    Humane Methods of Slaughter Act: USDA Has Addressed Some Problems
    but Still Faces Enforcement Challenges (30-JAN-04, GAO-04-247).

    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.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-04-247
        ACCNO:   A09168
      TITLE:     Humane Methods of Slaughter Act: USDA Has Addressed Some
    Problems but Still Faces Enforcement Challenges
         DATE:   01/30/2004
      SUBJECT:   Animals
    	     Food and drug law
    	     Livestock products
    	     Inspection
    	     Noncompliance
    	     Law enforcement

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    GAO-04-247

    United States General Accounting Office

    GAO

                           Report to Congressional Requesters

    January 2004

                                     HUMANE METHODS
                                    OF SLAUGHTER ACT

        USDA Has Addressed Some Problems but Still Faces Enforcement Challenges

    GAO-04-247

    Highlights of GAO-04-247, a report to Congressional Requesters

    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.

    GAO recommends that FSIS (1) record specific information on the type and
    causes of violations; (2) establish additional clear, specific, and
    consistent criteria for districts to use when considering enforcement
    because of repetitive violations; (3) require that districts and
    inspectors clearly document the basis for enforcement that are due to
    repetitive violations; (4) develop a mechanism for determining the level
    of effort inspectors devote to the HMSA; (5) develop criteria for
    determining the appropriate level of inspection resources needed; and (6)
    assess whether that level is sufficient to effectively enforce the act.
    FSIS generally agreed with our findings and recommendations.

    www.gao.gov/cgi-bin/getrpt?GAO-04-247.

    To view the full product, including the scope and methodology, click on
    the link above. For more information, contact Lawrence J. Dyckman at (202)
    512-3841 or dyckmanl@gao.gov.

    January 2004

    HUMANE METHODS OF SLAUGHTER ACT

    USDA Has Addressed Some Problems but Still Faces Enforcement Challenges

    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.

    Livestock Being Moved inside Slaughter Facility

    Contents

      Letter

    Results in Brief
    Background
    The Most Prevalent Violation Was Ineffective Stunning, but the

    Overall Frequency and Scope of Humane Slaughter Violations Is Difficult to
    Determine FSIS Took Inconsistent Enforcement Actions to Address
    Noncompliance FSIS Data on Inspection Resources Devoted to Overseeing

    Humane Handling and Slaughter Requirements Are Inadequate Conclusions
    Recommendations for Executive Action Agency Comments and Our Responses

                                           1

                                          4 6

    17

    23

    26 29 29 30

      Appendix I Scope and Methodology

          Appendix II         Comments from the Food Safety and Inspection
                                              Service                          34
                                           GAO Comments                        38
         Appendix III         GAO Contacts and Staff Acknowledgments           40
                                           GAO Contacts                        40
                                          Acknowledgments                      40

      Table

    Table 1: Number of States and Slaughter Plants Covered by Each FSIS
    District, as of October 2002

      Figures

    Figure 1: Stunning of Animals 8 Figure 2: Location of Plants Covered by
    the HMSA, as of October 2002 9

    Figure 3: Location of Plants Covered by the HMSA That Accounted for 80
    Percent of U.S. Meat Production during Fiscal Year 2002 10

    Figure 4: Location of Inspectors Observing Compliance with the

    HMSA at a Typical Mid-Size Plant 13 Figure 5: Violations Documented in
    Noncompliance Records

    between January 2001 and March 2003 21

    Abbreviations

    DVMS District Veterinary Medical Specialist FSIS Food Safety and
    Inspection Service HMSA Humane Methods of Slaughter Act USDA U.S.
    Department of Agriculture

    This is a work of the U.S. government and is not subject to copyright
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    its entirety without further permission from GAO. However, because this
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    separately.

    United States General Accounting Office Washington, DC 20548

    January 30, 2004

    The Honorable Robert F. Bennett
    Chairman
    The Honorable Herb Kohl
    Ranking Minority Member
    Subcommittee on Agriculture, Rural Development,

    and Related Agencies
    Committee on Appropriations
    United States Senate

    The Honorable Henry Bonilla
    Chairman
    The Honorable Marcy Kaptur
    Ranking Minority Member
    Subcommittee on Agriculture, Rural Development,

    Food and Drug Administration, and Related Agencies
    Committee on Appropriations
    House of Representatives

    More than 125 million cattle, sheep, hogs, and other animals ultimately
    destined to provide meat for human consumption were slaughtered in
    fiscal year 2002, at some 900 federally inspected facilities throughout
    the
    United States. In response to public concerns about cruelty to livestock
    in
    meatpacking plants, the Congress passed the Humane Slaughter Act of
    1958. The act established as the policy of the United States that the
    slaughtering and handling of livestock be carried out only by humane
    methods. The act's provisions applied only to plants desiring to sell meat
    to the federal government.1 Twenty years later, the Congress passed the
    Humane Methods of Slaughter Act (HMSA) of 1978 to ensure that at all
    federally inspected slaughter establishments, not just those selling meat
    to
    the federal government, adopt humane handling and slaughter practices.2
    In particular, the act specifies that animals must be quickly rendered
    insensible to pain before they are slaughtered.

    1Pub. L. No. 85-765, 72 Stat. 862 (1958).

    2Pub. L. No. 95-445, 92 Stat. 1069 (1978). Among other things, the act
    amended sections 3 and 10 of the Federal Meat Inspection Act, 21 U.S.C.
    sections 603 and 610.

    The Food Safety and Inspection Service (FSIS), within the U. S. Department
    of Agriculture (USDA), is responsible for enforcing the Humane Methods of
    Slaughter Act. FSIS inspection personnel are stationed at each federally
    inspected slaughter facility to examine every carcass to ensure that it is
    safe for human consumption. Although their responsibilities are primarily
    for food safety, these inspectors are also responsible for monitoring
    compliance with the act and the applicable regulations at slaughter
    facilities throughout the country. FSIS guidance states that when
    inspectors observe noncompliance with the act's provisions, they should
    document the incident in a noncompliance record.3 Inspectors are also
    authorized to take enforcement action by temporarily shutting down parts
    of the plant's operations until management provides satisfactory
    assurances that the situation will be promptly remedied. In more serious
    cases, the agency may temporarily suspend plant operations by removing
    FSIS inspectors from a part of the facility or from the entire facility
    until the problem is corrected. Finally, the FSIS administrator can file a
    complaint to withdraw the grants of inspection from a facility, which
    prevents its products from entering interstate or foreign commerce. By
    law, slaughter facilities cannot slaughter and process animals for sale in
    commerce without federal inspectors present.4

    In recent years, the Congress has taken various actions to strengthen
    USDA's resources and to better ensure that the agency enforces the humane
    handling and slaughter provisions of the act. In fiscal year 2001, the
    Congress earmarked funds for the agency to enhance humane slaughter
    practices.5 In response, FSIS created the position of District Veterinary
    Medical Specialist (DVMS) in each of its districts. The DVMSs are the
    primary contacts for all humane handling and slaughter issues in each FSIS
    district office, and they are 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. In fiscal year 2002, the Congress further directed
    that the Secretary of Agriculture should fully enforce the Humane Methods
    of

    3Throughout this report, we use the terms "noncompliance" and "violation"
    interchangeably. This is consistent with FSIS regulations and directives.

    47 U.S.C. sections 603, 604.

    5Pub. L. No. 107-20, 115 Stat. 155, 164 (2001).

    Slaughter Act and report annually to the Congress on the number of
    violations and trends recorded by FSIS inspectors.6 Fiscal year 2003
    appropriations legislation included $5 million for additional inspection
    activities.7 Also, in a recent congressional conference report for fiscal
    year 2003 appropriations, the conferees directed us to review and report
    to the appropriations committees on the scope and frequency of humane
    slaughter violations and to provide recommendations on the extent to which
    additional resources for inspection personnel, training, and other agency
    functions are needed to properly regulate slaughter facilities.8

    In response to this congressional directive, and through subsequent
    discussions with your staff, we (1) analyzed the frequency and scope of
    humane handling and slaughter noncompliance incidents documented by FSIS
    inspectors, (2) analyzed FSIS actions to enforce compliance with humane
    handling and slaughter provisions, and (3) assessed the extent to which
    additional resources may be needed to ensure that humane handling and
    slaughter provisions are enforced. To perform our work, we obtained and
    analyzed all available FSIS records of noncompliance with humane handling
    and slaughter requirements between January 2001 and March 2003. We
    reviewed enforcement actions that the FSIS inspectors took between January
    2001 and March 2003 and that FSIS district managers took between October
    2001 and July 2003. To obtain information on resources dedicated to humane
    handling and slaughter oversight, we interviewed FSIS program officials
    and reviewed available workforce data. We also reviewed all of the
    completed DVMS summary reports that outline the officials' overall
    observations after each plant visit. To obtain their views on the adequacy
    of personnel and training resources, we conducted structured interviews
    with district managers, deputy district managers, and DVMSs in all 15 FSIS
    districts. Finally, we obtained the views of humane slaughter experts,
    industry association representatives, and animal welfare groups. We
    conducted our work between April 2003 and November 2003 in accordance with
    generally accepted government auditing standards. Appendix I describes our
    methodology in more detail.

    6Farm Security and Rural Investment Act of 2002, Pub. L. 107-171, Section
    10305 116 Stat. 134.

    7Pub. L. No. 108-7, 117 Stat. 11, 22 (2003).

    8H. Conf. Rep. No. 108-10 (2003).

      Results in Brief

    Incomplete and inconsistent FSIS inspection records made it difficult to
    determine the frequency and scope of humane handling and slaughter
    violations. Available FSIS records show that during the 28 months between
    January 2001 and March 2003, inspectors wrote 553 noncompliance records to
    document violations of the HMSA and the implementing regulations at 272
    facilities across the United States. According to these inspection
    records, ineffective stunning, which does not quickly render animals
    insensible to pain as required by the act, was the most prevalent type of
    noncompliance. To a lesser extent, the records documented poor facility
    conditions that could lead to animal injury and failure to provide water
    to animals awaiting slaughter as other prevalent violations. However, in
    conducting this analysis, we found internal control problems that call
    into question the reliability of FSIS's records regarding compliance with
    the act. First, because the agency had not stored its noncompliance
    records in electronic form, it could not provide us with at least 44
    additional records from the period between January 2001 and March 2003. In
    addition, almost half of the DVMSs with whom we spoke reported that
    inspectors did not always document noncompliance when they should have
    because they were unsure about regulatory requirements; for example, they
    were not sure if a violation was too minor to be documented. Second, the
    noncompliance records did not consistently document the scope and severity
    of violations. Inspectors are required to document HMSA noncompliance
    through narrative that includes the applicable statutory or regulatory
    provision, a concise description of the violation, and any other relevant
    evidence; but the records show that inspectors did not describe violations
    in a consistent manner. For example, while some noncompliance records
    provided detailed information on the causes of observed ineffective
    stunning and the number of animals impacted, other records only mentioned
    that ineffective stunning occurred but provided no additional details.
    Incomplete and inconsistent data can make it difficult for FSIS to
    accurately assess compliance with the act and to report the results to the
    Congress. Despite these data limitations, in its March 2003 report to the
    Congress, USDA indicated that during fiscal year 2002 "very few
    infractions were for actual inhumane treatment of the animals." Officials
    informed us that their analysis was based on a sample of approximately
    half of the noncompliance records available. In contrast, our analysis of
    all of the noncompliance records FSIS provided for fiscal year 2002 shows
    that one fourth of the 366 noncompliance incidents documented by
    inspectors, were for incidents of ineffective stunning-a violation that
    USDA characterized in its report to the Congress as "actual inhumane
    treatment." FSIS has made recent efforts to improve documentation,

    including better tracking of documentation and new guidance to inspectors.

    FSIS took inconsistent enforcement actions to address noncompliance with
    the HMSA. For example, we found that plant 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. Half of the DVMSs we interviewed attributed
    the inconsistent enforcement actions to inspectors' inexperience, lack of
    clarity regarding their authority, or the misperception that certain
    violations are minor. We found similar inconsistencies at the district
    management level. District managers can decide to take the more serious
    enforcement action of withdrawing inspectors from the plant, thus
    suspending a plant's operations, when they are notified of serious
    violations. However, they lack clear criteria on when to do so, and this
    can lead to inconsistencies in enforcement. We found, for example, one
    case in which a district manager did not suspend plant operations after
    inspectors had issued 16 noncompliance records to a slaughter facility
    documenting the plant's failure to properly stun animals. In contrast,
    another facility's failure to provide access to water and to maintain
    acceptable pen conditions led to a suspension of operations. As a result,
    FSIS cannot ensure that humane slaughter requirements are consistently
    enforced across districts, undermining FSIS efforts to effectively enforce
    the act. In November 2003, FSIS issued guidance that should help
    inspectors determine when it is appropriate for them to take enforcement
    actions. However, the guidance is less explicit about when district
    actions are warranted. For example, the guidance does not identify
    thresholds at which repetitive instances of noncompliance at the same
    facility would require action by district officials.

    FSIS does not have data on the number of inspectors devoted to compliance
    with the HMSA or on the amount of time that inspectors spend on humane
    handling and slaughter requirements. Without such information, FSIS cannot
    determine the appropriate number of inspectors for different sized plants
    or the number of inspectors needed overall to effectively enforce the act.
    FSIS headquarters and district officials believe that, for the most part,
    the current number of inspectors is sufficient to monitor and enforce
    humane handling and slaughter requirements. In particular, district
    officials believe that the present number of DVMSs is adequate to cover
    each district's HMSA responsibilities. However, the officials said that
    despite improvements made by the hands-on training provided by DVMSs, they
    remain concerned about inspectors' overall level of knowledge regarding
    HMSA requirements. When we discussed this

    matter with FSIS headquarters officials, they said that, in addition to
    the new November 2003 directive that provides clearer guidance, the agency
    is currently taking steps to improve inspectors' knowledge. For example,
    the agency is developing scenarios for inspectors that will illustrate how
    to implement the HMSA requirements.

    To help ensure adequate enforcement of the HMSA, we are recommending that
    the Secretary of Agriculture direct FSIS to (1) include in noncompliance
    records specific information on the type and cause of violations, (2)
    establish additional criteria for when districts are to take enforcement
    actions in cases of repetitive violations, (3) require that district
    offices and inspectors clearly document the basis for enforcement actions
    that they take in response to repetitive violations, (4) develop a
    mechanism for determining the level of resources that the agency devotes
    to humane handling and slaughter activities, (5) develop criteria for
    determining the appropriate level of inspection resources, and (6)
    periodically assess whether that level is sufficient to effectively
    enforce the act.

    FSIS commented on a draft of this report and generally agreed with our
    findings and recommendations. FSIS also provided a number of specific
    comments, which we incorporated in the report as appropriate.

    Background 	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.9 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

                       9Pub. L. No. 85-765, 72 Stat. 862 (1958).

    rapid and effective, before being shackled, hoisted, thrown, cast, or
    cut."10 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."11

    FSIS has issued regulations and directives to enforce the act. Important
    requirements of these regulations and guidance include the following:

    o  	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;

    o  	Dragging of disabled and other animals unable to move, while
    conscious, is prohibited;

    o  	All holding pens and driveways and ramps must be designed, built, and
    maintained to prevent injury to livestock;

    o  	Livestock should be provided with water in holding pens, and food if
    held for more than 24 hours;

    o  	The use of electrical prods and other devices to move livestock must
    not be excessive and should be used as little as possible.

    107 U.S.C. Section 1902 (a). The act applies to those establishments
    processing cattle, calves, horses, mules, sheep, goats, pigs, and other
    equines. It does not apply to poultry, bison, reindeer, and catalo.

    117 U.S.C. Section 1902 (b).

    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.

                             Figure 1: Stunning of Animals

    As of October 2002, 918 plants were covered by the HMSA in the United
    States. Figure 2 shows the distribution of these plants.

    Figure 2: Location of Plants Covered by the HMSA, as of October 2002

    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.

    Figure 3: Location of Plants Covered by the HMSA That Accounted for 80
    Percent of U.S. Meat Production during Fiscal Year 2002

    FSIS is responsible for ensuring compliance with the Humane Methods of
    Slaughter Act.12 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.13

    12The FSIS is also responsible for ensuring the safety of most meat,
    poultry, and processed egg products.

    13FSIS classifies plants according to their size: large plants-those with
    500 or more employees, small plants-those with 10 to 499 employees, and
    very small plants-those with fewer than 10 employees, or annual sales of
    less than $2.5 million.

    Table 1: Number of States and Slaughter Plants Covered by Each FSIS District, as
                       of October 2002 Plants covered by the HMSA

                                               Very     Small    Large      Total
    FSIS District     States Covered        small    plants   plants   plantsa
                                              plants
          Alameda              CA                    4       25        3
          Albany      CT,ME,MA,NH,NY,RI,VT          71        4        0
          Atlanta        FL, GA, PR, VI             50       12        0
        Beltsville    DE, D.C., MD, VA, WV          26       13        2
          Boulder    AZ, CO, NM, NV, UT, AK,
                                         AS,
                       GU, HI, ID, OR, WA           79       15        8
          Chicago          IL, IN, OH               25       28        6
          Dallas               TX                   17       27        4
        Des Moines           IA, NE                 23       18       18
          Jackson          AL, MS, TN               25       11        2
         Lawrence            KS, MO                 52        8        9
          Madison            MI, WI                 33       10        4
        Minneapolis    MN, MT, ND, SD, WY           26       32        7
    Philadelphia          PA, NJ                112       23        3
          Raleigh          NC, SC, KY               36       14        4
        Springdale         AR, LA, OK               20        7        1
           Total                                   599      247       71

    Source: GAO presentation of FSIS data.

    aFSIS did not provide size information for one plant, so the total number
    of plants under the three size categories does not equal 918.

    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.14 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.15 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

    14FSIS did not provide us with the specific number of inspectors that are
    assigned to meat slaughter facilities.

    15Throughout this report, we refer to veterinarians and Consumer Safety
    Inspectors as "inspectors."

    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.16

    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.

    167 U.S.C. sections 603, 604.

    Figure 4: Location of Inspectors Observing Compliance with the HMSA at a
    Typical Mid-Size Plant

    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:17

    o  A unique record number,

    o  The date of the violation,

    o  The plant identification number,

    o  Humane handling regulations applicable to the incident reported,

    o  A written description of the violation,

    o  The name of plant personnel notified of the violation, and

    o  	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:

    o  	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.

    o  For more serious violations, the district manager can suspend
    inspection

    until the violation or violations are addressed.18 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.

    17FSIS Directive 5001.1, Revision 1: Verifying an Establishment's Food
    Safety System, May 21, 2003.

    18If there is an egregious situation of inhumane handling and slaughter,
    the inspector in charge may also immediately suspend inspection and
    immediately notify USDA's district office for prompt documentation of the
    suspension action.

    o  	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.19 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.20 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

    19Pub. L. No. 107-20 (2001).

    20FSIS determined the DVMSs who would only perform humane handling and
    slaughter related work after sending a survey to all DVMSs asking them if
    they would be interested in performing only HMSA work or if they would
    like to perform other duties. The other five DVMSs still have humane
    handling responsibilities, but can also assist with food safety and food
    security.

    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.21 When she repeated the survey in 2002, this
    time visiting 80 different plants, she found that 94 percent were able to
    do so.22 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.

    21Survey of Stunning and Handling in Federally Inspected Beef, Veal, Pork,
    and Sheep Slaughter Plants; Agricultural Research Service, USDA.
    3602-20-00, January 7, 1997.

    222002 Restaurant Audits of Stunning and Handling in Federally Inspected
    Beef and Pork Slaughter Plants;
    http://www.grandin.com/survey/2002.restaurant.audits.html.

      The Most Prevalent Violation Was Ineffective Stunning, but the Overall
      Frequency and Scope of Humane Slaughter Violations Is Difficult to Determine

    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.

        Inspection Records Were Incomplete and Inconsistent, Making It Difficult to
        Determine the Frequency and Scope of Noncompliance

    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.23 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.24 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.

    23FSIS issued its "Rules of Practice" in September 5, 2001, in FSIS Notice
    36-01 to ensure that all inspection program personnel are knowledgeable
    about the enforcement actions that the agency may take, the circumstances
    under which the various types of enforcement actions are appropriate and
    can be taken, and the procedures that the agency will follow in doing so.
    According to FSIS, the rules of practice provide a key link between
    inspection and enforcement activities. The guidance elaborates on the
    regulatory enforcement actions described at 9 C.F.R. pt. 500. In November
    2003, FSIS issued a new directive to its inspection personnel that
    provides clearer direction regarding enforcement.

    24This contrasts with the dozens of ways that inspectors can classify
    different types of food safety violations ranging from sanitation
    procedures to labeling accuracy.

    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,25 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.26

    25See Food Safety and Inspection Service, Humane Handling and Slaughter
    Enforcement Activities, Report to Congress, March 2003.

    26USDA only provided us with four examples of cases where they did not
    consider the reported violation to have caused direct injury to animals,
    therefore resulting in 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.

    Figure 5: Violations Documented in Noncompliance Records between January
    2001 and March 2003

    Note: Our analysis of the 553 noncompliance records identified 675
    violations. A noncompliance record can include more than one violation.

    aThe ineffective stunning and conscious animals columns in the figure are
    not mutually exclusive. Specifically, in 112 cases, ineffective stunning
    resulted in one or more conscious animals moving to slaughter. In 55
    cases, ineffective stunning was documented but not that a conscious animal
    was slaughtered. This could happen if, for example, multiple stunning
    efforts were required to render the animal unconscious. In 21 cases,
    inspectors noted that an animal was observed to be conscious at slaughter,
    without indicating ineffective stunning. This could happen if an animal
    regained consciousness after being effectively stunned.

        FSIS Is Taking Steps to Improve Inspector Awareness of Documentation
        Requirements and Introduced Changes in Its Documentation Process

    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 2003.27 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.

    27FSIS Directive 6900.2, "Humane Handling and Slaughter of Livestock,"
    November 25, 2003. This directive informs inspectors of the requirements,
    verification activities, and enforcement actions for ensuring that the
    handling and slaughter of livestock, including the slaughter of livestock
    by religious ritual methods, is humane. The directive also explains how
    inspectors should approach these activities. Specifically, the directive
    leads the reader through the existing regulatory requirements and explains
    in simple, easy to read and understand language how inspection program
    personnel should verify compliance with each of these regulations and what
    actions they should take if there is noncompliance.

      FSIS Took Inconsistent Enforcement Actions to Address Noncompliance

    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.

        Records Show Inspectors Took Inconsistent Enforcement Actions in Response to
        Noncompliance

    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.28 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.29 In one
    particular incident, the inspector who prepared the noncompliance record
    wrote that he observed six

    28From January 2001 through March 2003, inspectors issued reject tags to
    temporarily interrupt the use of equipment or facilities or to slow down
    or stop production lines 214 times. The most prevalent reasons for these
    reject tags were ineffective stunning and conscious animals observed being
    slaughtered.

    29While our analysis included 167 instances of ineffective stunning, we
    could not determine from the documentation provided how many animals were
    impacted in two of these cases. Therefore, this analysis is based on 165
    incidents.

    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.

    District Managers Have In addition to the enforcement actions available to
    inspectors stationed at Also Taken Inconsistent slaughter facilities,
    district managers may suspend the operations of an Enforcement Actions
    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.

      FSIS Data on Inspection Resources Devoted to Overseeing Humane Handling and
      Slaughter Requirements Are Inadequate

    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.30 According to FSIS district
    officials, the 17 DVMSs are sufficient to oversee humane handling and
    slaughter activities in each district.

    30This was the result of an FSIS realignment of its district offices. When
    USDA introduced the DVMS position, it assigned one DVMS to each of its 17
    districts. In May 2002, an organizational realignment consolidated FSIS's
    17 district offices into 15. In the realignment, the Pickerington, Ohio,
    office became a satellite office in the Chicago district, and the Salem,
    Oregon, office became a satellite office in the Boulder, Colorado,
    district. As a result, the Chicago and Boulder districts now have two
    DVMSs each.

    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.31
    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.32 FSIS officials
    believe that this will be a successful way of sharing knowledge throughout
    the agency on key policy issues.

    31FSIS senior officials said that the reason they are sending this survey
    primarily to veterinarians at this point is because Consumer Safety
    Inspectors are unionized, which makes implementation of a survey
    instrument to them a cumbersome and lengthy process.

    32The first HIKE was issued in the fall of 2003.

    Conclusions

    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.

    Recommendations for 	We are making six recommendations to the Secretary of
    Agriculture to further strengthen the agency's oversight of humane
    handling and

    Executive Action 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

    o  	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

    o  	establish additional clear, specific, and consistent criteria for
    district offices to use when considering whether to take enforcement
    actions because of repetitive violations;

    o  	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

    o  	develop a mechanism for identifying the level of effort that
    inspectors currently devote to monitoring humane handling and slaughter
    activities;

    o  	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

    o  	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,

                                    Agency Comments

                                   and Our Responses

    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.

    Lawrence J. Dyckman Director, Natural Resources and Environment

                           Appendix I: Scope and Methodology

    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:

    o  	Ineffective stunning (i.e., one or more animals had to be stunned more
    than once);

    o  	One or more conscious animals showed signs of consciousness past the
    stun box, i.e, when they were hoisted, cut, or bled;

    o  	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;

    o  Excessive use of electric prods or other devices;

    o  	Mishandling of ambulatory animals, such as hitting, kicking, or
    dragging a conscious animal;

    o  	Mishandling of disabled animals, such as keeping such animals among
    ambulatory animals, increasing the risk of further injury;

    o  Lack of access to water;

    o  Lack of access to food; and

    Appendix I: Scope and Methodology

    o  	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

    Appendix I: Scope and Methodology

    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.

    Appendix II: Comments from the Food Safety and Inspection Service

    Note: GAO comments supplementing those in the report text appear at the
    end of this appendix.

    See comment 1. (Page numbers in the draft report may differ from those in
    this report.)

    See comment 2.

    Appendix II: Comments from the Food Safety and Inspection Service

                                     See comment 3.

                                     See comment 4.

                                     See comment 5.

    Appendix II: Comments from the Food Safety and Inspection Service

                                     See comment 6.

                                     See comment 7.

                                     See comment 8.

    Appendix II: Comments from the Food Safety and Inspection Service

                                     See comment 9.

    Appendix II: Comments from the Food Safety and Inspection Service

    The following are GAO comments on the Food Safety and Inspection Service
    letter, dated January 14, 2004.

                                      GAO Comments

    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

    Appendix II: Comments from the Food Safety and Inspection Service

    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.

    Appendix III: GAO Contacts and Staff Acknowledgments

      GAO Contacts Acknowledgments

    (360327)

    Lawrence J. Dyckman (202) 512-3841 Maria Cristina Gobin (202) 512-8418

    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.

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