNBC cited in its

report that there were 15 fatalities between 1998 and 2005 in which firefighters ' PASS

devices failed or did not work properly. Specifically, the report quoted the CDC's former

Fire Safety Engineer, Eric R. Schmidt, as saying that CDC offcials told him to

"minimize his fact gathering during investigations" and that he was instructed to "omit

critical facts" regarding the performance of the PASS devices.

OIG conducted an investigation of the allegations and of the methods used by

CDCINIOSH in investigating firefighter fatalities. OIG investigators interviewed Mr.

Schmidt, CDC offcials, and reviewed documentation related to the specific allegations,

as well as governing program authorities and operational guidelines. In conclusion, OIG

found no indication of wrongdoing by CDC management. Rather, the allegations

primarily stem from a difference of opinion concerning NIOSH investigative procedures.

NIOSH uses a public health research model to examine workplace fatalities in a variety

of employment settings. The goal of this model is to conduct a "risk assessment" and

identify strategies that can prevent fatalities under similar circumstances in the future and

to disseminate the results of this assessment as quickly as possible. This researchoriented approach differs from investigative methods used by more traditional law

enforcement organizations.

The investigative guidelines used by the NIOSH firefighter fatality investigators have

been modified since the time ofMr. Schmidt's employment and continue to evolve.

However, in conducting this investigation, we identified opportnities for improvement
Page 2 - The Honorable John Kerr

of the methods used to conduct the firefighter fatality investigations and in the timing of

the investigations and the dissemination of the results. This letter summarizes the

findings of our investigation and our suggestions for improvement.

I. Background: The Fire Fighter Fatality Investigation and Prevention Program

Pursuant to the Occupational Safety and Health Act of 1970 (Pub. L. No. 91-596),

NIOSH was established to conduct research and make recommendations for the

prevention of occupational injury and illness. Federal regulations (42 CFR Part 85A)

define an investigation conducted by NIOSH as "research projects, experiments,

demonstrations, studies, and similar activities ofNIOSH...." (42 CFR § 85a.2). The

regulations authorize NIOSH to "enter without delay any place of employment for the

purpose of conducting investigations of all pertinent processes." (42 CFR § 85a.3).

However, during an investigation, an instruction is necessary that a person involved in

the investigation is "free to withdraw his consent and to discontinue participation in the

investigation any time without prejudice to the subject." (42 CFR § 85a.2).

In fiscal year 1998, Congress appropriated $2.5 milion to CDC/NIOSH to address the

problem of occupational firefighter fatalities. Specifically, NIOSH is to use the

additional funding to conduct investigations of firefighter line-of-duty deaths.

Program Overview

Approximately 100 firefighters die in the line-of-duty each year. About half of these

fatalities result from traumatic injuries, while a large portion of the remaining fatalities

stem from heart attacks occurrng in the line-of-duty. Since the inception of the Fire

Fighter Fatality Investigation and Prevention Program (FFFIPP), the program has

provided reports and recommendations related to close to 350 incidents involving a

firefighter fatality (or multiple fatalities) occurrng in almost all 50 States.

There are currently no requirements regarding how the NIOSH FFFIPP should utilize its

funding for the investigation of firefighter deaths. The FFFIPP is a relatively small

program, with a staff of approximately 14 investigators. The essentially flat funding

since 1998 has resulted in a reduced number of investigations over time. As a result,

NIOSH prioritizes certain types of investigations. For example, priority is given to those

events that account for a large number of deaths and those likely to result in new types of

safety recommendations.

In January of 1998, NIOSH convened a meeting in Washington, DC, to obtain input from

primary stakeholders, including representatives of fire departments, unon

representatives, and fire service organizations, to help provide direction for the new

FFFIPP. These stakeholders most frequently mentioned the desire to focus on

conducting line-of-duty investigations to identify factors contributing to firefighter

fatalities and to disseminate this infoimation to fire departments throughout the country.

Since January 1998, NIOSH has periodically consulted with stakeholders to ensure that

the FFFIPP is meeting their needs and to identify ways in which NIOSH might improve
Page 3 - The Honorable John Kerry

upon the program to increase its impact on the safety and health of firefighters across the

country. Most recently, NIOSH held a public stakeholders meeting in March 2006.

Investigative Methods and Reporting

NIOSH staff conduct on-site investigations to gather facts surrounding a line-of-duty

firefighter fatality and to identify potential contributory factors. NIOSH is notified of

firefighter line-of-duty deaths by the U.S. Fire Administration (USFA) and individual fire

departments and unions may also notify NIOSH of deaths and specifically request

investigations. Firefighter fatality investigators look at what happened before, during,

and after the event, and when applicable, use other agencies' investigative reports to help

them develop a more complete picture of the events that led to the death of the

firefighter(s) in question. NIOSH investigators typically do not respond immediately to a

fatality, but attempt to respond within 3 to 6 weeks of the death(s). In questioning a

NIOSH official, she indicated that this allows others, such as local law enforcement, time

to complete their investigations, for families of the deceased to have mourned, and for the

firefighters and other witnesses to be more focused during the interviews.

The NIOSH FFFIPP is based on the Fatality Assessment and Control Evaluation (FACE)

model that was already in place and being utilized by NIOSH to identify and study other

types of fatal occupational injuries. FACE uses a public health approach to fatal injury

investigations. The goal of this approach is to prevent occupational fatalities across the

Nation by identifying and investigating work situations at high risk for worker injury and

then formulating and disseminating prevention strategies to those who can intervene in

the workplace. FACE is a research model, not an enforcement modeL. Accordingly,

investigators do not enforce compliance with State or Federal occupational safety and

health standards and do not determine fault or blame. For example, the names of

employers, victims, and/or witnesses are not used in written investigative reports.

A report is completed for each investigation which summarizes the sequence of events

that led to the firefighter death or injury and includes recommendations for preventing

future deaths and injuries under similar circumstances. These recommendations have

most frequently been directed to fire departments and have suggested improvements to

standard operating procedures or guidelines, personal protective equipment,

communications, rapid intervention teams, strategies and tactics, and staffing.

In addition to conducting investigations ofline-of-duty deaths of firefighters, the NIOSH

FFFIPP also conducts Health Hazard Evaluations which entail epidemiological studies of

workplace exposures. Additionally, when multiple NIOSH FFFIPP investigations

identify common safety and health concerns, NIOSH develops educational documents

that summarize the hazard and recommend prevention measures. Examples of topics

addressed by these evaluations and educational documents include: structural collapse,

exposure to electrical hazards during wildfires, live-fire training in acquired structures,

deaths from tanker truck roll-overs, dive training, and hazards of working alongside

roadways.
Page 4 - The Honorable John Kerry

II. Allegations of Mismanagement

In the February 2007 MSNBC reports, Eric R. Schmidt, a former employee ofNIOSH

FFFIPP, said that he was instructed to "omit critical facts" regarding the performance of

P ASS devices in an investigation of three firefighter fatalities in a December 1999

residential fire in Iowa. The article includes quotes from a February 14,2000,

"Performance Guidance" document in which Mr. Schmidt's supervisor at the time, Dawn

Castilo, instructed him to "minimize your fact gathering during investigations to those

pieces of information which are needed to summarize the chain of events or that have

direct implications for prevention recommendations."

Nature and Context of Allegations

Mr. Schmidt worked for NIOSH from June 1999 to June 2000 as a fire safety engineer in

the early years ofthe FFFIPP. Prior to his employment with NIOSH, he had worked as a

Fire Captain, a firefighter, and fire prevention engineer. At the time of his employment

with NIOSH, Mr. Schmidt was the only investigator with a background in firefighting.

Additionally at that time, FFFIPP investigators relied on the general FACE investigative

procedures. (Subsequent to the time of Mr. Schmidt's employment, investigation

guidelines based on the FACE model have been developed for specific application to the

FFFIPP. )

Based on our investigation, OIG determined that Mr. Schmidt's allegations of

mismanagement and problems occurrng during his employment stem primarily from a

difference of opinion in the interpretation of the governing investigative procedures. Mr.

Schmidt did not report any cover-up of an investigation into the possible failures of PASS

devices. He indicated to investigators that he did not believe that the management at

NIOSH was corrpt or dishonest in any way. In response to questions regarding whether

he was told to omit critical facts from his investigations, he said that "no one ever said

cover this up or don't show this because someone doesn't want us to show this."

Mr. Schmidt explained to OIG investigators that the allegation that he was told to "omit

critical factors" and "minimize your fact gathering during investigations" stems from a

difference of opinion between Mr. Schmidt and his supervisor, Ms. Castilo, regarding

the manner in which firefighter fatality investigations should be conducted. He believed

the program should be administered with more of an investigative focus and less of a

research emphasis. However, as noted previously, consistent with applicable regulations,

NIOSH's research of occupational fatalities of all types (not just firefighter fatalities) is

based on a public health model and not on an investigative modeL. .

Mr. Schmidt reported to OIG that his goal in bringing to attention possible failures with

P ASS devices was to shed light on what he perceived as shortcomings in the investigative

methods used in the FFFIPP. He also stated that the potential failures of PASS devices

are not really the main issue; the devices were used as an example to ilustrate problems

with the procedures that are used in the firefighter fatality investigations. "The issue is

the procedures, or lack of, that are used in the investigation." CDC/NIOSH management

confirmed that during the course of his employment with CDC, Mr. Schmidt did not raise
Page 5 - The Honorable John Kerr

'concerns to management regarding the performance of PASS devices, nor did he request

to pursue a line of inquiry regarding PASS devices. i

Mr. Schmidt was terminated from his employment with NIOSH on June 16, 2000, prior

to the end of his probationary period. OIG determined through interviews and

documentation gathered, including performance documentation, internal e-mails, and

work products, that Mr. Schmidt's termination was not related to his desire to investigate

P ASS devices. Rather, as noted in the February 2000 performance guidance memo

provided to Mr. Schmidt by Ms. Castillo and in the documentation provided at the time

of his termination on June 16, 2000, there were concerns regarding the timeliness and

completeness of his written reports, as well as his ability to follow instructions and to

work well with the rest of the team.

Mr. Schmidt appealed his termination to the Equal Employment Opportnity

Commission and the Merit Systems Protection Board, requesting reinstatement to his

position with NIOSH. Both of these cases were dismissed. In his appeals, Mr. Schmidt

did not raise a concern with PASS devices or indicate that his supervisor prevented him

from pursuing issues related to PASS devices. Further, Mr. Schmidt's investigative

materials left with his supervisors at the time of his termination did not mention the need

for NIOSH to follow up and gather additional information related to PASS devices.

NIOSH/FFFIPP Attention to PASS Devices

In 2005, the National Fire Protection Association (NFP A) published an alert advising

emergency responders that high temperatures could cause a reduction in the volume of

PASS alar signals. OIG was, however, unable to substantiate allegations that

mismanagement by CDC/NIOSH was connected to deaths of nine firefighters between

2001 and 2005, prior to the publication of the NFP A alert. OIG determined that at the

time ofMr. Schmidt's employment and subsequently, NIOSH included examinations of

PASS devices in its investigations, sent these devices for testing when warranted, and

when evidence was suffcient, called attention to potential problems with PASS devices.

The investigative guidelines used in conducting FACE evaluations at the time of

Mr. Schmidt's employment instructed that the investigator should provide a detailed

description of the incident in the narrative, including a description of the personal

protective equipment and/or safety equipment used or available and a description of other

equipment involved. Consistent with these guidelines, NIOSH specifically addressed the

fuctioning ofP ASS devices in reports of investigations conducted during that time.

To illustrate, in the report ofthe investigation on which Mr. Schmidt was working when

he received the February 2000 feedback on his performance and which he uses to support

his allegations of mismanagement, NIOSH describes the examination ofthe firefighters'

P ASS devices. In this report, which summarizes the investigation of three fatalities

i In an October 2, 2000, letter to Dr. Linda Rosenstock, the Director of NIOSH at that time, Mr. Schmidt

noted his concerns related to NIOSH FFFIPP investigative procedures. In that letter, he used the PASS

devices as an ilustration of an issue that warrants further attention but did not provide specifics of his

concerns or suggestions on what action should be taken with regard to PASS devices.
Page 6 - The Honorable John Kerr

occurrng in a December 1999. fire in Iowa, NIOSH reported that the victims' integrated

and manual PASS devices were not heard sounding during the incident. Each of the

victim's self-contained breathing apparatus (SCBA) with an integrated PASS was

examined by the NIOSH investigators and was deemed too damaged by heat for testing.

All three victims also wore a second, manual, PASS device. These PASS devices were

also checked and found to be severely damaged but in working condition. It was

unkown if the manual PASS devices were turned off after the victims' removals from

the structure or if they had not been turned on prior to entering the structure. The report

summarzing the December 1999 incident was finalized by NIOSH in April 2001 and

posted to the Web and distributed to the mailing list shortly thereafter. This report was

also included in a packet of reports that NIOSH sent to a mailing list of about 35,000 fire

departments in late summer of200l.

In a second example, in a February 2001 NIOSH report, which summarizes the

investigation of two firefighter deaths occurrng on February 14,2000, NIOSH reported

that the SCBAs used by the firefighters were referenced in a manufacturer safety notice.

NIOSH reported that the manufacturer notice stated that the PASS alarms could

inadvertently alarm, reset, or be shut off, possibly by interference from portable 2-way

radios. Neither of the SCBAs in this incident could be tested, however, due to severe

heat damage. This report was finalized in February 2001 and posted to the FFFIPP Web

site and distributed to the mailing list shortly thereafter. This report was also included in

the packet of reports sent nationwide to fire deparments in late summer 2001.

NIOSH officials noted in response to questions by OIG investigators that they did not

receive any questions or comments from firefighters or fire departments on the role of

PASS devices in these incidents following the mailings of these two reports. In addition,

they also remarked that drafts of each of these reports were reviewed by external experts

and that none of the experts suggested that they follow up on these findings. Reviewers

of the April 2001 report included a representative from the NFP A that has a consensus'

standard for testing and pedormance criteria for PASS devices and a representative from

the National Institute for Standards and Technology (NIST). NFP A conducted its own

independent investigation of the incident in the April 2001 report; however, its

investigative report also did not consider the pedormance of the PASS devices as a

critical factor in the incident.

According to official documents reviewed by OIG investigators, in January 2005, after

noting a pattern in PASS devices not being heard or being barely audible, FFFIPP

investigators contacted the NFP A committee chair by phone to alert the committee to

evidence of potential performance issues of PASS devices identified during

investigations conducted between 2001 and 2004. NIOSH then began working together

with NFP A on a revision to the PASS pedormance standard. Based on the NIOSH

findings, NIST conducted its study on the pedormance ofP ASS devices under high

temperatures and issued the results in September 2005.

In early 2007, NFPA issued the 2007 edition ofNFPA 1982, Standard on Personal Alert

Safety Systems, which contains revisions providing for strengthened performance
Page 7 - The Honorable John Kerr

requirements and testing addressing PASS alarm signal degradation and other issues. In

the updated standards, NFP A has increased durability requirements for new PASS

devices. Applicable manufacturers had 6 months to comply when producing the new

P ASS devices. The new edition also addresses other problems with the PASS devices

that have been brought to the attention ofNFP A by NIOSH and others. The changes

include more rigorous testing in areas of shock, water infiltration, vibration, and heat.

The NFP A also added a muffle test, which means that if a firefighter is unable to move, is

unconscious or trapped and he/she is covering or on top of their PASS device, it still must

be heard.

III. Future Directions of the FFFIPP

In May 2007, NIOSH released a summary document on its future role in firefighter death

and injury investigations. This plan describes future directions for the program based on

a March 22, 2006, public stakeholders meeting and an evaluation report conducted by

RTI InternationaL. The public meeting included representatives from the USF A, the

National Volunteer Fire Council, NFPA, the International Association of Fire Chiefs, and

the International Association of Fire Fighters, among others. Eleven individuals,

(including Mr. Schmidt) submitted written comments to the docket.

Additionally, NIOSH contracted with RTI International to evaluate the FFFIPP. As part

ofthe evaluation, RTI surveyed 3,000 fire departments and conducted a series of focus

groups with front-line firefighters in the spring of2006. The firefighters were asked to

comment on the extent to which FFFIPP reports, recommendations, and other products

were being utilized, specifically related to use in training, development of procedures,

guidelines, policies and practices, and other prevention efforts. The final evaluation,

which contains recommendations for program enhancements, is expected to be completed

and posted on the NIOSH FFFIPP Web site in the near future.

Based on the stakeholder input and survey results, NIOSH determined future directions

for the FFFIPP. Some of the program goals include:

continue to make the main focus of the program performing fatality investigations

and maintain investigative activity at or near the current level;

make the prioritization of investigations transparent by posting the program's

decision flow chart on the FFFIPP Web site (this char has been posted and may

be found at http://www.cdc.gov/niosh/fire/pdfs/FFFIP DecisionChart.pdf);

address the issue of safety "culture" by looking more thoroughly at the incident

departent's occupational safety and health program;

strive to make recommendations more straightforward and practical;

increase references to "best practices" and standards in reports and

recommendations;

explore modifications to the FFFIPP fatality reports to make them more userfrendly and to enhance messages, including formatting changes and the

development of training aides for reports; and
Page 8 - The Honorable John Kerry

increase coordination with other NIOSH Divisions conducing research on

firefighter safety and health, including the NIOSH National Personal Protective

Technology Laboratory.

iv. Improvement of the FFFIPP Program

In the course ofOIG's review of the NIOSH FFFIPP investigations, we noted several

critical areas where the program could be enhanced, as well as significant constraints

which limit effectiveness.

First, there are opportunities to establish criteria with which to measure the progress and

outcomes of the program. For instance, the FFFIP operates under a general appropriation

with limited resources and lacks specific directions regarding how the program must be

administered. As such, there are no standards to hold the organization accountable for

how the funds are used or with which to measure the success of the program.

Establishment of expectations and outcomes would assist program managers and

policymakers in evaluating how the program is working.

Second, NIOSH should explore possible ways to initiate investigations closer to the date

of the actual fatality. By delaying the investigation, memories of those at the scene may

not be as fresh or complete, and in some investigations, the fire site itselfhas been altered

or destroyed by the time NIOSH investigators arrve. NIOSH should also explore

methods to publicize significant investigative recommendations more timely, for example

when there are potential equipment safety concerns.

Finally, limitations in NIOSH's authority may inhibit the success of the FFFIPP. For

example, the individuals that NIOSH interviews as part of its investigations are not

required to respond to NIOSH's questions. As a consequence, NIOSH strives to maintain

an atmosphere of collegiality in conducting investigations, including having a policy of

not identifyng individuals and manufacturers in its investigations, to obtain and/or

maintain cooperation. There may be other areas in which the investigative authority of

NIOSH related to the FFFIPP could be changed to provide the necessary investigative

tools and methods to achieve program objectives. As such, CDC may wish to evaluate

the existing investigatory authorities governing the FFFIPP.

V. Conclusion

Our investigation into the allegations of potential misconduct by management within

CDC/NIOSH did not find any evidence of wrongdoing related to preventing investigators

from examining PASS devices as part of firefighter fatality investigations. The NIOSH

FFFIPP conducted its investigations within its authority and according to investigative

processes consistent with its mandate.
Page 9 - The Honorable John Kerry

OIG notes that allegations in the MSNBC report appear to reflect a shared concern about

an issue from the perspectives of different vantage points. While Mr. Schmidt advocates

for an investigative/enforcement model, NIOSH has adopted a public health approach to

these investigations. As noted by Mr. Schmidt, the focus on the PASS device detracts

from the underlying issue, which is how theNIOSH FFFIPP can optimize the utilization

of its resources under its current authorities and produce and disseminate information that

can best ensure the prevention of future firefighter fatalities. Mr. Schmidt's opinion of

how this can be done differed from management at the time of his employment at

NIOSH. Seven years later, processes and procedures in the NIOSH FFFIPP have

evolved, and NIOSH continues to take steps to build and improve upon this program.

Firefighter organizations have publicly stated that the FFFIPP has made a positive

difference in preventing firefighter fatalities. For example, the findings ofFFFIPP

investigations have led to revisions in NFP A standards, changes in fire training programs,

and equipment design. The program is viewed as an improvement over what the fire

service has had in the past and is attributed to leading to many improvements and

unkown saved lives. OIG appreciates the opportunity to have examined this issue and

to contribute toward the efforts to improve the NIOSH firefighter fatality program.

Should you have any questions or if you would like to discuss this matter further, please

contact me, or your staff may call Claire Barnard, Director of External Affairs, at

202-205-9523.

Sincerely,

~¿~Daniel R. Levinson

Inspector General
("'~ DEPARTM OF HEALTI AN II SERVICES .,1-

Offce of Inspector General

Office of Investigations

330 Independence Avenue, S.W.

Washington, DC 20201

FEB 09 2007

The Honorable John Kerry

United States Senate

Washington, DC 20510

Dear Senator Kerry:

I am wrting in response tö your letter dated February 5,2007, requesting that my office

examine the alleged blocking of an investigation by the Center for Disease Control

on the Personal Alert Notification System (PASS). In response to your request, we are initiating a

review of ths matter. Depending upon the results ofthe initial review, we wil determine the

appropriate action and be back in touch with you when we have information to provide.

We appreciate your interest in the programs of the Deparent. If you would like to discuss this

request, please contact me, or have your staff call, Claire Barard Director of External Affairs,

at 202-205-9523. .

,SincereIY'dL .

~

Deputy Inspector General

for Investigations
JOHN KERRY

MASSACHlISET"rS

CO¡"-i1Mirn::rs:

COi\¡líVERCE, SCIENCE,

AND TRANSPORTArlON

..(" . ~rnat£

FJNp,NCE

WASHINGTON, DC 29570-21 02

FOR.EI13N RELAfIOl!S

SMAL.l BUSINESS

Februar 5, 2007

The Honorable Daniel Levinson

Inspector General

Departent of Health and Human Services

Room 5541 Cohen Building

330 Independence Avenue, SW

Washington, DC 2020 i

Dear Inspector General Levinson:

I write regarding an investigative report airing tonight on MSNBC that accuses offcials with the

Centers for Disease Control (CDC) of blocking an investigation into the deaths of six firefighters

whose personal safety equipment failed between 1998 and 2000 and failing to take action until

nine more firefighters died under similar circumstances. These allegations are deeply troubling

and should be followed up immediately with a federal investigation.

The MSl\l:C report cites fifteen fatalities between i 998 and 2005 in which the firefighter's

Personal Alert Notification System (PASS) devices, which sound a high-pitched alarm when a

firefighter remains stationary too long, failed or did not work properly. Specifically, the report

quotes the CDC's fonner chief fire investigator, Eric Schmidt, as saying that CDC officials told

him to "minimize (your) fact gathering during investigations" and thát he'was instructed to "omit

critical facts" regarding the perfonnance of the PASS devices. According to MSNBC, the CDC

was indifferent to Mr. Schmidt's evidence and did not want him to differ with its final reports on

the fatalities.

The CDC fired Mr. Schmidt in 2000 for "marginal" performance in his investigative duties

despite evidence he gathered that suggested a link between faulty PASS devices and these tragic

deaths. Subsequent testing of these devices by an independent laboratory showed that they do

not work properly in several conditions common in firefighting.

The allegations made by MSNBC are disturbing and warant an exhaustive federal review.

We owe it to the families of the deceased firefighters as well as the nearly i mìlion firefighters

who stíl use PASS devices to get answers and hold the negligent parties to account. Therefore, I

request that you initiate an investigation into the CDC's handling of its investigations and

determine the veracity ofthesealle ' ns.

i:irt;iil: ii.Jm.:~~r'ty.;~~:k¿~ Úatj!,goo;

\w...:., :\~lrn';Y,y.w s:eiia!-t~:i¡~)"'f'.ho;ft\,f

:tf,tll'h;:))'ON r~ECYClED PAPF:B