Humane Methods of Slaughter Act: Actions Are Needed to Strengthen Enforcement
Published: 2010-02-19T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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, 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. 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.

section_title: Letter
paragraphs: 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.
We have previously reported on weaknesses in FSIS’s management of  HMSA, particularly its reporting of violations and use of inconsistent  criteria for enforcement. 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.
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  survey response rate of 93 percent. 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. 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.
subsections: section_title: Background
paragraphs: 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.
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, or a gunshot—that,  as required by HMSA regulations, is rapid and effective in rendering the  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:  lifting head straight up and keeping it up (righting reflex),    vocalizing.
Figure 2 shows stunning methods consistent with HMSA.
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  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. 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    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.
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  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.
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. 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.
section_title: Weaknesses Persist in FSIS’s Enforcement, Training and Guidance, and Data Management
paragraphs: 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.
subsections: section_title: GAO Survey Results and FSIS Data Indicate Inconsistent Enforcement
paragraphs: 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.
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.
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  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. 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   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, 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.
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,  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. However the inspector  placed a reject tag on the stun box and cited the incident as egregious in   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. 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  over each other, and 55 percent would suspend plant operations for failing  to provide water over a weekend.
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.
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. For example, the Des Moines and the Chicago districts, which  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  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 three- quarters 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.
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.
section_title: Weaknesses in Guidance and Training May Contribute to Inconsistent Enforcement
paragraphs: 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.
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  because of repeat violations. 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 inspectors- in-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  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. 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. 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. 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  consistency of noncompliance reports for food safety issues. 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.
section_title: FSIS Has Only Recently Begun to Consider Using Additional Tools to Evaluate HMSA Performance
paragraphs: 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. Several of the DVMSs we interviewed acknowledged that they  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.
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. 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.
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  staff often, or always, alert each other about inspectors’ movements  between areas by radio or whistle, for example.
section_title: FSIS Has Not Fully Analyzed Humane Handling Data to Consistently Enforce HMSA
paragraphs: 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  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.
section_title: FSIS Cannot Fully Identify and Plan Resource Needs for HMSA Enforcement
paragraphs: 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.
subsections: section_title: FSIS Does Not Track HMSA Enforcement and Other Inspection Funds Separately
paragraphs: 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.
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.
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.
section_title: FSIS Does Not Have a Long-term Plan for Addressing HMSA Staffing
paragraphs: 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. 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.
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. 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  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.
section_title: FSIS Does Not Have a Comprehensive Strategy for Enforcing HMSA
paragraphs: 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  congressional decision making by providing more objective information  on program performance.
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  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.
section_title: Conclusions
paragraphs: 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  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-in- charge, 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.
section_title: Recommendations for Executive Action
paragraphs: 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.
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; 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.
section_title: Agency Comments and Our Evaluation
paragraphs: 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.
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.
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  appendix V.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: 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,  very small, and large plants. We obtained an overall survey response rate  of 93 percent.
Table 3 shows the population and sample size distribution of slaughter  plants by large, small and very small plant size. Each of the inspectors-in- charge 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.
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  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.
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.
section_title: Appendix II: Location of Inspectors Observing HMSA Compliance at Typical Mid- Sized Plant
paragraphs: 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.
section_title: Appendix III: HMSA Suspensions for FSIS Districts
paragraphs: 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.
section_title: Appendix IV: Comments from the U.S. Department of Agriculture
paragraphs: The following are GAO’s comments on the U.S. Department of  Agriculture’s letter dated January 22, 2010.
subsections: section_title: GAO Comments
paragraphs: 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.  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  establish additional, clear, specific and consistent criteria for district  offices to use when considering whether to take enforcement actions  because of repeat violations. 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-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 obtained an overall survey response rate of   93 percent. 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   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.
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  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.
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: 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.