Who Does the CPSC Protect?

This spring saw the reign of a popular infant sleeping device unravel. The Fisher Price Rock ‘N Play Sleeper was a type of infant hammock, consisting of a fabric and padding-covered plastic shell, suspended on a foldable metal frame. The Rock ‘N Play was the brainchild of Fisher Price industrial designer Linda Chapman, whose first-born had suffered colic years earlier. At the time, she testified, there was no good way to elevate an infant’s head, neck and torso, to relieve its gastric discomfort.

Fisher Price’s product development team started work on this idea in 2008 and began to sell it in October 2009, marketed as a safe way to put your baby to sleep, unattended, for prolonged periods, even though the company had no research to back that claim. Nearly a decade later, Fisher Price, which had sold 4.7 million units, recalled the product – but not because of efforts by the federal agency charged with protecting consumers from dangerous products – but by a reporter at Consumer Reports.

On April 8, the magazine published a story that tied the Rock ‘N Play to 32 infant deaths. Consumer Reports Special Projects editor Rachel Rabkin Peachman had investigated the safety record of the sleeper over three months, obtaining, through a commission error, unredacted incident reports.

(Last month, the CPSC notified numerous companies that their information had been disclosed in violation of Section 6B of the Consumer Product Safety Act, which gives manufacturers a lot of control over what negative information the CPSC can disclose about them. Since 2017, CPSC apparently released information to 29 recipients, affecting more than 11,000 firms. The CPSC requested that the recipients destroy or return the documents and refrain from publishing the information. Consumer Reports refused.)

Peachman found that there were more than three times as many deaths as the CPSC and Fisher Price disclosed in a vague April 5th warning to consumers. And with 32 fatalities associated with the Rock ‘N Play in the news, the dam broke. A coalition of consumer safety advocates and the American Academy of Pediatrics, which had repeatedly expressed concerns about the safety of inclined sleep products clamored for a recall. One week later, Fisher Price announced a limited recall. On April 11th, Consumer Reports called for the recall of Kids II’s inclined sleep product, Rocking Sleepers, after it found four infant deaths associated with that product. On April 26th, Kids II recalled 694,000 units.

“I cannot think of a single product that we worked on – not a class of products, but where an individual product led to that many deaths from the one company,” says Nancy Cowles, executive director of Kids in Danger, a member of the coalition. “Thirty-two deaths seem like an intolerable number. Clearly, action should have happened well before it got to that point. Who knew what about those deaths other than Fisher Price?”

The number of infant fatalities attributed to the Rock ‘N Play is likely to increase as some previously unaccounted deaths are reexamined for connections to the product.

What the public record does show, is an agency at odds with itself, safety advocates, pediatricians and regulators in other countries. Despite a long record of accord between the CPSC and the American Academy of Pediatrics, which has been for 27 years, issuing safe infant sleep recommendations for supine placement on a firm mattress in a crib devoid of soft sleeping materials, the agency began to shift its stance in the wake of demands from juvenile products manufacturers. It did so, even as the safety records for such products grew worse.

Only five months after the Rock ‘N Play hit the store shelves, the U.S. Consumer Product Safety Commission, under the mandates of the Consumer Product Safety Improvement Act, began to propose rulemaking for bassinets and cradles. The regulation, as first published in April 2010, would have eliminated bassinets and cradles with a rest angle of greater than 5º, based on a 1995 Australian study that videotaped the behavior of 11healthy infants sleeping in all commercial sleep products at the time. The study was conducted to assist the Adelaide State Coroner with an inquest into the death of two infants, and the Department of Public and Consumer Affairs to develop Australian Standards for rocking cradles. The study concluded that infants should never be left unattended in freely rocking cradles, and that Australian Standards should recommend that cradles cannot tilt to greater than 5 degrees. As part of the rulemaking, the CPSC outlined the need to establish a safe rest angle: “When a bassinet or cradle is not in a swinging or rocking mode, it needs to be level to facilitate a safe sleeping environment for infants. There was one death and several close calls associated with non-level bassinets/cradles.”

Fisher Price and Kids II, which manufactured inclined sleep products, and its trade representative, the Juvenile Products Manufacturing Association immediately protested. According to deposition testimony from Kitty Pilarz, Mattel’s senior director of  product safety, Fisher Price submitted comments composed by its outside counsel, Jones Day, asserting that the Rock ‘N Play filled an important, CPSC-recognized “niche market” for “products intended to calm colicky babies.” The JPMA had certified it as compliant with the ASTM standard (even though the standard did not address the Rock ‘N Play’s unique design), allowing Fisher Price to advertise it as "the only infant seat that meets industry safety standards for bassinets." There had been no injury incidents, so if the CPSC persisted in prohibiting the Rock ‘N Play, it might make matters worse, as “parents deprived of any appropriate product for calming their tired, colicky infants will look elsewhere and substitute products dangerous for that purpose.”

In the next nine years, the events involving the Rock ‘N Play would run on two tracks. On one, the CPSC and industry would come together to codify the safety of inclined sleep products via voluntary and mandatory standards. On the other, the AAP, the child safety advocacy community, and regulators in other countries would publicly reject inclined sleepers as safe for newborns, while the infant death toll involving the Rock ‘N Play and other inclined sleep products would rise.

Infant Deaths in Inclined Sleepers

In July 2010, Baby Matters, of Berwyn, Pa. recalled 30,000 Nap Nanny portable baby recliners, after  a 4-month-old girl from Royal Oak, Mich. died in one. The Nap Nanny was a wedge-style inclined sleep product with a harness, invented by a Philadelphia sportscaster Leslie Kemm Gudel, who had no product design experience or expertise in infant sleep. At the time, the CPSC and the firm had received 22 reports of infants, primarily younger than 5-months-old, hanging or falling out over the side of the product. Other Nap Nanny models continued to be sold, until three years later when the CPSC forced Baby Matters to recall all 165,000 units. The commission had received at least 92 incident reports, including five of infant deaths. Baby Matters closed up shop in November 2012. As of 2014, a total of six infants died in the product.

In September 2010, the CPSC posted a blog warning parents against using any type of sleep positioner: “CPSC and the U.S. Food and Drug Administration (FDA) are warning parents and caregivers to stop using sleep positioners. Over the past 13 years CPSC and FDA have received 12 reports of infants between the ages of 1 month and 4 months who have died when they suffocated in these positioners or when they became trapped between a sleep positioner and the side of a crib or bassinet. Both types of sleep positioners claim to help reduce the risk of Sudden Infant Death Syndrome (SIDS) by keeping babies on their backs, help with food digestion and reflux, ease colic, and prevent flat head syndrome.” The FDA and CPSC staffs have stated that there is currently no scientific evidence supporting these medical claims. The American Academy of Pediatrics (AAP) already tells parents to avoid “commercial devices marketed to reduce the risk of SIDS.”

In 2011, according to reporting by Consumer Reports, the first known death incidents in a Rock ‘N Play surfaced.

In 2012, The CPSC and the FDA  issued warnings to parents against using inclined sleep products, after the Centers for Disease Control published a weekly morbidity report on infant deaths that included inclined sleep products. “We urge parents and caregivers to take our warning seriously and stop using these sleep positioners,” Inez Tenenbaum, CPSC chairwoman said in a statement. “The sleep positioner devices come primarily in two forms. One is a flat mat with soft bolsters on each side. The other, known as a wedge-style positioner, looks very similar but has an incline, keeping a child in a very slight upright position.”

A June 2013 internal email from Fisher Price to the CPSC, which was produced in litigation, mentioned that the company was investigating a possible death in a Rock ‘N Play. In October of that year, the death of two-month-old Dayana Torres in Hildalgo County, Texas, was also linked to a Rock ‘N Play sleeper.

In November 2015, the CPSC published a report of injuries and deaths associated with nursery products, finding that in a three-year period covering 2010-2012, there were 17 deaths were associated with infant sleep products. They included seven deaths in an inclined sleeper, most in a foam-style sleeper which was being used inside a crib.

In May 2018, the CPSC issued a vague warning to parents urging them to always use restraints with inclined sleep products and to stop using them as soon as the baby can roll over. The alert acknowledged that the CPSC was aware of infant deaths associated with inclined sleep products: “Babies have died after rolling over in these sleep products.” No particular product, manufacturer, or death tally was named. Safety advocates today surmise that the alert was prompted by deaths in a Rock ‘N Play, but that Fisher Price hid behind Section 6 (b). Without the crucial identifying information, the warning was useless, because most parents would have no idea what an “inclined sleep product” was.

Nearly a year later, on April 5, the CPSC issued another warning – this time with Fisher Price acknowledging 10 deaths in a Rock ‘N Play sleeper since 2015. On April 8, Consumer Reports published its story revealing 32 deaths linked to the product. On April 11th, the magazine published n update linking four infant deaths to inclined sleep products manufactured by Kids II. 

Opposition to Rock ‘N Play

While the injuries, deaths, and close calls remained largely hidden, Fisher Price went looking for new markets for the Rock ‘N Play. It did not get the same concessions from regulatory agencies in other countries. In 2011, officials in Canada and Australia rejected the Rock ‘N Play as a sleep product. The company withdrew it from the Australian marketplace rather than change its marketing. In Canada, it was sold as a “soothing seat.” In the UK, where it is sold as a sleeper, the influential Royal College of Midwives refused to endorse the Rock ‘N Play for anything other than a playtime accessory of short duration: “It was agreed that: this would not be suitable for a new born infant as babies cannot be placed in a semi-prone position; This should not to be used for infants under six weeks; The lying surface is not suitable as an infant cot – and must not be used as infant cot to sleep next to mother's bed because babies must always sleep flat on their backs;  Unreservedly – this product must only be used for no more than two hours in a day and for the purpose of play/interaction with parents/siblings etc,” they wrote.

Pediatricians in the U.S. also raised the alarm. In 2012, Dr. Natasha Burgert, a Kansas City, Mo. Pediatrician published open letter to Fisher Price calling it “irresponsible to promote the Rock n’ Play™ Sleeper as an safe, overnight sleeping option for infants. By continuing to do so, you are putting babies at risk.  The Rock n’ Play™ Sleeper should not be used for extended, unobserved infant sleep for the following reasons. First, design features of this product are known to increase the risk of sudden infant death syndrome (SIDS). Second, I have personally seen infants with brachycephaly/plagiocephaly [flat head] and torticollis [twisted neck] as a direct result of using this product. Finally, infants are often left with poor sleep habits that continue long beyond the product’s use.”

Another blogging pediatrician, Dr. Roy Benaroch, published a similar opinion, and reached out to Fisher Price directly to express his concerns in great detail. He received a form reply: “Thank you for your inquiry and comments. We did receive your email on February 7. 2013.  We have provided these comments to the appropriate people within Fisher-Price. The Rock ‘n Play Sleeper complies with all applicable standards. We encourage consumers who have questions or concerns about providing a safe sleeping environment for their babies to discuss these issues with their doctors or pediatricians.”

The AAP, which had been issuing sleep recommendations to reduce the incident rate of SIDS since 1992, continued periodically to sharpen its advice to caregivers. In 2011, it issued specific safe sleep guidelines, which inclined sleep products could not meet, such as: “Infants should be placed for sleep in a supine position (wholly on the back) for every sleep by every caregiver until 1 year of life; Use a firm sleep surface—A firm crib mattress, covered by a fitted sheet; Sitting devices, such as car safety seats, strollers, swings, infant carriers, and infant slings, are not recommended for routine sleep in the hospital or at home; If an infant falls asleep in a sitting device, he or she should be removed from the product and moved to a crib or other appropriate flat surface as soon as is practical.”

The AAP also directly addressed the claims made by manufacturers in 2010, that their products were a godsend for babies with intestinal problems:

“The supine sleep position does not increase the risk of choking and aspiration in infants, even those with gastroesophageal reflux, because they have protective airway mechanisms. Infants with gastroesophageal reflux should be placed for sleep in the supine position for every sleep, with the rare exception of infants for whom the risk of death from complications of gastroesophageal reflux is greater than the risk of SIDS (ie, those with upper airway disorders, for whom airway protective mechanisms are impaired)”

Giving Inclined Sleep Products a Safety Stamp

Nonetheless, the CPSC and inclined sleeper manufacturers proceeded to develop safety standards. An ASTM sub-committee was formed, headed by Michael Steinwachs, a retired Fisher Price Product Integrity Engineer who worked on the development of the Rock ‘N Play.

In October 2012, the CPSC made official its regulatory approach to exclude inclined sleep products from the bassinet and cradles rulemaking that was underway. In a Supplemental Notice of Proposed Rulemaking the Commission wrote: [The] Commission believes that a separate standard targeted specifically to these products will more effectively address any hazards associated with them. Due to the significant progress in the development of a separate voluntary standard to address hammocks and inclined sleeping products, the Commission is not including them within the scope of this proposed rule.”

The ASTM released the first voluntary standard for inclined sleep products in May 2015 and a revision in 2017. And in April 2017, the CPSC published a Notice of Proposed Rulemaking specifically for inclined sleep products, in which it noted 14 fatalities between 2005 and 2016, with eight in rocker-like inclined sleep products. The CPSC pronounced itself satisfied that the current voluntary ASTM standard would address “the primary hazard patterns identified in the incident data.” All that was needed was “more stringent requirements” relating to the standard’s definition of accessory—which meant removing the term ‘‘rigid frame’’ from the definition, because, the CPSC said, not all inclined sleep products have a rigid frame. In fact, the CPSC was aware of a new inclined sleep product had entered the market without such a frame.

The child safety community was visibly dismayed. A coalition of groups, including Kids In Danger, Consumer Federation of America, Consumers Union, Consumer Reports, Public Citizen, and U.S. PIRG, submitted comments pointing out that there had been no studies showing that babies sleep better on an incline, nor any studies on the impact of continuous restraining sleeping infants on their development or safety. They urged the CPSC to promulgate a standard that ensure the same safe sleep as a full-sized crib.

The AAP  expressed “concerns about all inclined sleep products and the hazards they may pose to infants, and we are concerned that a safety standard could give parents and caregivers the mistaken impression that these products have been proven safe…The AAP continues to recommend that infants with gastroesophageal reflux should be placed for sleep in the supine position for every sleep, with the rare exception of infants for whom the risk of death from complications of gastroesophageal reflux is greater than the risk of SIDS (i.e., those with upper airway disorders, for whom airway protective mechanisms are impaired), including infants with anatomic abnormalities such as type 3 or 4 laryngeal clefts who have not undergone antireflux surgery. Elevating the head of the infant’s crib while the infant is supine is not recommended. It is ineffective in reducing gastroesophageal reflux; in addition, it might result in the infant sliding to the foot of the crib into a position that might compromise respiration.”

Controversy and Contradictions

Back in 2008, when Fisher Price was developing the Rock ‘N Play, there was no research to support the safety of inclined sleepers, because the products didn’t really exist. As documents produced in litigation show, Fisher Price couldn’t rely on data, so it called in a San Antonio family physician, named Gary Deegear, who aslo worked as an injury forensics consultant, to provide guidance.

“I'm not sure that we did specific research at this time about incline angles other than talk to Dr. Deegear,” Pilarz said in a deposition.

The decision to incline the rocker at 30 ° was an educated guess, somewhere between the 45° angle of infant car seat and a flat surface. In February 2009 email, Pilarz described the justification for this design decision:

“Dr. Deegear stated pediatricians recommend babies with reflux sleep at 30 degrees, this is just fine, or sleep in a car seat overnight for months or even a year The Back to Sleep campaign places children on their backs, and elevated positions of the head is fine. He is not aware of research on this. He will do a quick search. I explained that we are also researching this issue. I also have a call in to a local group of pedestrians to see if they are willing to offer an opinion.”

In that email exchange, Dr Deegear also sent Fisher Price the AAP’s safe sleep guidelines, which say nothing of the sort.

Similarly, the CPSC had no research to support a rulemaking decision to codify the safety of inclined sleep products in a way that would prevent infant deaths in these contrpations with any real confidence. What they did have on the one hand, was a major juvenile products manufacturer servicing a thriving market of parents desperate for sleep and on the other, the longstanding safe sleep recommendations of the AAP, which the commission has repeatedly endorsed.

“This idea they are giving the consumer something that will help them is not at all true,” Cowles says. “Fisher Price produced 5 million of these sleepers. There has been no reduction in sleep-related deaths. You would think that you would have seen some reduction, if these things were so effective. They convinced parents it would help their babies sleep, because we are all looking for a way to help babies sleep. And parents assume that if it’s for sale, someone made sure it was safe. That’s clearly not true with this product.”

Even former CPSC Chairman Inez Tenenbaum, on whose watch the CPSC took their peculiar stance, testified as an expert witness for Fisher Price in a personal injury lawsuit. Tenenbaum, now a lawyer in private practice with the Wyche Law Firm firm in South Carolina, testified in February 2018 that “the AAP has not come out against the incline[d] sleepers… The AAP has never said not to use an incline[d] sleeper.” You’d think the for the $1,000 an hour she charged Fisher Price for her expert opinion she might have read the AAP’s April 2017 comments to the docket in which they criticized the commission for giving parents the impression that theses products were safe when there was no evidence to support it.

But for the CPSC’s error and Consumer Reports persistent reporting, the public would never have known just how flimsy the foundation for these consequential decisions is.

Fisher Price’s walk-the-plank recall only reimburses parents who purchased a Rock ‘N Play in the last six months, pretty much ensuring that many units will remain uncaptured and many infants will be exposed to the risk of injury and death. That troubles Rachel Weintraub, the Consumer Federation of America’s executive director.

“This recall, while better than no recall has numerous problems. I am concerned, because from what we know about recall effectiveness, that this recall is not a recipe for success – much more needs to be done,” she said.

The Rock ‘N Play and other inclined sleepers have gotten so toxic, that earlier this month, the CPSC told Consumer Reports that it planned to “reevaluate” the entire product category. Steinwachs stepped down from the ASTM inclined sleep products standards sub-committee. Last week, its member rejected a call from safety advocates and the AAP to withdraw the product category, but intended to look into it further when it re-convenes in October.  

“We plan to keep pushing,” Weintraub says.

 

CPSC Takes on ROV Fire Hazards

For more than a decade, the U.S. Consumer Product Safety Commission has been tracking the hazards associated with Recreational Off-Road Vehicles (ROV), with a focus on their poor handling, lateral stability, and dynamics. But the epidemic of Polaris ROV fires has shifted the commission’s attention to the dearth of industry standards to prevent ROV designs and malfunctions from sparking deadly fires.

In September, the CPSC’s Directorate of Engineering Sciences Caroleene Paul met with the Specialty Vehicles Institute of America to lay out the commission’s case for setting fire prevention standards in the wake of a $27.25 million civil penalty levied against Polaris Industries. The Medina, Minnesota, manufacturer paid the fine to settle two charges of untimely disclosure to the CPSC that “models of RZR and Ranger recreational off-road vehicles (ROVs) contained defects that could create a substantial product hazard or that the ROVs created an unreasonable risk of serious injury or death.”

Polaris agreed to that penalty – without any admissions of guilt – in April. One charge concerned 133,000 model year 2013-2016 RZR 900 and model year 2014-2016 RZR 1000 ROVs that caught fire while consumers were driving, posing fire and burn hazards to drivers and passengers. According to the commission, by the time Polaris reported the defect to the CPSC in April 2016, it had tallied 150 fires, including one death to a 15-year old passenger, 11 burn injuries, and a fire that consumed ten acres of land. The other charge concerned model years 2014-2015 Ranger XP 900 and Crew 900 vehicles that had heat shields that became loose and fell off. Polaris received 36 reports of fire and made two design changes before informing the CPSC.

Neither the recalls, nor the fine have stopped the Polaris fires. In fact, in December 2017, the agency and the manufacturer released a joint statement admitting as much:

… users of the vehicles that were repaired as part of the April 2016 recall continue to report fires, including total-loss fires. The 2017 RZRs were not included in the April 2016 recall, but these models have also experienced fires. The CPSC and Polaris continue to work together to ensure fire risks in these vehicles are addressed. However, at this time, the CPSC and Polaris want to make the public aware of the fires involving these vehicles.

One can only hope that voluntary standard-setting is a companion activity for the CPSC, because as that process proceeds at its molasses-in-January pace, Polaris ROV owners face considerable risks of harm in the interim. 

“So far, the response from the CPSC and Polaris has been underwhelming. Even after these recalls, Polaris ROVs are continuing to ignite and cause enormous human damage,” says attorney Jeffrey Eisenberg, of the Salt Lake City firm of Eisenberg, Gilchrist & Cutt, who has represented 10 families of Polaris fire victims. Among them is Colby Thompson. In July, Thompson was riding his 2017 Polaris RZR up an embankment in Bozeman, Montana, when the ROV burst into flames. The RZR had only been driven 20 miles; Thompson’s burns to his upper body were so severe, he was placed in a medically induced coma.

“Polaris has ignored this problem for far too long, and has done too little to remedy its RZR problems,” said Eisenberg. “There is no way that a RZR manufactured in 2017 with 20 miles of service should combust. My clients have paid the ultimate price for this corporate misconduct.”

The Hottest ROVs on the Market

Why can’t Polaris keep its powerful ROVs from burning up? A class-action lawsuit complaint, filed April 5 in U.S. District Court in Minnesota, alleges that Polaris fires are caused by a design defect plaguing multiple models spanning the 2011-2018 model years.

Polaris has been the undisputed king of the ROV market for at least a decade, netting $3.36 billion in sales in 2016. One of the biggest factors in its commercial success has been the production of high-powered ROVs featuring its in-house designed Pro-Star engine family, introduced in the 2011 RZR XP 900, and phased in to all of its ROVs by 2015. The civil action further argues that the real root cause of the fire risk is:

an unusually high-powered “ProStar” engine that is tucked directly behind the occupant compartment. The ProStar engine produces more power than the engines in competing vehicles and, accordingly, more heat. The ProStar’s exhaust gas piping routes forward toward the occupants, then turns 180 degrees, creating a U-shape, and exits from the rear. The piping lacks proper ventilation and heat shielding, and is positioned within inches of combustible plastic body panels. Thus, the hottest area of this high-performance engine is located inches behind the occupants, in an area of the vehicle that is enclosed with little room for air flow to dissipate the high heat. The extremely high temperatures, combined with inadequate cooling and heat shielding, result in the melting of the plastic body panels and the ignition of any combustible material surrounding the engine, including organic debris, leading to potentially deadly fires.

When tallying all of the Polaris products that combine a high-performance engine with poor placement and inadequate venting, the lawsuit, filed in April 2018, alleged that the true total of the damage since 2013, based on Polaris’ recalls, is more than 250 fires, more than 30 severe injuries, and at least three deaths. Those numbers are likely a significant undercount because, according to CPSC and Polaris, some models have burned but have not been recalled and fires continued to occur even in models that had recall repairs.

Setting ROV Standards

There are currently no mandatory safety standards governing the design and manufacture of off-road recreational vehicles. In October 2009, the CPSC published an Advance Notice of Proposed Rulemaking to address the “unreasonable risks of injury and death associated with Recreational Off-Highway Vehicles,” related to their rollover propensity.

(The CPSC distinguishes ROVs from ATVs as “motorized vehicles having four or more low pressure tires designed for off-road use and intended by the manufacturer primarily for recreational use by one or more persons.” ROVs are commonly called Side-by-Sides for their seating arrangement. Unlike an ATV, which is straddled by the rider with handlebar steering,  ROVs resemble small, rugged, Jeep-like vehicle, accommodating one to six occupants.)

The commission moved to rulemaking after determining that voluntary standard efforts did not do enough to rein in deaths and injuries caused by the vehicles’ poor lateral stability and vehicle handling, and the lack of occupant protection features, such as seatbelts. This touched off a seven-year, concerted effort between the CPSC and industry to beef up ROVs’ performance requirements. In November 2016, after the Recreational Off-Road Vehicle Association (ROHVA) and the Outdoor Power Equipment Institute (OPEI) finalized amending their ANSI voluntary standards to the CPSC’s satisfaction, the staff recommended that the rulemaking be terminated. The staff concluded that the new standards would likely reduce ROV rollovers, by increasing lateral stability and decreasing occupant ejections through seat-belt use and improved side retention.

The brief public portion of the meeting in September at the Grand Hyatt hotel at Dallas-Fort Worth airport featured a presentation on voluntary standards-setting to address ROV fire hazards by Mechanical Engineer Han Lim of the CPSC’s Division of Mechanical Combustion Engineering. Attendees included Honda, Polaris, Yamaha, Kawasaki, Textron and members from the OPEI.

Lim noted the lack of any safety standards regarding ROV thermal or fire issues, despite the diverse sources of ignition – debris intrusion, fuel tank integrity, and flammable plastic body panels, for example. Since 2004, ROV manufacturers have launched some 47 recalls for a variety of defects that could result in fires, such as fuel tanks, hoses, and filters; electrical components; and exhaust systems. In addition, the CPSC has launched at least 120 ROV fire In-Depth Investigations since 2004, when the agency began to track this trend.

The CPSC recommended forming task groups to study the recall data and CPSC In-Depth Investigation reports in formulating improvements and standards. Lim recommended the group focus on fuel tank punctures, structural integrity of the engine, the fuel system and electrical components and spacing requirements to shield ignitable parts from excessive heat. Lim also suggested that the group look at surface temperature limits to prevent contact burn injuries and standards to prevent debris penetration. The CPSC ended its presentation by speculating that manufacturers already had internal standards that addressed thermal issues, and by expressing its preference that industry representatives codify them in a voluntary safety standard. The commission offered its assistance in that process. The OEMs thanked the CPSC, agreed to look over the data and get back to the agency, but set no timetable for doing so.

Market Pressures Raise the Heat on Honda Pioneers

Polaris is hardly the only manufacturer to create a fire hazard in the pursuit of market share. The May 15 recall for all 2016-2017 and some 2018 Honda Pioneer 1000 ROV models for fire and burn hazards is another good example of how trying to wrap every desired market attribute into one ROV without adequate cooling and thermal protection can create fire-prone designs.

Honda introduced the Pioneer 1000 in 2015 for the 2016 model year, to compete in the side-by-side market with competitor vehicles that seated four to six passengers and cargo, but with the improved trail capabilities associated with smaller two-occupant models. Typically, manufacturers use a longer wheel base to fit more passengers and cargo, but do so typically enlarges the turning radius and reduces its maneuverability on off-road trails. Honda bragged that it had overcome that problem with its own “packaging technology,” that mostly consisted of placing an engine in the center of the vehicle under the occupant compartment. Roomy? Check – the Pioneer fit up to five occupants. Peppy? Check – a large displacement twin-cylinder delivered 72 HP and a top speed of 67 mph. Agile? Check – the Pioneer 1000 boasted a shorter wheelbase and turning radius.

What did customers get for all of that? Hotter-than-hell occupant compartments and major thermal management problems that produced complaints, burns, fires, and a Honda Product Improvement Campaign, followed by the recall.  

In August 2017, Honda issued Product Improvement Campaign for a “Cabin Comfort Improvement Kit,” which included weather stripping, seals, and rubber mats and pads, presumably to reduce the high temperatures in the occupant seating area. According to the bulletin:

American Honda Motor Co., Inc. is conducting a Product Improvement Campaign to improve cabin comfort on 2016 and 2017 model year Pioneer 1000 vehicles. With the addition of an accessory roof and windscreen/windshield and under hot weather conditions, occupants may experience uncomfortable heat coming from the engine compartment. A cabin comfort improvement kit that reduces the entry of hot air and lowers front seat area surface temperatures is available.

Nine months later, Honda was forced to recall all 2016-2017 and some 2018 Honda Pioneer 1000 because the “muffler can overheat, causing the plastic heat shield to melt or catch fire, posing a fire and burn hazard to consumers.” The Honda Powersports website offered an additional root-cause fact: the heat shield itself was melting or igniting due to “one engine cylinder misfire condition.”

Mitigating Heat Build-up with Better Design

Polaris’ and others’ inability to design an ROV that can go fast without burning up itself and its passengers has created a whole aftermarket for accessories that mitigate heat accumulation –which owners don’t discover they need until they experience the problem themselves. One 2016 article for UTV enthusiasts introduced six products to keep a RZR Turbo from overheating:

We have heard a few RZR Turbo owners complaining of their engines overheating. Under super hard driving, under load, we have had it happen to us too. So there has [sic] been a number of companies trying to address the issue, and they have come up with some pretty interesting products.

The universe of heat-reducing products includes the Polaris RZR Regulator Rectifier. Manufactured by Rick’s Motorsport Electrics, the Rectifier “is built using Mosfet Technology, allowing the regulator to run cooler & more efficiently. Rick’s worked with RZR owners to customize a part that is easy to install and will solve common overheating issues.” There is also the CBR Radiator & Heat Exchanger Combo: “If you’re going to race or even fully build out a XP Turbo, getting completely rid of any potential heating problems is a major concern. CBR has been building custom, oversized and race spec’d radiators and intercoolers for a long time now. The BMP 2016-Up RZR XP Turbo Slip-On Double Barrel Exhaust “drastically reduces heat buildup.”

Finally, a clutch-cooling device called “The Blow Hole,” a fan that expels hot air “even at low ground speeds as opposed to the OEM rpm dependent clutch fins. According to a review in ATV MTNK, the Blow Hole pulls approximately 225 CFM of air through the clutch ductwork.”

Meanwhile, Can-Am, a brand owned by Bombardier Recreational Products, has tried to get the design right the first time. In 2013, BRP debuted the Can-Am Maverick 1000 series, with a 1,000cc twin-cylinder Rotax engine, rated for 101 horsepower.  In this design, the engine is located underneath the center of the chassis and beneath the passenger compartment, but it modified the air intake and exhaust tract to create what the company calls “High-Flow Dynamics.”  

According to reviewer John Arens in ATV Illustrated, First Look: “The air intake location, the air plenum size, and exhaust valve size were all increased, and the exhaust tubes are now a dual, tuned length system that flows through dual mufflers at the rear. We’ve always noticed a slight throttle lag in the past thanks to air flow restrictions, and the new High-Flow system should eliminate that trait.” Elsewhere, he noted: “[w]ith the area around the muffler now open for better airflow, temperatures around the exhaust system are reduced as well.” Unlike the Polaris ROVs, the dual exhaust pipes remained separate, with a “tuned length system that flows through dual mufflers at the rear.”

In 2012, reviewer Lance Schwartz of ATV Rider pointed out another key difference between the RZR and the Can-Am: “Exhaust gases travel from the cylinders through individually tuned headers, resonators, industry-first catalytic converters and eventually exit through dual exhausts.”

How Long Before Industry Addresses its Fire Problems?

The federal government spent seven years tango-ing with ROV manufacturers over voluntary standards to prevent their products from flipping over, spewing or crushing occupants. That dance included the threat of rulemaking, independent CPSC lateral stability testing, and innumerable meetings with industry types to get to a place of – if not a mandatory standard – recognition and notice that manufacturers must design these vehicles to certain criteria to prevent these crashes, injuries and deaths.

What’s it going to take to make the industry address its thermal problems? As the public portion of the September industry-CPSC confab only lasted for about 30 minutes, it was hard to take the temperature of the room. But perhaps the regulated and the regulator can learn something from the last go-round, and cut right to setting rigorous safety and engineering design standards so that manufacturers don’t ignite the vehicle or the occupants on their way to the bank.

 

Deadly Treestands

It was a tough hunting season in New York State last fall – at least four hunters died in falls from treestands, according to the New York State Department of Environmental Conservation. The North Carolina Wildlife Commission tallied three deaths from tree stand falls in the 2016-2017 hunting season. On the last day of 2017, a hunter from Milwaukee died after he fell out of a tree stand in Sauk County. Kansas City Royals manager Ned Yost nearly died in November when he fell 20 feet from a treestand at his Georgia home. Yost fell through the floor of the stand, breaking his pelvis and several ribs, and would have bled to death, had he not had his cellphone, according to news accounts.  

Falls from treestands now kill and injure more hunters than guns. For example, in 2014, the Indiana Department of Natural Resources reported that in 182 reported hunting accidents over a five-year period, 100 – or 55 percent – involved falls from treestands. But how many of these incidents are the result of user error, manufacturing or design defects is unknown. The non-profit International Hunter Education Association, which gathers detailed hunting incident data from state agencies, is the only national clearinghouse of hunting injury and fatality statistics. Its reporting form solicits detailed information on each incident about the hunter, the equipment, and the reason for the fall, from state environmental officials who regulate hunting, but the IHEA does not publish its data. 

The injuries from these falls can be devastating. A recent study by researchers at the University of Wisconsin department of neurosurgery and University of Alabama at Birmingham examined treestand injuries from 1999 to 2013, and found that 55 percent resulted in spinal injuries. 

Not surprisingly, hunter safety information offered by groups such as the Treestand Manufacturers Association, which bills itself as “a nonprofit trade association that specifically devotes its resources to promoting treestand safety through education,” only examine the issue through the lens of hunters’ behavior. But, consumer complaints, recalls and investigations by the U.S. Consumer Product Safety Commission indicate that some treestands fail because they are poorly designed and cheaply manufactured. Outdoors Underwriters Inc, an insurance company that caters to hunters and outdoors organizations and businesses, recently published an analysis of the 27 most serious treestand injuries, defined as “injuries that had medical bills in excess of $50,000, or partial disabilities, and/or fatalities.” In this subset of claims, more than a quarter – or seven cases involved a mechanical issue with the stand. Similarly, the Tree Stand Safety Awareness Foundation found a significant percentage of equipment failure its injury and death statistics from 724 falls that occurred in 10 states from 2010 to- 2016. Among the top five causes of falls: 39 percent were attributed to human error; 31 percent were attributed to a strap break, a stand break or a step/ladder failure. 

Since 2000, there have been at least 14 treestand recalls for cables and chains that snap, bad welds, pin breaks, and webbing problems. For example, In November 2016, Summit recalled 270 Summit Explorer SD Closed Front Climbing Treestands because a weld in the treestand’s frame could suddenly break. In October 2015, Global Manufacturing Company recalled 5,300 model year 2014 API Outdoors “The Marksman” model climbing treestands, following the report of one user who suffered a broken vertebra, fractured rib and sprained shoulder when the cable assembly released and led to a fall.

Hunters have also reported treestand failures to the commission. On March 14, a hunter reported a November incident: 

While deer hunting this morning using an API Marksman climbing treestand, I was coming back down the tree and a structural support on the stand broke in two, resulting in me flipping backwards out of the stand and hitting on my back. Thankfully, I was only 4 feet off the ground when it happened resulting in a bruised back and a torn calve muscle. I have pictures of the stand along with the model number. I see that this stand has an unrelated recall for the chains but my feeling is this stand needs to be taken off the market completely and an effort to eliminate anybody from using this stand in the future. 

On March 5, another hunter reported a September 10 incident:

I purchased my API stand from Bass Pro about 4 years ago. On Sunday it suffered a total structural failure while I was using it. The standing platform cracked in half, suddenly without warning. Luckily, I was in a full harness and my fall was arrested. As background information, I have used this stand about 30 times. I also have kept it inside when stored and never left it out in the elements for more than a day or 2. I've always used care in using the stand as not to put undue wear on it. When the stand failed, I was climbing up the tree. At the time of failure, I was standing on the platform and not moving either the top or bottom section of the stand. The failure was sudden and fast, it was like the floor dropped out.  The pictures attached show the failure points. It failed at the location where the foot strap is connected to the standing platform. In this location, there is less structural material. It is also where your feet attached to the stand when climbing, and the pressure of downward force is focused. 

The commission also regularly conducts epidemiologic investigations into treestand injury and death incidents – which may not lead to a recall, despite findings of a product failure. For example, in 2002, the CPSC conducted an investigation of the “Baby Grand Lite” Model GS2300 treestand because of possible weld problems that caused the seats to fail. Initiated by a complaint from a Fowlerville, Michigan hunter who suffered back injuries after his treestand failed, the investigation led CPSC staffers to obtain exemplar seats. The examination found that the welds were substandard. In May 2002, the Commission issued a Product Safety Assessment Report indicating that “the weldments showed poor welding technique had been used” and that “fracture surfaces of the failed weldments showed various weld discontinuities,” including incomplete fusion, no fusion between the tab and channel of the seat frame, no evidence of a weldment between the seat arm and the folding portion of the stand, and weld porosity. The report concluded that the welding of the treestand seat frame channel to the mounting tabs was not done with the highest quality welding technique in the subject stand and the two samples provided by the company.

(Despite the injury incident that prompted the epidemiologic investigation, and the discovery of weld failures in two of the exemplar stands examined, the CPSC did not take further action in this case.)

In 2015, the CPSC also investigated a February 2015 incident in which a 50-year-old male from Wall Township, New Jersey fell 15 feet, as he prepared to descend, when the bolt on his API Crusader treestand broke, the frame cracked and the snap pin wire snapped. 

Most of the recalled treestands were manufactured in China, sold in the U.S. at major outdoors equipment retailers and imported by a tangle of U.S. companies – some of which appear in public filings to be related. This means that a single manufacturer could be supplying different importers with the same basic treestand that is branded under different names in the U.S. If the manufacturer uses sub-standard materials or assembly practices, the failures can appear unrelated, because the importers’ brand name and model names may be different.  

In November 2015, Gene “Vic” Moore fell approximately 20 feet to the ground after the foot section on his API Crusader Treestand failed. Moore broke his right leg in multiple places and was left with a permanent injury, says Attorney David Whittington of the Summerville, South Carolina firm of Knight and Whittington. Moore purchased the treestand in November 2014, and had used it for less than a year when it collapsed. Whittington is exploring the possibility that manufacturing practices and design choices, made solely to make it easier to pack and transport into the woods, were among the reasons for the stand's failure. 

“One of my client’s concerns has to do with the safety of other hunters and concerns about the safety of this particular treestand,” Whittington says. “My client was specifically drawn to this model because it was marketed as inexpensive, lighter weight and more portable, but now, as he reflects on it, he is concerned the manufacturer sacrificed safety when trying to improve sales by making this stand easier for hunters to carry into the woods.” 

The Failure to Regulate

Like many consumer products, treestands are only subject to voluntary regulations, despite an attempt in the early 2000s to place the platform devices under federal standards. In March 2002, Carol Pollack-Nelson, a former CPSC employee and safety consultant, petitioned the CPSC to establish a mandatory standard for hunting tree stands to address their design and construction, and to ban safety belts in tree stands. Pollack-Nelson argued that hunting tree stands posed a serious injury and death risk, and that safety belts “can prove to be a deadly precaution, as there is risk of fatality caused when it constricts around the chest and/or abdomen.” 

“I first learned about the issues contained in my petition through my work in a case in which a 15-year-old boy strangled to death in the single strap waist belt. In this case, the 15-year-old was hunting by himself on his family’s property,” Pollack-Nelson said in an email. “He’d been hunting his entire life and had just received a new treestand for Christmas, the night before his death. He went out on Christmas day and was later found by his family, hanging from the belt. The top part of his climbing stand was no longer affixed to the tree. With all of his body weight suspended by a single strap, worn “properly” around the chest, he was unable to breathe or rescue himself.”

The briefing package that the CPSC staff prepared for the commission documented the hazards of using treestands for hunting. The staff cited 6,000 injuries attributed to treestand use that were treated in U.S. hospital emergency rooms in 2001 based on a review of National Electronic Injury Surveillance System (NEISS) data. It also reviewed the Injury or Potential Injury Incident Database (IFIl), the In-Depth Investigation Database (INDP), and Death Certificate Database, and found 137 incidents involving treestands from 1980 through 2001, including 62 deaths and 55 injuries. Of the total incidents, 54 mention treestand failures resulting in 6 deaths and 40 injuries; eight fatalities involved hanging or traumatic asphyxiation by a safety belt or harness.  In April 2004, the staff recommended that the petition be denied, because it concluded that the standards adequately addressed the products’ structural integrity, stability and adherence to the tree, under a rated static load condition.

Despite the commission’s rejection of a mandatory standard, the CPSC staff worked with the ASTM Hunting Tree Stand Subcommittee and the TMA to assess the voluntary standards related to dynamic loading conditions, and to address safety when a hunter is entering, exiting, ascending, and descending a hunting treestand. 

One of the issues that emerged was the problems created by safety harnesses. The Treestand Manufacturer’s Association agreed to require a full body harness be included with any treestand that seeks TMA certification. Hunters’ failure to use full-body harnesses while hunting in treestands is often cited as a reason for the large number of falls. But the use of harnesses itself can sometimes lead to fatalities. Hunters can escape the broken bones of a fall, only to suffer what is known as suspension trauma after being suspended  in a harness for extended periods with no way to extricate themselves. For example, in a 2003 CPSC investigation involving API Grand Slam Shooting Star and other epidemiologic reports, hunters died trying to extricate themselves from a full-body harness

Suspension trauma is a well-documented succession of medical events that can include nausea, burning sensations in the extremities, fainting, shock, respiratory distress and death. Studies show that humans cannot survive in an immobile suspended position for very long without sustaining serious injuries. 

Salena Zellers Schmidtke, a biomechanical engineer and safety expert, noted that serious injuries can occur to people suspended from a harness for as little as ten minutes:

“After ten minutes of inactive suspension, which could easily occur if the person is injured, the body can go into shock because of blood pooling in the legs,” she says. “This can result in breathing problems, brain damage and even death.”

Some of the CPSC’s work with the voluntary standards involved prodding the TMA to write better voluntary standards regarding requirements for self-rescue. While the agency regarded industry standard TMS 06-02, and ASTM standard F2337, requiring a full body harness as “a significant safety improvement,” there was still concern about the absence of a requirement to ensure that hunters can extricate themselves while suspended. 

In 2009, the commission wrote a letter chastising the association for its lack of progress on this issue: 

Since July 2003, when CPSC staff first requested that ASTM address the issue of self- rescue, the only standards-related progress made has been limited to suspension relief. CPSC staff would like to see standards modified to include performance requirements that would ensure a hunter's ability to safely return to the ground in an emergency situation. It is our understanding that a number of safety devices that would likely meet such requirements are already available. CPSC staff views self-rescue as equally important to harness use, recognizing that the latter is a critical component in the overall scheme of safety and self-rescue. ….CPSC staff understands that many treestand users choose not to wear safety harnesses or other safety devices. Given this fact, staff encourages TMA and the industry as a whole to try to gain an understanding as to why hunters do not utilize safety-related equipment or devices which are readily available. For example, might a more user-friendly harness design (one that is easier to wear, adjust, untangle, etc.) help to encourage harness use? Has the TMA conducted any studies or surveys to attempt to understand why hunters do not wear basic safety devices that could prevent severe injury, paralysis, or death?

The CPSC conducted its own evaluation of harnesses in 2011. “An Evaluation of Injuries from Falls and Suspension Traumas Related to Treestands" summarized the CPSC staff assessments of various full-body harnesses, sold separately or included with a treestand. The CPSC tests found that “all of the harnesses tested produced pressure points.” According to the commission’s annual summary of voluntary standard activities, the report also discussed the injuries sustained after falling from a treestand and the causes and effects of suspension trauma. The 2011 Standards Activities Report noted that CPSC staff would release the test report when it was approved. The report was never finalized or published.  

The CPSC continued to participate in voluntary standards setting through 2014, after which the agency cut back its involvement to simply monitoring.

Have voluntary standards done anything to lessen the death and injury toll from treestand equipment failure? With a lack of centralized data collection it’s difficult to discern. Certainly, what death and injury data do exist show that equipment defects are at the root of a good portion of falls from elevates stands. The CPSC’s interest in the issue has been waning, but the falls, with their broken bones, damaged spinal cords, and sudden deaths continue.  

CPSC Slaps Office Depot 3.4 Million Times in Chair-tastrophe

The U.S. Consumer Product Safety Commission has fined paper-and-pencil-pusher Office Depot $3.4 million for its failure to report defects in its Gibson Leather and Quantum office chairs. The two shared a common problem – a sudden collapse of the seat base and a common retailer with a high resistance to recalls – but had different failure modes and price points.

According to the May 11 settlement agreement, the U.S. Consumer Product Safety Commission rapped Office Depot for violating the Consumer Product Safety Act by years-long lags between when it knew it had a problem with the chairs and when it notified the CPSC and launched a recall. In addition to the civil penalty, Office Depot had to agree to institute the industry-reviled internal compliance program, complete with formal policies, confidential reporting mechanisms, employee training programs, and records retention rules.

Office Depot neither admitted nor denied the charges, but commission Chairman Elliot F. Kaye made it clear that the CPSC believed its case was strong enough.

“When a company has received information about nearly 200 incident reports and more than 35 injuries yet fails to report to CPSC as required by law, as Office Depot did, there must be accountability,” he said in a statement. “Office Depot failed to report serious incidents to CPSC immediately, as the law clearly requires. More importantly, Office Depot failed to take responsibility and care for the safety of their customers.”

In October 2009, Raynor Marketing recalled 150,000 Quantum Realspace PRO 9000 Series Mid-Back Multifunction Mesh Chair and Multifunction Mesh Chair with Headrest, which retailed at $350. Manufactured by a Chinese company, Comfort Office Furniture, and sold exclusively through Office Depot, the chairs officially fell apart when the bolts attaching the seatback on the recalled chairs loosened and detached. But, according to the settlement, Office Depot first learned about a seat back failure in 2007. It also knew that the manufacturer had instituted design changes in 2008 and 2009, but continued to field injury and incident reports. By the time of the recall, there were 13 injuries and 33 complaints of seat detachments.

The Gibson chair case was a lot more egregious. From 2003 to 2012, Office Depot was the exclusive seller of 1.4 million units, manufactured by the Wonderful Year Furniture Company, and imported by Swinton Avenue Trading Company.  The retailer began getting complaints in 2005 about a bad weld which caused the chair to break. By the time the CPSC caught up with the case, Office Depot had racked up 153 incidents and 25 injury reports. It only came clean after the Commission staff opened an investigation in December 2012. Office Depot didn’t launch a recall until May 2014.

From Falls to Fines

The Safety Record Blog cannot help but note that Office Depot would not be the star of today’s CPSC press release, without some outside help.

The first to sound the alarm was a Florida blogger named Jessica Clackum, who in late 2006, suffered a fall when her 14-month-old Swinton Avenue Trading Company chair collapsed, after the weld at the base of the chair failed. Clackum had contacted Office Depot looking for restitution, but the managers shrugged. She tracked down the Swinton Avenue Trading Company, but the entity turned out little more than a Florida address with no means for redress. She poured her outrage into a blog that attracted literally hundreds of complaints. In April 2009, an Office Deport Senior Customer Relations Manager named Casey Ahlbum even posted a response solemnly reciting the company pledge: “At Office Depot Taking Care of Business is the unwavering commitment that we make to our customers, providing unprecedented value, selection, quality and service,” he wrote.

In March 2010, fellow victim Nancy Losey of San Antonio, Texas routed her complaint more directly. In March 2010, Losey broke her hip in a fall from a Gibson Leather Office, an injury that required a hip replacement. Losey’s attorney Paula Wyatt determined that the Gibson had the same design and product registration number as Office Depot’s Biella Office Chair, also with a bad weld, also manufactured by the Wonderful Year furniture company, also imported by Swinton Avenue Trading Company, and also sold exclusively by Office Depot. But in April 2012, Swinton recalled 307,000 Biella chairs, after 11 reports of the breaking chairs, and injuries. In October 2012, Wyatt alerted the CPSC to these stunning coincidences.

In November 2012, The Safety Record Blog threw a little gasoline on the fire by publicizing Wyatt’s effort to get the Commission’s attention; in December the CPSC launched an investigation; 18 months later Office Depot announced a recall. And, if you’ve gotten this far in the story, you know what happened next.  (You can read our fine coverage at: Office Depot Declines to Launch Recall for a Chair that Launches Occupants Backwards; CPSC Investigates Chair Office Depot Tried to Forget; and Office Chair From Hell Finally Recalled)

“I’m not surprised at how much time it took, but I’m surprised that they are being fined,” Clackum said. “We have heard about some companies investigated, found guilty and fined, but more often than not it’s swept under the rug and there are no consequences. I feel like the consumer has just won a major victory and it’s not just about a chair. It’s about the fact that consumers have rights and it sends a warning to other companies you can’t get away with this.”

The Commission approved the settlement on Friday on a 3-2 vote on party lines.  In a statement explaining his “no” vote, Republican-appointed Commissioner Joseph P. Mohorovic conceded that Office Depot was “woefully late” in reporting and deserved a penalty. But he protested the amount of the fine and how it was determined. The Office Depot case, in his view, didn’t fit the penalty factors criteria established by a 2010 rule — the victims weren’t among the vulnerable populations of elderly or children, there weren’t enough injuries relative to the number of units sold, and the injuries weren’t serious enough:

 

“Last October, we secured a record $4.3 million settlement from a company for failing to report minibikes that were catching on fire, causing severe burns to at least one child,” he stated. “That we would settle on a penalty anywhere near that for failing to report desk chairs that rarely broke, more rarely risked injury, and very rarely risked serious injury indicates that there is little coherence in our approach to penalties, much less any that an outsider could divine from our settlements. We owe it to everyone involved – companies, consumers, and our own staff – to do better.”

Kaye, however, made it clear that a $3.4 million penalty is more a floor than ceiling.

“While this well-deserved civil penalty is not even close to the level Congress authorized and expected when enacting the Consumer Product Safety Improvement Act, I have put violators on notice that we will seek much higher penalties, as appropriate,” he said. 

By the by, the commission is still getting complaints about the Quantum chair – about 18 post-recall, and consumers are reporting pretty clearly that the real problem isn’t loose bolts, it’s bolts made of soft metal that suffer fatigue and shear clean off. Here’s the most recent, lodged in April of this year:

A chair broke causing injury to myself and I Googled for it and found out it had been recalled which was news to me. Reading the recall notice, it says that "bolts attaching the seatback on the recalled chairs can loosen and detach, posing a fall and injury hazard to consumers". This misstates the problem entirely. The real problem is not that bolts loosen and detach, the problem is that the bolts fail under tension load. That means that tightening them may make the problem MORE likely to occur and one may think that tight bolts would mean that they are safe. The bolts supplied in the seat back attachment are made from pot metal and not hardened steel. The failure mode occurred with bolts fully tight. The recall notice must state that the problem is that the bolts are not strong enough for the task and NOT say that the bolts may come loose. A thinking person may be mislead to believe that he is safe if the bolts are tight and this is not the case. Please have them change this language and keep them from misstating the facts. I have a neck injury as the result of two snapped bolts causing a fall against a filing cabinet.

Maybe, as Office Depot is getting together its compliance plan, it can re-notify the unsuspecting owners of its Quantum chairs that they are eligible for a refund – and properly describe the defect while they are at it.

Office Chair from Hell Finally Recalled

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After years of subjecting an unsuspecting public to an office chair with “welds” that break, flipping the occupant backwards, Office Depot, the exclusive seller of the sudden ejection machine, is recalling 1.4 million units sold between 2003 and 2012. According to a release issued by the U.S. Consumer Product Safety Commission, the office supply company had received 153 reports of the seat plate weld cracking or breaking, including 25 contusions, abrasions, injuries to the head, neck and a fractured back and hip.

That hip fracture was sustained by Nancy Losey of San Antonio, Texas, who in March 2010, was sitting in a Gibson chair when it suddenly collapsed. The chair was manufactured by the Wonderful Year Furniture Company, imported by Swinton Avenue Trading Company, based in Boca Raton, Fla, and sold by Office Depot.  The seat plate underneath her chair had separated from the chair base, because of a weld failure at that juncture. Ms. Losey fell to the floor and broke her hip, requiring a hip replacement surgery.

 In October 2012, San Antonio attorney Paula Wyatt, who represented Losey in a product liability case against Swinton Avenue Trading, set this resolution into slow motion, by writing to the U.S. Consumer Product Safety Commission alerting them to Losey’s injuries, and the amazing similarities between the Gibson and the Biella Office Chair, which bore the same product registration number and same bad weld in same critical place, but had already been recalled in April 2012. At the time, the Biella only had 11 complaints, compared to 18 between 2009 and 2010, for the Gibson. But, there were fewer Biella’s out there – 307,000 units. Under that recall, the remedy was a $55 store card – the price of the chair.

 The CPSC opened an investigation, but there was no immediate action. And today there was no immediate response to our question: Why in the heck did this take so long? CPSC spokesman Scott Wolfson did say:

“CPSC produced a humorous video a few years ago to promote the use of SaferProducts.gov and it involved a man falling off of an office chair.  The video was based on actual incidents and today’s recall of a related hazard with office chairs is another example of the importance of reporting safety incidents via SaferProducts.gov.”

The Safety Record Blog gave Wyatt an assist by writing about this evil piece of furniture (see Office Depot Declines to Launch Recall for a Chair that Launches Occupants Backwards and CPSC Investigates the Chair Office Depot Tried to Forget), and highlighting the frustrations of one Jesse Clackum, who blogged about her fruitless attempts to make the Swinton Avenue Trading Company take responsibility for the collapsing chair. In late 2006, Clackum, based in Florida, was one of the Gibson Leather Office Chair’s hapless victims. Her version of a Swinton Avenue Trading Company office chair, retailing at $119.00, was only 14-months old when it collapsed after the weld at the base of the chair failed. Clackum immediately contacted Office Depot looking for restitution, but the office supply retail giant blew her off, and told her that she should have bought the extended warranty.  Clackum tracked down the manufacturer – the Swinton Avenue Trading Company, an entity which turned out to be unreachable – no phone number, just a PO address. Continue reading

As the 6(b) Turns

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The U.S. Consumer Product Safety Commission has voted to publish a Notice of Proposed Rulemaking removing the “unnecessary and unjustifiable,” in the words of Acting Commission Chairman Robert Adler, re-notification procedure which forces the commission to seek the manufacturer’s blessing every time it releases the same information about a product to a different source.

The rule is designed to rid the commission of situations in which, for example, two reporters working on the same story query the commission about a product a week apart. The commission staff dutifully sets off on the ten-day path, through the manufacturer, before it can deliver an answer to the first reporter. A week later, the commission is required to take all of the same steps – even though the manufacturer has already vetted it for inaccuracies – to give the second reporter the same information.

“This is not in keeping with the acting chairman’s aim for the CPSC to be more transparent while following the law,” says commission spokesman Scott Wolfson. “The onus is still on the agency to ensure fairness and accuracy, that principle does not go away. But this rule change would ensure more efficiency and we’ll be able to serve the public faster.”

In the Information Age, consumer product manufacturers have been unusually successful at keeping the public information regulations surrounding product defect positively medieval. While consumers have myriad Internet resources to find out if a particular product is any good, when it comes to finding out if it is safe, consumers are still at a disadvantage. Section 6(b) of the Consumer Product Safety Act – beloved by industry, reviled by consumer advocates — gives manufacturers a lot of control over what negative information the CPSC can disclose about them. The CPSC cannot release information that might be considered trade secrets or “misleading” and “inaccurate” information.  The CPSC can disclose the existence of an investigation, under procedures designed to ensure the accuracy of whatever information is made public. The CPSC gives manufacturers 10 days to review any statements about their products and typically the two entities release agreed-upon language. Continue reading

A Compliance Investigation on Home Elevators: Going Down

It took six weeks of near-daily asking, but the U.S. Consumer Product Safety Commission has finally allowed a statement on its actions regarding home elevator entrapment hazards to trickle out of the bedrock that is 6B (the section of the Consumer Product Safety Act that allows manufacturers to control the flow of information from the CPSC.):

“The agency has an active and ongoing compliance investigation regarding the safety of residential elevators and the entrapment hazard they can present,” the CPSC said.

This “active and ongoing” compliance investigation emanates from a March presentation that Atlanta attorneys Andy Cash and Dave Krugler made to the CPSC staff on behalf of the Helvey family, whose six-year-old son suffered a severe head injury after becoming entrapped in a home elevator on Christmas Eve, 2010. The Helvey’s elevator was a National Wheel-o-Vator, now owned by Thyssenkrupp. The CPSC has jurisdiction over elevators used in residential settings as a consumer product. They are not subject to any mandatory federal standards, only industry-written voluntary standards, which may or may not have been adopted by states as a legal requirement.

And as part of its official statement, the CPSC also said this:

“While CPSC investigates the role and responsibilities of manufacturers and installers when it comes to the safety of residential elevators, owners of residential elevators should take steps to ensure children do not have unsupervised access to in-home elevators.” 

Michael and Brandi Helvey strongly refuted any suggestions that parents are to blame – the classic manufacturers’ response when their mis-designed or mis-manufactured products start causing harm in the marketplace. They had been scrupulous in installing gates on all the stairs, styrofoam covers on the sharp stone corners of the fireplace, childproof kitchen cabinet locks and a front door deadbolt to ensure Jacob couldn’t get out. Continue reading

New CO Study Shows that Home Generators Can Emit Dangerously High CO Levels

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A new study simulating carbon monoxide levels in detached and manufactured homes commissioned by the U.S. Consumer Product Safety Commission shows that that operating a generator for 18 hours is likely to result in high CO exposures whether the generator is in the house or the garage; and that generators that have been modified to limit CO emissions using a shut-off mechanism or other technology can significantly reduce exposure compared to generators without emissions controls.

Last September, our blog Home Use Generators: Dangerous and Behind the Curve documented the rising incidence rate of CO poisonings linked to the use of home generators as extreme weather events and an aging power grid result in more and more prolonged outages. The agency’s response has been to closely track the data and promulgate a stronger warnings rule. Heightened hazard language has done little to dissuade homeowners from putting portable generators in locations that can create significant health risks for home occupants.

The simulation study authors noted that CPSC has recorded 755 deaths from CO poisoning associated with home generators, from 1999 through 2011, with nearly three-quarters of those occurring between 2005 and 2011, and many of which occurred during power outages. Continue reading

The Elevator Design Hazard That’s Been Killing Children for Decades

On Christmas Eve 2010, three-year-old Jacob Helvey tried to take the small National Wheel-O-Vator elevator in his Atlanta home to follow his mother Brandi, who had gone to the second floor to momentarily move some laundry. The Helveys are protective parents who didn’t allow their son to play in the elevator, so Jacob had never taken it by himself before. He accidentally entrapped himself between the hoistway door, which in home elevators, is a swing-type door that resembles any closet or room door, and the accordion-style door that encloses the elevator itself. Once that outer door closes, it automatically locks – a safety feature to ensure the hoistway door cannot be not opened while the elevator is in operation. It’s an old design that was common in small commercial buildings when elevators had attendants, and is still used today in home elevators.

[flashvideo file=video/BrickmanAnimation.flv image=”video/BrickmanAnimationPrevew.jpg” /]

Animation by Dennis Brickman, Engineering Systems, Inc.

Helvey, at 3-feet-2-inches and 31 pounds, was situated with his back against the accordion door, and his head turned sideways in its valley. Brandi could hear a commotion downstairs and summoned the elevator to check it out. As the elevator rose, and re-leveled, Jacob’s body fell through the space between the sill and the elevator car. When it stopped, the elevator was on Jacob’s back, with his head above the sill, compressed for 10 minutes while his mother, Brandi, pried the door open and a neighbor and police used a shovel and 2 by 6 to ease the elevator off his body  He suffered brain damage. Jacob, now five and a half years old, is slowly progressing, say his parents Brandi and Michael. Continue reading

The Ill of the Grill

If you experience searing pain after searing a steak on the grill, a small wire grill brush bristle may be to blame. Tristin Beck of Mount Lake Terrace, Washington and Brittany Berg of Coeur d’Alene, Idaho, were among the most recent cases to hit the news. Both teens wound up in a hospital operating room after accidentally ingesting a filament of grill brush wire embedded in the food they had been eating.

This phenomenon gained prominence last year, after U.S. Senator Charles E. Schumer and Consumer Reports joined together to call on the U.S. Consumer Product Safety Commission to determine whether grill brushes were safe and to warn consumers of the potential hazard, based on incidents that occurred in New Jersey and Washington State. The Centers for Disease Control followed up with an item in its Weekly Morbidity and Mortality Report (WMMR) authored by a team of Rhode Island emergency room doctors and radiologists documenting the not-so-rare occurrence of grill brush wire ingestion. Continue reading