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 [email protected].

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
protection in the United States. It may be reproduced and distributed in
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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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