On July 9, 1998, NIOSH was notified of this incident by the International Association of Fire Fighters (IAFF) who requested that an investigation be conducted. On August 18, 1998, a NIOSH Safety and Occupational Health Specialist, and an Engineer, traveled to Florida to conduct an investigation of the incident. Meetings were conducted with the State Fire Marshal’s investigator, the Captain of the department arson unit, the department training officer, the fire fighters who witnessed the incident, and the victim. Site visits were conducted at two of the department’s air supply shops, including the shop that filled the cylinder that flashed, and the department’s logistics building. Photographs of the incident scene were also obtained from the fire department. Records of the cylinder air samples taken on the day of the incident were reviewed and appeared to be accurate and sufficient. NIOSH investigators also met with a representative from the independent testing laboratory who was contracted by the fire department to evaluate the regulator involved in this incident.
The fire department serves a population of 165,000 in a geographical area of 85 square miles. The fire department is comprised of approximately 580 employees, of whom 525 are fire fighters who are cross-trained as Emergency Medical Technicians (EMTs). The fire department requires all new fire fighters to complete the State requirements for fire fighters, which consist of 395 hours of basic training. The basic training program covers 40 hours of first responder, Haz-Mat I and II, oxygen handling, and all aspects of Level I and Level II fire fighter training, as recommended by the National Fire Protection Association. Currently all new fire fighters are State certified as well as certified paramedics. The victim has 17 years of experience as a fire fighter.
INVESTIGATION
On June 12, 1998, at approximately 0730 hours, the victim arrived at his assigned station (Station 17) and prepared to start his 0800 hour shift. Arriving early, the victim decided to perform an equipment check on the Engine to which he was assigned as two additional fire fighters finished their shift by washing the Engine with a garden hose. As the victim sorted through the Engine’s equipment compartments, he opened the airway equipment compartment, removed the airway bag, and prepared to perform a routine pressure check. The airway bag consisted of an aluminum cylinder filled with 99.7% pure oxygen, an aluminum regulator attached to the cylinder, and airway supplies (Photo 1). To charge the cylinder and check its oxygen pressure, the victim set the cylinder upright, from a horizontal to vertical position. As he opened the cylinder post valve, the cylinder emitted a loud popping sound and then flashed, releasing two 4-foot flames, one toward the victim and the other toward the Engine (Photo 2). The victim turned, pushing the cylinder away, and fell to the ground with his clothes ignited from the waist up. One of the fire fighters, who was washing the other side of the Engine, stated that he heard a noise which sounded like one of the brake lines had burst. As he leaned under the Engine to check the lines, he saw the victim fall to the ground surrounded by flames. The other fire fighter washing the Engine stated that he watched the victim open the cylinder valve and heard the cylinder emit a loud pop and then flash, releasing two 4-foot flames, one toward the victim and the other toward the Engine. The fire fighter who witnessed the incident called for the other fire fighter washing the Engine to bring the hose he was using around to the victim. The fire fighter stretched the garden hose around the Engine, and spraying water on the victim, extinguished the flames approximately 10 seconds after the cylinder flashed. The fire fighter then turned the hose on the cylinder, which was emitting a loud whistling sound. The cylinder continued to burn for approximately 30 to 40 seconds before the fire was completely extinguished. The fire fighter turned the hose back on the victim, trying to cool him down as the on-duty medical personnel provided assistance. They removed his shirt and wrapped him in a burn blanket, and approximately 2 to 3 minutes later, he was placed in a rescue vehicle. A fire fighter/medic who had just arrived to start his shift saw the commotion, and proceeded to the rescue vehicle. The medic entered the rescue vehicle and took over medical responsibilities. The medic stated that en route to the local trauma center, they secured the victim’s airway, started intravenous fluids, and flushed his eyes. During transport, the medics reported that the victim had approximately 35 to 40 percent first-, second-, and third-degree burns. The victim was later air-lifted to an area burn center.
NIOSH investigators visited the oxygen cylinder refilling stations located at Stations 34 and 28. The cylinder involved in the incident was filled at Station 28, where the filling station is separate from all other activity, and the environment is air conditioned, organized, and clean. This filling station is kept locked when not in use. The filling station at Station 34, however, is housed in the station’s bay along with the trucks and equipment. The bay is not air conditioned. After the incident, for additional safety at Station 28, the fire department installed a steel cage with a steel rolling door to enclose the cylinders while they are being filled. NIOSH investigators also reviewed the logs in which the station recorded information about filling the cylinders with oxygen, and the logs appeared to be up-to-date and sufficient. The records indicated that on the 12th of June, a Captain from the fire department, along with a representative from an independent medical service, checked the oxygen quality at both
