Botched APS investigation in CO leak at Finch means no answers for parents

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ATLANTA - A four-month Channel 2 Action News investigation has found that Atlanta Public School officials completely botched the investigation of a near-lethal gas leak inside a school.
 

More than 40 children and adults were sickened by a carbon monoxide leak at Finch Elementary School in southwest Atlanta in December 2012.
 
Investigative reporter Richard Belcher was the first reporter to see the state and school system reports on the mysterious gas leak.
 
The carbon monoxide in the school was measured at 30 times the accepted level – enough to kill a person within two hours -- but the school system’s response was so deeply flawed that one expert says APS will never know what caused it.

“The fireman (is) saying that was the highest carbon monoxide he had ever known,” one parent said at the time.
 
Despite the high levels, no one died or suffered lasting injuries.
 
“This is obviously a very serious matter. We have launched a full investigation,” APS superintendent Errol Davis said at the time.
 
More than a year later, Channel 2 asked parents if they got the full answer of what happened. They said no, they could have been told more.
 
The Finch parents did not get the full story, but no one has it.
 
Channel 2 has gotten the first look at the investigations of the incident by the state fire marshal and the school system. Neither report answers the basic question: What caused the leak?
 
The state fire marshal’s report said it could reach no conclusions about the boiler at Finch because the equipment was disassembled prior to the investigation.
 
Attorney and former Superior Court Judge Keegan Federal said APS ignored clear state regulations about boiler accidents.
 
“You can’t just dismantle it after there’s been an accident until the chief inspector comes by and determines the cause and tells you you can dispose of it,” Federal said. “It certainly indicates to me that they have not properly handled this incident.”
 
Dr. Ruston Hunt, an industrial engineer and dean of the extended university at Southern Polytechnic University, said it is fair to say that APS does not know what really caused the near-lethal incident.
 
Hunt read the APS and state fire marshal reports and said the incident remains a mystery.
 
“As far as I can tell. Certainly the two explanations that were given and referred to throughout these two reports, for me, don’t make any sense,” Hunt said.
 
Hunt said the length of the exhaust flue from the boiler cannot explain the intense concentration of gas in the school. And he does not buy APS’s conclusion that a closed valve deprived the boiler of water.
 
“Frankly, I don’t see any connection between those two,” Hunt said.
 
 
Within hours of the incident, APS had disassembled and then replaced the suspected boiler.
 
“Very prematurely. Eight o’clock that night they made decision to replace the boiler without ever determining that the boiler was the problem,” Hunt said.
 
In the end, parents students and teachers do not have an answer and will never get one because of the way APS handled the aftermath and the investigation.
 
Belcher requested an interview with APS several weeks ago, but the school system never responded.
 
Belcher also investigated the disciplinary actions against two workers who were who were initially accused of having a role in the gas leak.
 
Within three days of the incident, APS Superintendent Errol Davis blamed the incident on human error, but it turns out, that was premature.
 
Maintenance workers Maurice Williams and Ivan Mann received written reprimands later one day after Davis made the announcement. The reprimands charged that the men “never mentioned that you had worked at Finch elementary (on the day of the leak)” and “made visits to the boiler room where the carbon monoxide leak occurred.”
 
After APS finished its internal investigation more than four months later, however, it quietly withdrew the reprimands. 
 
Hunt said the APS report has a he-said, she-said quality to it, instead of figuring out the cause.
 
“Frankly, documenting a lot of hearsay and not much effort to really determine. In fact, they even say in the report, it was not our goal to figure out the cause of the accident,” Hunt said.
 
Hunt said the APS report seemed more concerned with administrative issues, such as, were the right forms filled out?
 
“Were people working at the level they were supposed to? Had they been trained? Did reporting occur when it was supposed to? And that sort of thing,” Hunt said.
 
Hunt said he does not believe administrative issues were the central problem, but that a mechanical problem allowed carbon monoxide into the school.
 
“There’s an advantage to blaming a person, because then, you’ve identified the problem. You can eliminate the problem. You don’t have to change your hardware or your procedures, your designs or any other things,” Hunt said.



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