The Congress passed the Humane Slaughter Act in 1958 in response to intense and broad-based public concerns about cruelty and abuse of livestock in meat-packing plants. At that time, the Congress determined that using humane methods of slaughter prevented the needless suffering of livestock, resulted in safer and better working conditions for employees, and brought about improvements in products and economies of slaughter operations, among other benefits. The act established as U. S. policy that the handling and slaughtering of livestock should be carried out using humane methods. However, the act applied only to plants wishing to sell meat products to federal government agencies. In 1978, the Congress passed the HMSA, which amended the Federal Meat Inspection Act and extended the policy nationwide by requiring that all federally inspected slaughter establishments adopt humane handling and slaughter methods. The HMSA requires that animals be “rendered insensible to pain by a single blow or gunshot or an electrical, chemical or other means that is rapid and effective, before being shackled, hoisted, thrown, cast, or cut.” The act also provides for a ritual slaughter exemption that allows the slaughter of animals in accordance with the ritual requirements of any faith “that prescribes a method of slaughter whereby the animal suffers loss of consciousness by anemia of the brain caused by the simultaneous and instantaneous severance of the carotid arteries with a sharp instrument and handling in connection with such slaughtering.” FSIS has issued regulations and directives to enforce the act. Important requirements of these regulations and guidance include the following: All animals must be effectively stunned before they are slaughtered. Stunning is effective when the animal feels no pain, is rendered instantly unconscious, and remains unconscious until slaughtered; Dragging of disabled and other animals unable to move, while conscious, All holding pens and driveways and ramps must be designed, built, and maintained to prevent injury to livestock; Livestock should be provided with water in holding pens, and food if held for more than 24 hours; The use of electrical prods and other devices to move livestock must not be excessive and should be used as little as possible. Figure 1 illustrates two separate stunning efforts—-one of a cow being stunned with a mechanical captive bolt and another of a sheep being stunned with an electrical stunner. As of October 2002, 918 plants were covered by the HMSA in the United States. Figure 2 shows the distribution of these plants. While the plants are concentrated heavily in the Northeast, they tend to be smaller plants. The 49 large producers, who account for approximately 80 percent of total production of meat in the country during fiscal year 2002, are mainly located in the Midwest, as figure 3 illustrates. FSIS is responsible for ensuring compliance with the Humane Methods of Slaughter Act. The FSIS is organized into 15 district offices that include: Alameda, Albany, Atlanta, Beltsville, Boulder, Chicago, Dallas, Des Moines, Jackson, Lawrence, Madison, Minneapolis, Philadelphia, Raleigh, and Springdale. Table 1 shows the states, number of plants, and type of plant, by size, for each FSIS district. In 2002, FSIS employed about 7,600 inspectors at red-meat plants and poultry facilities to inspect each carcass after it is slaughtered to ensure that it is safe for human consumption. Inspectors include at least one veterinarian assigned to each plant, who is required to evaluate the general health of animals before they are slaughtered, and Consumer Safety Inspectors, who are not veterinarians and have varying inspection responsibilities throughout the plant. FSIS officials maintain that as they carry out their food safety and other activities, all inspectors are responsible for monitoring compliance with humane handling and slaughter requirements at plants that are covered by the HMSA from the time livestock come into the custody of the plant to the time of slaughter. According to the FSIS, while the HMSA requires inspectors to observe the entire handling and slaughter process, inspectors do not have to observe all animals all the time for HMSA compliance. In contrast, the Federal Meat Inspection Act requires that each animal be examined prior to slaughter and each carcass be individually inspected after slaughter to ensure that the meat is safe for human consumption. Typically, animals arrive on plant premises, are unloaded from trucks, and then are held in the stockyard area where FSIS inspectors perform the required antemortem inspection. During this inspection, disabled animals are separated from the herd. Animals are then moved through curved holding chutes and forcing pens onto the stunning platform, where they are stunned before being slaughtered. Figure 4 illustrates the areas in a typical, mid-size plant from which inspectors can observe for HMSA compliance, although inspectors are not always present in all areas. When inspectors observe a violation of the HMSA or its implementing regulations, they are required to notify plant management and document, with a noncompliance record, the violation and the actions taken by the plant to correct it. Inspectors can document more than one violation, and different types of violations, in a single noncompliance record. According to FSIS guidance, each noncompliance record should include the following information: A unique record number, The date of the violation, The plant identification number, Humane handling regulations applicable to the incident reported, A written description of the violation, The name of plant personnel notified of the violation, and The plant management’s written response stating both the immediate action to correct the violation and any subsequent action to prevent its recurrence. In response to HMSA noncompliance, FSIS can take a number of enforcement actions—actions that impose restrictions on a facility’s ability to operate. These actions include the following: For less serious violations of the HMSA, inspectors at a facility can issue a “reject tag” to quickly respond to violations that management can readily address. Inspectors physically place these reject tags on a piece of equipment or an area of the plant. This action temporarily prohibits the use of a particular piece of equipment or area of the facility until the violation is corrected. For more serious violations, the district manager can suspend inspection until the violation or violations are addressed. This action, which removes FSIS inspectors from facility premises (or part of the facility), suspends operations at the facility (or part of the facility) because slaughter facilities may not operate without federal inspectors present. In cases where a plant fails to respond to FSIS concerns about repeated and/or serious violations, the administrator of FSIS can withdraw inspection. This enforcement action removes the grant of inspection from a facility, which prevents the facility’s products from entering interstate and foreign commerce. The facility must reapply for and be awarded a grant of inspection before it may resume operations. This action is rarely used. Agency supplemental appropriations in 2001 included $3 million, of which no less than $1 million was to be used to enhance the agency’s humane slaughter practices. USDA used $1.25 million of these funds to hire 17 DVMSs to serve as program coordinators for all humane handling issues. By March 2002, a DVMS was at work in each of the FSIS district offices. The DVMSs, who received extensive training on humane handling and slaughter techniques and related inspection procedures, are the primary contacts for inspectors in each FSIS district office and the liaisons between the district offices and headquarters on humane handling and slaughter compliance. As of May 2003, the 17 DVMSs had visited 576, or about 63 percent, of 918 plants covered by the HMSA. Thirteen of the 16 DVMSs we interviewed said that they had visited all or almost all of their assigned plants at least once. According to these 16 DVMSs, when they came on board, all of them participated in a number of district activities that went beyond the scope of humane handling and slaughter of animals, such as biosecurity and food safety issues. For example, nine DVMSs reported that these activities took 40 to 50 percent of their time. In March 2003, however, an FSIS memorandum directed all but five of the DVMSs to only perform humane handling activities. As a result, the activities of 12 DVMSs changed, and their current focus is solely the implementation of the HMSA. Despite these actions, concerns about the treatment of animals at U.S. slaughterhouses persist. For example, two animal welfare groups, the Humane Society of the United States and the Humane Farming Association, believe that enforcement of the act could be improved. These groups maintain that more continuous monitoring of compliance with the HMSA is necessary. Also, according to the Humane Society, USDA oversight is especially critical at facilities that specialize in disabled animals and old dairy cattle, as well as those with slaughter production lines that operate at high speeds. Conversely, meat industry associations we contacted maintain that the way animals are handled and slaughtered has improved in response to pressure from customers of fast food restaurants and industry audits of slaughter establishments. When Dr. Temple Grandin, a renowned animal science authority, conducted a survey of 24 slaughterhouses in 1996 at USDA’s request, she found that only 36 percent were able to stun 95 percent of the cattle on the first try. When she repeated the survey in 2002, this time visiting 80 different plants, she found that 94 percent were able to do so. While Dr. Grandin’s second survey shows a significant improvement, it still indicates that hundreds of thousands of animals were not stunned on the first try, as required by the act. Thus, there may be undetected instances of inhumane treatment. Dr. Grandin believes that effectively stunning animals on the first try 100 percent of the time is unachievable—that is why she proposed an objective scoring method as an alternative. Objective scoring uses definite thresholds for various types of humane handling and slaughter incidents and provides a means to promote consistency within and across slaughter establishments. When we discussed the objective scoring approach with FSIS officials, they pointed out that the approach may have merit, particularly as a monitoring tool. However, the officials pointed out that the HMSA requires that animals be effectively stunned on the first try with one single blow or gunshot. Therefore, objective scoring would not be an appropriate regulatory tool because it allows for less than 100 percent effectiveness in stunning. That is, under the objective scoring method, a plant’s humane slaughter procedures would be considered adequate if, for example, 95 percent of the animals were stunned with one single blow or gunshot on the first try. Our ability to assess the frequency and scope of noncompliance with the HMSA was limited because FSIS could not provide us with documentation for all of the noncompliance incidents and because the documentation provided was not always complete and consistent. The 553 noncompliance records that the agency provided to us show that, between January 2001 and March 2003, there were 675 HMSA violations at 272 facilities— approximately 30 percent of the more than 900 slaughter facilities in the United States. The most prevalent noncompliance documented was the ineffective stunning of animals, in many cases resulting in a conscious animal reaching slaughter. FSIS has made recent efforts to improve documentation—including steps to improve inspector awareness of documentation requirements, better tracking of noncompliance documents, and issuing new HMSA guidance in November 2003. The universe of inspection records that FSIS provided to us was incomplete, making it difficult to assess the frequency of noncompliance with the HMSA. FSIS provided us with 553 documented records of noncompliance with the act and the implementing regulations covering the 28-month period from January 2001 through March 2003. However, we found internal control problems that call into question the reliability of the information in the FSIS records regarding HMSA compliance. Our analysis indicates that the extent of noncompliance with the HMSA and the implementing regulations is likely to be greater than what is reflected in the 553 records for several reasons. First, according to FSIS officials, inspectors wrote at least 44 additional noncompliance records during this period—January 2001 to March 2003. However, while their recordkeeping system indicates that these noncompliance records exist, the agency could not locate the actual noncompliance documents for our review. The officials said that the records were not electronically stored and that they would rather improve tracking of such documentation in the future than attempt to locate the missing records. This internal control problem is being addressed, according to FSIS officials, because the agency has transitioned to a system that stores all noncompliance records electronically. Second, according to several DVMSs’ observations during their in-plant evaluations of humane slaughter activities, the frequency of noncompliance with the act is likely to be underreported. At least 7 of the 16 DVMSs we spoke with believe that inspectors have not always documented violations in noncompliance records when they should. The DVMSs said that some inspectors were not always aware of regulatory requirements and may have felt documentation was unnecessary because they either determined the offense was not serious or that it could be easily remedied. The principal guidance provided to inspectors—known as the “Rules of Practice”—does not specifically instruct inspectors on whether to document a violation if that violation does not result in an enforcement action and leaves it to the discretion of the inspector when an enforcement action is called for. However, recently, FSIS issued a directive that requires inspectors to document all violations in noncompliance records. Third, because inspectors do not engage in continuous animal by animal observation for humane handling and slaughter compliance purposes, violations may occur that are not recorded by inspectors. Our ability to determine the overall scope and severity of humane slaughter violations was further limited by the inconsistent way inspectors document violations in noncompliance records. Inspectors describe noncompliances by narrative—for example, by specifying whether the violation involved ineffective stunning or lack of access to water. Our analysis of noncompliance records related to HMSA showed that inspectors do not describe violations in a consistent manner and their narratives can vary substantially. For example, while some noncompliance records provide detailed information on the observed causes of ineffective stunning and the exact number of animals impacted, other records only mention that ineffective stunning occurred. Additionally, because narrative is the only way an inspector can describe the HMSA noncompliance, the agency cannot easily extract and analyze information. Inspectors do include a code so that violations related to HMSA can be distinguished from violations related to food safety, but it is a universal code for all HMSA violations; and it does not provide any additional information about the type or severity of the violation. As a result, it is difficult for FSIS to quantify, interpret, and report the data related to the scope and severity of documented instances of noncompliance. Incomplete and inconsistent data can make it difficult for FSIS to adequately assess how well HMSA standards are being enforced and to report those results to the Congress and other interested parties. In 2002 legislation, the Congress stated that USDA should track violations of the HMSA and report the results and relevant trends annually to the Congress. In its March 2003 report to the Congress, USDA reported that during fiscal year 2002 it documented 379 noncompliance incidents out of 70,403 times when inspectors made observations for compliance with the HMSA. This averages to approximately six observations for HMSA compliance per month, or less than two observations per week, for each the 918 plants that are covered by the act. By analyzing approximately half of the noncompliance records available for fiscal year 2002, FSIS concluded in the report that the majority of these violations were related to facility conditions (e.g., slippery flooring, large gap between pen bars, etc.) and animals provisions (failure to provide water or food). It then concluded that “very few infractions were for actual inhumane treatment of the animals (e.g. dragging or ineffective stunning).” However, our evaluation of USDA’s data showed otherwise. We analyzed all the available noncompliance records for fiscal year 2002 and identified 366 noncompliance incidents, of which 92 (one-fourth) were for ineffective stunning—a violation that USDA characterizes as “actual inhumane treatment.” Likely reasons for the discrepancy between our analysis and USDA’s report are that we analyzed all available records, while FSIS officials told us that USDA’s analysis was based on a subjectively selected sample of approximately half of the available records. Additionally, FSIS’s violation documentation system—specifically its sole reliance on narrative to document HMSA violations—required both FSIS officials and us to interpret the inspectors’ narratives to identify the number and types of violations identified in the documentation. The FSIS official who conducted the analysis told us that upon close examination of these narratives, some instances that appear to be cases of direct animal injury in fact were not and would therefore not be considered by the agency to be actual inhumane treatment of animals. We found similar results when we analyzed noncompliance records over a longer period—January 2001 to March 2003. During this period, FSIS produced 553 noncompliance records indicating some type of noncompliance with the HMSA. These noncompliance records were written for 272 plants, or about 30 percent, of the 918 plants that were covered by the act. Our analysis of these noncompliance records identified 675 violations. Of these violations, 167 were for ineffective stunning, meaning animals were not quickly rendered insensible to pain as required by the HMSA and the implementing regulations. We found that over 67 percent of the 167 ineffective stunning violations resulted in conscious animals being slaughtered. Other less prevalent violations included facility conditions that could lead to animal injury and lack of access to water. Our interviews with the DVMSs support these data. Among the 16 DVMSs we spoke with, the most prevalent violations they reported observing when they visited plants to evaluate humane handling and slaughter practices were ineffective stunning, poor facility conditions, and lack of access to water. Figure 5 summarizes the types of violations we identified, using FSIS documentation. FSIS has recently taken steps to improve inspector awareness of documentation requirements and to correct the limitations in its inspection documentation process. According to DVMSs and other FSIS district officials with whom we spoke, as the DVMSs began playing an active role in working with inspectors at plants covered by the HMSA, the inspectors’ level of knowledge regarding interpreting and documenting noncompliance has improved. In particular, DVMSs told us that inspectors are becoming more aware of the need to document noncompliance incidents that previously may have been considered to be too minor to document or may not have been considered a violation at all. As a result, the number of documented records for noncompliance incidents increased from January 2001 through March 2003. For example, in the first quarter of fiscal year 2002, FSIS inspectors issued 56 noncompliance records documenting HMSA violations. This number increased to 134 in the first quarter of fiscal year 2003. Similarly, the number of noncompliance incidents documenting relatively minor violations increased as well. For example, during the same time frames, documented incidents for facility conditions that could cause injury to animals prior to slaughter increased from 5 to 40, and documented incidents of lack of access to water increased from 9 to 37. The DVMSs attributed the increase in part to the enhanced awareness of humane handling and noncompliance documentation requirements on the part of the inspectors. Additionally, FSIS officials told us that the introduction of a humane handling procedure code in its Performance Based Inspection System (the computer-based system it uses to track compliance with all FSIS regulations), which took effect in October 2001, should help FSIS better track noncompliance records that document HMSA violations. While this change may address the agency’s internal control problems regarding record maintenance, it will not, as we discussed earlier, provide sufficient data on the type of HMSA violations or make it easier for the agency to quantify, interpret, and report the data related to the scope and severity of the documented noncompliances. FSIS also released a new directive, “Humane Handling and Slaughter of Livestock,” in November 2003. This directive also provides additional guidance and informs inspectors on many aspects of HMSA compliance. Importantly, the directive specifically instructs inspectors to document all violations of the HMSA and implementing regulations, regardless of the severity of the violation or whether an enforcement action is called for. Our review of noncompliance records indicates that FSIS has taken inconsistent enforcement actions in response to violations of the Humane Methods of Slaughter Act and applicable regulations. Inspectors stationed in slaughter plants have not consistently issued “reject tags”—the enforcement action used for less serious violations—to temporarily stop a plant from using a piece of equipment or an area of the plant until the violation is corrected or appropriate actions are taken to prevent recurrence of the incident. Also, district managers were not using consistent criteria to suspend plant operations when more serious violations occurred. FSIS inspectors took enforcement actions in almost 40 percent of the documented noncompliance cases between January 2001 and March 2003. FSIS officials and guidance indicate that it is not appropriate to take an enforcement action for all violations. For example, while stunning an animal more than once is clearly an instance of noncompliance with humane handling and slaughter requirements, an inspector may not feel that an enforcement action is necessary if a plant employee stuns an animal more than once because of certain unavoidable conditions, such as an animal moving its head just prior to being stunned. Nevertheless, our analysis of the noncompliance records indicates that inspectors are not consistently taking enforcement actions. Specifically, they are not consistently using reject tags. The records show that serious violations appear to have taken place—violations that involved multiple instances of ineffective stunning or several animals being conscious during slaughter—but that inspectors did not take any enforcement action. For example, our analysis of enforcement actions taken in the 167 instances of ineffective stunning shows that inspectors used reject tags to temporarily suspend stunning operations in more than half of the 86 cases involving ineffective stunning of a single animal but in less than half of the 79 cases that involved multiple animals. In one particular incident, the inspector who prepared the noncompliance record wrote that he observed six conscious animals being slaughtered during a period of 5 minutes, and he considered the incident unacceptable; however, he did not take enforcement action. This inaction was in sharp contrast to many other cases where inspectors took enforcement actions, for relatively less serious violations, such as lack of access to water. According to half of the 16 DVMSs we interviewed, inspectors often do not take enforcement action when they should. DVMSs attribute this inconsistent use of enforcement action to several factors. For example, some inspectors are hesitant to issue reject tags for ineffectively stunned animals because they are not veterinarians and are unsure about what signs indicate that an animal is still conscious after it has been stunned. They also noted that some inspectors lack the experience or knowledge regarding their authority to issue reject tags or simply misinterpret routine incidents—even though they are violations—as not warranting enforcement actions. FSIS did not provide data for the level of experience of inspectors. However, as part of the inspectors’ new hire program, FSIS includes a module on humane handling issues; inspectors have no other formal training on the HMSA and its enforcement. Most of the deputy district managers and half of the DVMSs noted that an overall lack of knowledge among inspectors about how they should respond to an observed noncompliance has been a problem in enforcing the HMSA. FSIS has begun to address the problem of unclear guidance by issuing a new humane handling and slaughter directive on November 25, 2003. This directive, for the first time, clearly states that inspectors are obligated to take enforcement actions when they observe inhumane treatment whether or not animal injury has resulted. Specifically, the directive states that inspectors must take action if either (1) a violation of humane handling and slaughter requirements has occurred that is not immediately causing injury or inhumane treatment of animals and the establishment has not taken appropriate preventative actions or (2) a violation of HMSA requirements has occurred and animals are being injured or treated inhumanely. Also, FSIS officials said that they have recently held meetings with the DVMSs and district officials that focused on making enforcement more consistent. In addition to the enforcement actions available to inspectors stationed at slaughter facilities, district managers may suspend the operations of an entire facility, or part of the facility, by removing the inspectors from the plant. Since FSIS inspectors must be present during slaughter operations, this effectively shuts down a facility. This enforcement action is more serious than the reject tags that inspectors can use and may be taken by district managers in the event of serious or repetitive violations. Between October 2001 and July 2003, district managers issued eight suspensions at seven slaughter plants that directly involved HMSA violations. According to FSIS, seven of the suspensions were issued in response to incidents involving the physical treatment of animals—four in response to inappropriate stunning or conscious animals observed at slaughter, two in response to the mistreatment of disabled animals, and one in response to excessive use of electric prods and force. One suspension was issued in response to facility conditions (a protruding fence board that was pointing toward the animals and could cause injury) and lack of access to water. In addition, during the same period, FSIS districts issued four letters to plants to inform them that if corrective actions were not taken to prevent recurrence of noncompliance incidents, the districts would proceed with suspension action. Our analysis of the 553 noncompliance records indicated that the severity and repetitiveness of the violations does not necessarily result in consistent enforcement actions by district managers. For example, in one case, inspectors had prepared 16 noncompliance records, all related to the ineffective stunning of animals. However, the district manager did not take enforcement action because, as he explained, the 16 incidents were not triggered by the same factor; if they had been, he said he would have suspended the plant. This contrasts with the opinion of another district manager who, commenting on this same situation, said that a case of so many related and relatively serious incidents is a definite candidate for a suspension. District managers said that they identify facilities for suspension by reviewing the noncompliance records and looking for “red-flags”— specifically, cases of serious and/or repetitive incidents of inhumane treatment of animals. While FSIS guidance stipulates that district level enforcement actions, such as suspensions, are appropriate when facilities have been unable to implement corrective and preventive actions in response to previously identified violations, the guidance does not contain suggested thresholds or criteria on when district actions are appropriate. More specifically, the guidance does not address how many repetitive instances of noncompliance should warrant district level enforcement actions. In the absence of uniform criteria, these enforcement decisions are likely to be inconsistent across FSIS districts, undermining FSIS’ efforts to effectively enforce the act. While the November 2003 directive provides some additional guidance on when suspensions are an appropriate response to multiple violations with the same or related cause, it does not provide any information on the number of related violations that would warrant a suspension. For example, in deciding whether a suspension is warranted, the directive states that district officials should consider the amount of time between violations—not the number of repeat violations—taken by the plant. FSIS officials noted that they have recently held meetings to emphasize consistent enforcement and discussed the issue at the October 2003 National Supervisory Conference attended by over 200 agency field supervisors. Because FSIS does not have adequate data on the number of inspectors responsible for enforcing the HMSA or the actual time they spend on humane handling and slaughter requirements—nor other information, such as criteria to determine the appropriate number of inspectors for different sized plants—it is difficult to determine if the number of inspectors is adequate to effectively enforce the HMSA. However, FSIS headquarters and district officials believe that, for the most part, personnel resources dedicated to monitoring and enforcing humane handling and slaughter requirements are adequate. District officials believe that the present number of DVMSs is adequate to cover each district’s HMSA responsibilities. The DVMSs are the primary contacts for inspectors in each FSIS district office and the liaisons between the district offices and headquarters on humane handling and slaughter issues. They are responsible for on-site coordination of nationally prescribed humane slaughter procedures and verification of humane handling activities, as well as dissemination of directives, notices, and other information related to the act. Fifteen districts have one DVMS and two districts, Boulder and Chicago, have two DVMSs each. According to FSIS district officials, the 17 DVMSs are sufficient to oversee humane handling and slaughter activities in each district. FSIS officials could not, however, provide us with quantitative data on the actual time in-plant inspectors spend enforcing HMSA or other quantitative data from which we could assess the adequacy of in-plant inspection resources dedicated to humane handling and slaughter. Without this basic information, it is difficult to determine with any degree of certainty or precision if the number of inspectors is adequate to effectively enforce the HMSA. Also, without this data, FSIS cannot determine the appropriate number of inspectors for different sized plants or the adequate number of inspectors overall to effectively enforce the act. FSIS recently conducted an analysis showing that inspectors spent an estimated 132,405 hours, or 63 full-time equivalents, on humane handling and slaughter activities in fiscal year 2003. To come up with this estimate, the agency asked the DVMSs to estimate the number of hours that inspectors spent observing humane handling, per shift per plant in their districts. The DVMSs aggregated this information to determine how many total hours, per plant per year, were spent on humane handing and slaughter. Additionally, FSIS officials said they have a pilot program in place to track hours spent enforcing the HMSA. However, without additional information, such as criteria to determine the appropriate number of inspectors for different sized plants, the agency has insufficient information to make good decisions regarding how to allocate inspectors, and we could not conclusively determine whether additional in-plant inspectors are needed to ensure compliance with the HMSA. Nevertheless, discussions with district officials suggest that additional resources devoted solely to enforcing the HMSA are not needed, but that additional inspectors who could conduct both food safety and humane handling activities would be beneficial. District managers and their deputies were in general agreement that there is no need for additional inspectors whose sole responsibility would be to observe for compliance with the HMSA. Five of the 29 district officials we spoke with who disagreed with this position told us that dedicated HMSA inspectors would be beneficial, primarily at larger plants only, or to supplement and follow up on the DVMSs’ work when DVMSs are not present at a plant. However, almost 40 percent of the district managers and their deputies reported a general need for additional inspectors—inspectors responsible for both humane handling and food safety. They noted that filling current vacancies and/or hiring more relief inspectors to cover for vacations and other expected and unexpected leave would benefit HMSA enforcement. Several officials said this would be true particularly in larger plants where the size and configuration of the facility make it difficult for inspectors to effectively monitor humane handling and food safety compliance at the same time. While stating that personnel resources for overseeing handling and slaughter requirements appear overall adequate, district officials expressed some dissatisfaction with the inspectors’ overall level of knowledge about humane handling and slaughter requirements. According to 17 of the 29 district officials and at least 9 of the 16 DVMSs we interviewed, despite improvements made by the hands-on training that DVMSs provided inspectors, additional training of inspectors would improve the agency’s ability to properly enforce the HMSA. Additionally, 14 DVMSs said that not all inspectors are fully knowledgeable about the requirements of the HMSA or the implementing regulations—including not being aware that certain actions are violations of the HMSA, or what their authority and obligations are when a violation has been observed. FSIS officials also believe that inspector knowledge needs to be improved, and they said that they are committed to doing this through additional training and other efforts. We agree that this is a reasonable first step—improving existing personnel’s knowledge—before making decisions about the need for additional resources. Accordingly, we are not making a recommendation that FSIS provide additional training. When we discussed this matter with senior FSIS officials, they said that they are currently taking steps to improve inspectors’ knowledge. As a first step, with the assistance of the DVMSs, FSIS is developing a survey of veterinarians’ and other supervisory inspectors’ overall training needs, including needs in the area of humane handling and slaughter. Additionally, the agency’s November 2003 directive consolidates many HMSA requirements into a single directive, making it easier for inspectors to understand and interpret the requirements. DVMSs are also developing scenarios that will illustrate to inspectors how to implement the HMSA requirements and help them better understand their job function as it relates to the act. These scenarios are distributed in the form of a monthly report (Humane Interactive Knowledge Exchange—HIKE) that FSIS employees will be able to access through the Internet. FSIS officials believe that this will be a successful way of sharing knowledge throughout the agency on key policy issues. The Congress first passed legislation in 1958 and subsequently in 1978 to address humane treatment of livestock. Recently, the Congress also provided USDA with additional resources and directed the Secretary of Agriculture to fully enforce the HMSA and implementing regulations. In response, FSIS created the DVMS position. According to many district officials, this step has enhanced knowledge among slaughter plant inspectors about their duties to ensure the humane handling and slaughter of animals. Additionally, very recent efforts, such as the new directive for inspectors, demonstrate a commitment to improving enforcement of the act. However, FSIS still faces challenges. The agency needs to address shortcomings related to adequately recording and analyzing documented instances of noncompliance with the HMSA and ensure consistent application of enforcement actions before it can assure the Congress and the pubic that animals are treated humanely and the act is being fully enforced. Finally, the lack of information on the level of effort FSIS dedicates to humane handling and slaughter activities prevents it from evaluating its own performance and making informed decisions on whether additional inspectors are needed. We are making six recommendations to the Secretary of Agriculture to further strengthen the agency’s oversight of humane handling and slaughter methods at federally inspected facilities. To provide more quantifiable and informative data on violations of the HMSA, we recommend that the Secretary of Agriculture direct FSIS to supplement the narrative found in noncompliance records with more specific codes that classify the types and causes of humane handling and slaughter violations. To ensure that district officials use uniform and consistent criteria when taking enforcement actions, we recommend that the Secretary of Agriculture direct FSIS to establish additional clear, specific, and consistent criteria for district offices to use when considering whether to take enforcement actions because of repetitive violations; require that district offices and inspectors clearly document the basis for their decisions regarding enforcement actions that are based on repetitive violations. To ensure that FSIS can make well-informed estimates about the resources it needs to enforce the Humane Methods of Slaughter Act, we recommend that the Secretary of Agriculture direct FSIS to develop a mechanism for identifying the level of effort that inspectors currently devote to monitoring humane handling and slaughter activities; develop criteria for determining the level of inspection resources that are appropriate on the basis of plant size, configuration, or history of compliance, once the mechanism is developed and in operation; and periodically, assess whether that level is sufficient to effectively enforce the act. We provided FSIS with a draft of this report for their review and comment. FSIS generally agreed with our findings and recommendations. In addition, FSIS provided a number of specific comments and clarifications, which we incorporated as appropriate. FSIS’s comments and our responses to them appear in appendix II. We are sending copies of this report to the Secretary of Agriculture and interested congressional committees. We will also provide copies to others on request. In addition, the report will be available at no charge on the GAO Web site at http://www.gao.gov. If you or your staff have any questions, please call me at (202) 512-3841. Contributors to this report are listed in appendix III. To assess the scope and frequency of humane handling and slaughter violations, we obtained and analyzed data from several sources. First, we obtained the U.S. Department of Agriculture’s March 2003 Report to Congress on Humane Handling and Slaughter Enforcement Activities, in which USDA presents their findings on noncompliance with the Humane Methods of Slaughter Act (HMSA) during fiscal year 2002. We reviewed that information and followed up with the Food Safety and Inspection Service (FSIS) officials who wrote the report to discuss the methodology they used when they conducted their analysis. Second, in structured interviews with 16 of the 17 District Veterinary Medical Specialists (DVMS), we discussed what they thought were the most common types of noncompliance with the HMSA, based on their visits to plants covered by the act in their districts. In addition, we also reviewed the written summaries that they prepared to document these observations. Third, we obtained from FSIS all available documentation of observed violations to the HMSA for the period January 2001 through March 2003, the period for which FSIS could provide us with the most complete documentation. This information was provided in the form of 553 records of noncompliance. To analyze this information provided in these forms and determine the frequency of violations, by type of violation, as well as their scope, we classified them as follows: Ineffective stunning (i.e., one or more animals had to be stunned more than once); One or more conscious animals showed signs of consciousness past the stun box, i.e, when they were hoisted, cut, or bled; Facility conditions that either caused injury to an animal or could cause injury to an animal, such as broken fences, protruding nails, slippery floors, and overcrowded pens; Excessive use of electric prods or other devices; Mishandling of ambulatory animals, such as hitting, kicking, or dragging a Mishandling of disabled animals, such as keeping such animals among ambulatory animals, increasing the risk of further injury; Lack of access to water; Lack of access to food; and Other instances of noncompliance with the HMSA or applicable regulations. Using these categories, we aggregated the information to determine the frequency of the various types of violations. In addition, to obtain a further indication of the “scope” of the violation for cases where animals were ineffectively stunned or where conscious animals were observed past the stun box, we created a code indicating whether a single animal or multiple animals were impacted. A GAO analyst knowledgeable of the subject matter conducted all the classifications. A second GAO analyst reviewed all forms and codes determined by the first analyst for accuracy. Any discrepancies were resolved through discussion between the two analysts. We also discussed our methodology with FSIS officials who did not have any objections with our approach. To further evaluate the information presented in the 553 reports, we reviewed FSIS regulations and guidance to inspectors regarding when they are required to write a noncompliance record and what they are supposed to include in it. In addition, in our structured interviews with 16 of 17 DVMSs, we obtained their views on inspectors’ documentation of noncompliance and factors, if any, which may impact it. To determine FSIS actions to enforce compliance with the humane handling and slaughter requirements, we obtained information on enforcement actions taken at the plant and FSIS district level. To determine how many times inspectors took enforcement actions, and under what circumstances, we analyzed the 553 noncompliance records we obtained from FSIS for the period between January 2001 and March 2003. We analyzed the narrative information in these records to determine when inspectors temporarily stopped use of equipment or part of the plant in response to a violation and for what type of violation. To determine how many times district managers took enforcement actions, we obtained and analyzed documentation for all plant suspensions and notices of intended enforcement actions by a district, for the period between October 2001 and July 2003. In addition, we reviewed FSIS guidance on when inspectors and districts should take enforcement action, and we talked with 16 of the 17 DVMSs about their views on inspectors’ enforcement of the act and regulations; and we also talked with all district managers about how they determine when to take enforcement action against a plant. To assess the extent to which additional resources may be needed to ensure that humane handling and slaughter provisions are enforced, we contacted FSIS headquarters officials, district managers and deputy district managers at the 15 FSIS district offices, and 16 of the 17 DVMSs. First, from FSIS headquarters, we obtained information officials put together on the estimated number of hours that inspectors devoted to implementation of the HMSA during fiscal year 2003. We also obtained documentation on the training available to inspectors regarding the HMSA and information on the agency’s upcoming plans to further address inspectors’ training needs and knowledge regarding the HMSA. Second, we conducted structured interviews with district managers and deputy district managers at all 15 FSIS districts to identify additional resource needs, such as additional inspectors, training, and guidance that would be necessary to ensure adequate implementation of the HMSA in their district. Third, we conducted structured interviews with 16 of the 17 DVMSs to obtain their observations on how knowledgeable inspectors are regarding the HMSA and their training needs. We supplemented our analysis of the results of this work with interviews with Dr. Temple Grandin, a renowned animal-handling expert; industry association representatives from the American Meat Institute and the National Meat Association; and animal welfare group representatives from the Humane Society of the United States, Humane Farming Association, and Humane Farm Animal Care, which provided us with their views on improving HMSA enforcement. To assess the reliability of the FSIS data cited in the background section regarding plants covered by the HMSA, plant production, size of plants, plants covered by each district, and DVMS visits to plants, we (1) performed electronic testing for obvious errors in accuracy and completeness and (2) had discussions with agency officials knowledgeable about the data. We determined that the data were sufficiently reliable for the purposes of this report. We conducted our review from April 2003 through November 2003, in accordance with generally accepted government auditing standards. The following are GAO comments on the Food Safety and Inspection Service letter, dated January 14, 2004. 1. We clarified our report to reflect this comment. 2. We clarified our report to reflect this comment. 3. We already include the fact that FSIS provided us with 553 noncompliance records. Additionally, we acknowledge that the 44 records that FSIS did not provide to us represent less than 10 percent of all the documented noncompliance records for the period. 4. We acknowledge that the internal control problem we identified is being addressed. However, we cite the internal control problem because it affected the humane handling data for the period of our analysis—January 2001 to March 2003. 5. The report clarifies that FSIS sampled approximately half of the available noncompliance records. We believe that we sufficiently indicate the differences in the approaches used by FSIS and us in analyzing those records. We acknowledge that the official who conducted the FSIS analysis is a trained veterinarian. However, our analysis relied directly on information provided by FSIS inspectors in noncompliance records. 6. We clarified our report to reflect this comment. 7. The final report clarifies that the 16 DVMSs we interviewed (out of 17 DVMSs) told us that they originally participated in activities beyond the scope of humane handling and slaughter of animals. 8. We have made a slight modification in the report language, but overall, we disagree with this comment. In our analysis, we did not attempt to reinterpret the narratives contained in FSIS noncompliance records that inspectors prepared after observing each violation. We categorized each record according to the type of violation to the HMSA and appropriate regulations. Regarding the first example in FSIS’s comments, if a noncompliance record indicated that it was issued because of ineffective stunning, that is the way we categorized the incident. Further, we did not attempt to impose a standard of whether or not documented noncompliance incidents resulted in animal injury for two reasons. First, FSIS did not provide us with any additional documentation, beyond the noncompliance records, indicating whether direct animal injury resulted from the incident. Second, whether or not an animal injury occurred is not a standard for writing noncompliance records, according to FSIS’s own directives. Finally, FSIS did not provide us with any additional examples or other information that, in their view, indicate that ineffective stunning violations reported in noncompliance records did not cause direct injury to animals, and therefore, did not result in actual “inhumane treatment.” The next three examples in FSIS’s comments do not pertain to ineffective stunning, but we used the same approach to categorizing these type of noncompliance records. 9. We acknowledge that FSIS instituted a humane handling inspections system procedure code, effective October 2001, which should help FSIS better track noncompliance records that document HMSA violations. However, we note that this is a universal code for all HMSA violations and does not provide any additional information about the type or severity of the violation. In addition to the individuals named above, Pauline Seretakis, Heather A. Holsinger, Katheryn E. Summers, Charles T. Egan, John W. Delicath, and Jennifer R. Popovic made key contributions. Other contributors include Aldo A. Benejam, Michele C. Fejfar, Karen K. Keegan, Julian P. Klazkin, and Katherine M. Raheb.

Summary: In 1978, the Congress passed the Humane Methods of Slaughter Act to ensure that cattle, sheep, hogs, and other animals destined for human consumption are handled and slaughtered humanely. Within the U.S. Department of Agriculture (USDA), the Food Safety and Inspection Service (FSIS) is responsible for enforcing the act. Recently, the Congress took additional actions to improve FSIS enforcement. GAO reviewed (1) the frequency and scope of humane handling and slaughter violations, (2) actions to enforce compliance, and (3) the adequacy of existing resources to enforce the act. Incomplete and inconsistent inspection records made it difficult to determine the frequency and scope of humane handling and slaughter violations. FSIS was unable to produce at least 44 of its inspection records that document violations of the Humane Methods of Slaughter Act (HMSA) and implementing regulations. Also, inspectors did not always document violations of the HMSA because they may not have been aware of regulatory requirements. Further, the records that FSIS provided did not consistently document the scope and severity of each incident. USDA is taking steps to address these issues. Enforcement actions to address noncompliance with the act and regulations were also inconsistent. For example, we found that FSIS inspectors temporarily halted stunning operations in more than half of the cases involving ineffective stunning of a single animal, but in less than half of similar cases involving multiple animals. We also found that FSIS officials may not be using consistent criteria to suspend plant operations--the enforcement action used when serious or repeated violations of the HMSA occur. As a result, plants in different FSIS districts may not be subject to comparable enforcement actions. In November 2003, FSIS issued clearer guidance to its inspectors and field personnel that should help resolve some of these problems. FSIS lacks detailed information on how much time its inspectors spend on humane handling and slaughter activities making it difficult to determine if the number of inspectors is adequate. In general, FSIS officials believe that, with the introduction of a District Veterinary Medical Specialist at each of the agency's field offices, the current number of personnel devoted to humane handling and slaughter compliance is adequate.