Two Career Fire Fighters Die in Four-Alarm Fire at Two-Story Brick Structure - Missouri
SUMMARY
On May 3, 2002, a 38-year-old male career fire fighter (Victim #1) died after he became lost and ran out of air while searching for a missing 38-year-old male career fire fighter (Victim #2) at a four-alarm, two-story structure fire. Victim #2 was identified as missing when he failed to respond to a member accountability roll call (MARC). Victim #1 reentered the structure to search for Victim #2 as part of a search-and-rescue team. Shortly thereafter, Victim #1 became lost and radioed Mayday several times. After extensive searches for both victims, they were removed from the structure and provided medical attention on the scene. They were then transported by Emergency Medical Services (EMS) to a local hospital. Victim #1 was pronounced dead on arrival, and Victim #2 was pronounced dead the following day.
NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should
INTRODUCTION
On May 3, 2002, a 38-year-old male career fire fighter (Victim #1) died after he became lost and ran out of air while searching for a 38-year-old male career fire fighter (Victim #2) at a four-alarm, two-story structure fire. On May 6, 2002, the fire department involved in the incident, and on May 8, 2002, the U.S. Fire Administration (USFA), notified the National Institute for Occupational Safety and Health (NIOSH) of the fatalities. On June 24 and July 23, 2002, the NIOSH Chief of the Trauma Investigations Section and two Occupational Safety and Health Specialists performed an on-site investigation. Meetings and interviews were conducted with the Chief and officers of the department, fire fighters, and other rescue personnel involved in this incident. Only those fire fighters and officers directly involved in this incident up to and including the removal of the victims were interviewed. NIOSH investigators also reviewed copies of the department standard operating procedures (SOPs), diagrams of the incident, training records, witness statements, run sheets, time line, coroner’s report, and SCBA tests, and they inspected the victims’ turnout gear and related equipment.
As part of the National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program, the Respirator Branch, National Personal Protective Technology Laboratory (NPPTL) conducted an evaluation of two Survivair 4500 p.s.i. 30-minute, self-contained breathing apparatus (SCBA) at the request of the Chief of the Fire Department. These SCBA’s were last used during interior fire-fighting operations at the structure fire on May 3, 2002 by Victim #1 and Victim #2. A summary of the NPPTL report is attached as Appendix I.
Training and Experience
The career fire department involved in this incident has 36 responding apparatus, 30 stations, 682 uniformed fire fighters and serves a population of approximately 325,000 in an area of about 62 square miles. Victim #1 had been a fire fighter for 11 years, 5 months, and Victim #2 had been a fire fighter for 11 years, 10 months. Both had successfully completed all state-required fire academy training, which complies with NFPA Level I and II.
Equipment
First Alarm
Engine Company 1 (E-1) - Captain, 3 Fire Fighters (FFs)
Engine Company 29 (E-29) - Captain, 3 FFs
Engine Company 7 (EC-7) - Captain, 3 FFs
Engine Company 11 (EC-11) - Captain, 3 FFs
Hook and Ladder 6 (HL-6) - Captain, 3 FFs
Rescue-1* - Captain, 5 FFs, 2 riders
802 Battalion Chief (BC-1) - Incident Command (IC)
804 Battalion Chief (BC-2)
Acting 810 Battalion Chief
Second Alarm
Engine Company 14 (E-14) - Captain, 3 FFs
Hook and Ladder 2 (HL-2) - Captain, 3 FFs
Engine Company 2 (EC-2) - Captain, 3 FFs
Engine Company 32 (EC-32)- Captain, 3 FFs
900 Command Post
821 Fire Investigator
Acting 803 Captain
Third Alarm
Engine Company 9 - Captain, 3 FFs
Engine Company 4 - Captain, 3 FFs
Engine Company 17 - Captain, 3 FFs
Squad 2 - Captain, 5 FFs
Hook and Ladder 4 - Captain, 3 FFs
805 Battalion Chief
820 Chief Investigator
Fire Chief
Fourth Alarm
Engine Company 22 - Captain, 3 FFs
Engine Company 12 - Captain, 3 FFs
Engine Company 36 - Captain, 3 FFs
Truck 15 - Captain, 3 FFs
* Both victims were assigned to Rescue-1.
Structure
The two-story commercial brick structure was of ordinary construction, situated in a connected row with several other properties with variable roof heights. The roof of the involved structure was relatively flat and sealed with built-up roofing materials. There were two entrances on the A-side at the ground level (Photo 1). The west entrance led to the upper level via a stairway, and the east entrance accessed the lower level through the doorway. Both entrances were secured by a padlocked swinging wrought-iron gate/door. There were no man doors noted at the lower level from the B- or D-sides (Diagram 1); however, there was one man door on the west end of C-side and a gated garage door at the east end of the C-side (Photo 2).
There were five openings on the second level, D-side (one being partially bricked, with the remainder being closed with block glass), two windows on the first level, A-side, and three relatively tall windows on the second level, A-side (Photo 1). Other than the block glass window on the D-side (Photo 3), all windows were either made of plexi-glass or sealed substantially with wood. The structure was uninhabited at the time of the incident.
The total area of the building was 3,150 square feet. The first level consisted of two rooms for a total of 1,575 square feet. The front room of the structure was approximately 300 square feet. The second level consisted of four rooms, and was also 1,575 square feet. The stairway access broke off into two entrances at the second level, one leading to the north and one to the east. (Diagrams)
INVESTIGATION
On May 3, 2002, at about 2102 hours, Central Dispatch (Fire Alarm) received a telephone call of a potential fire at a commercial property. Fire Alarm dispatched the first alarm. Crews arrived at the scene at 2105 hours. On arrival at 2108, the Incident Commander observed fire fighters making entry to the upper and lower levels of the structure from the A-side, which had light gray smoke coming from the front. Initial size-up indicated that the fire was at the first level. The IC called for police traffic control and assigned E-7 to be backup water for E-1. E-1 had one 1¾-inch pre-connect pulled for entry into the lower-level entrance (east). E-29 was assigned to back up HL-6.
Fire fighters from Rescue 1, E-1, E-7, and E-29 forced entry to the west entrance upper-level access door (on the left at ground level) and progressed up the stairway to the second level to conduct a primary search, check for fire extension, and to ventilate the windows. At the same time, a fire fighter from E-1 pulled a "TNT" force-entry tool and forced entry to the east entrance lower-level access door (on the right at ground level). The crew from E-1 then advanced 1¾-inch hoseline through the east entryway to the first level, backed-up by the crew from E-11. A fire fighter from E-1 initially had the nozzle but handed it off to the Captain of E-1. A positive pressure ventilation (PPV) fan was set in the doorway of the first (west) entrance to provide ventilation. When the team hit the fire with the hose line at the first level, it appeared as though they had knocked the fire down immediately. During this fire attack, several fire fighters noted that there were holes in the ceiling of the first floor, and they noted embers and fire when ceiling tile was pulled.
After it had appeared that fire had been knocked down, the crews believed that the fire had extended to the second level. The crews from E-1 and E-11(without the Captain from E-11) pulled the handline out of the first floor entry and advanced to the upper-level entrance and up the stairs to the second floor.
At approximately 2114, the Captain from E-11 became separated when he progressed further into the building as the rest of the crew pulled out. He had reportedly opened an overhead roll-up type garage door that accessed the outside at the first level (C-side). As he turned around, he saw the fire flare up and roll across the ceiling toward him. A van was parked by the garage door, but did not obstruct his movement. The smoke, fire, and heat significantly intensified at this time, and the Captain from E-11 could not retreat back through the building. When he attempted to leave the structure through the garage door opening, he realized that a lock on a metal security gate outside of the garage door prevented his escape (Photo 2). Using channel 2, the Captain from E-11 called for the IC twice with no response and BC#2 once with no response. He then called Fire Alarm and stated that he was forced to the floor by fire and heat and needed extrication out the back of the structure by the garage door. The Captain from Rescue-1 was in the immediate area behind the structure. After repeated failed attempts to cut the lock on the gate, the Captain from Rescue-1 enlisted the aid of two citizens who helped him pull the gate up and partially off its hinges. At the same time, two 1¾-inch hoselines were pulled off of E-1 and working at the A-side. Simultaneously, on the upper level, fire fighters from Rescue-1, E-1, E-7, E-11, and E-29 were checking for fire extension and began ventilating the windows. According to radio transmissions, Fire Alarm called the IC at 2116 and informed him that he had a fire fighter trapped (Captain of E-11) in the rear of the building in the garage area by the overhead garage door. After extrication of the Captain at approximately 2118, the IC called for all fire fighters from the first level to be accounted for, and at that time it was believed that all members were accounted for. The IC instructed the Captain from E-29 to advance a 2½-inch hoseline from E-1 A-side to the rear of the structure (C-side). A 2½-inch hoseline was also pulled off E-11 and pulled to the C-side.
A fire fighter from E-29 who was ventilating windows on the second level saw and heard Victim #2 behind him, and he stated that Victim #2 appeared to be lost. Visibility was very poor at this time, and it was getting very hot. Simultaneously, at 2118, the IC conducted a member accountability roll call (MARC), where all fire fighters are to exit the building and report to their companies for accountability. The fire fighter told Victim #2 that he knew the way out, and they began crawling toward where he thought the stairway was. He then lost Victim #2 and started to feel as though he was becoming lost himself. He backtracked the way he had come and found Victim #2 lying facedown and unresponsive on the floor. He attempted to pull the victim toward where he thought the stairs were, but he was unsuccessful. He immediately radioed for help. According to transcript tapes, he called for help and Mayday several times. [NOTE: The audio transcript tapes illustrated that radio traffic was very congested at times during this incident.] When he began to run out of air and it was apparent that no one had heard his distress calls, he was forced to leave Victim #2. As he made it to the stairs, he ran out of air and his mask began sucking to his face. He escaped the building at approximately 2120 and yelled to BC-2 that a fire fighter was down on the second floor. He then ran to have his SCBA tank replaced.
The fire fighter did not reenter the structure, but a search party was formed and several other fire fighters (including Victim #1) reentered the second level of the building to search for Victim #2. Victim #2 was found by a fellow fire fighter from Rescue-1. Several other fire fighters assisted in his removal down the stairs. Victim #2 was immediately provided emergency medical treatment.
The captain from Rescue-1 took another head count of his men and, realizing that Victim #1 was now missing, informed the IC. Another search party was formed and the building was reentered to the second level. A second 1¾-inch line was advanced up to the second floor just as a personal alert safety system (PASS) device was heard in the rear of the structure (Victim #1). A fire fighter on the rescue team located Victim #1 near the D-side. At this time conditions had seriously deteriorated and the intense heat drove some of the fire fighters back. Fire fighters brought a ladder to the adjacent one-story building on the C-side, and they made entry through a window on the D-side. The window was heavily boarded up, so the wood had to be forcefully opened. Victim #1 was found in the prone position and removed through the window of the second level, D-side, onto the adjoining one-story building. Victim #1 was then brought to the lower level in a stokes basket by HL-2. Emergency medical treatment was provided to Victim #1. Both victims were immediately transported to a local hospital via EMS. It was later determined that Victim #1 was missing for approximately 29 minutes, and Victim #2 was missing for approximately 20 minutes.
CAUSE OF DEATH
According to the coroner’s report, the cause of death for both victims was smoke inhalation. The carbon monoxide level in the blood was noted to be less that 10% in Victim #1, and 47.9% in Victim #2. Victim #1 had third-degree thermal injury over 40% of his body, and Victim #2 had third-degree thermal injury over 18% of his body surface area.
RECOMMENDATIONS/DISCUSSION
Recommendation #1: Fire Departments should ensure that team continuity is maintained. 1, 2
Discussion: Team continuity involves knowing who is on your team and who is the team leader, staying within visual contact at all times (if visibility is obscured then teams should remain within touch or voice distance of each other), communicating your needs and observations to the team leader, rotating to rehab and staging as a team, and watching your other team members (practice a strong "buddy-care" approach). These key factors help to reduce serious injury or even death resulting from the risks involved in fire-fighting operations by providing personnel with the added safety net of fellow team members. As teams enter a hazardous environment together, they should leave together to ensure that team continuity is maintained.
Recommendation #2: Fire departments should ensure that a rapid intervention team is established and in position immediately upon arrival. 3-5
Discussion: A Rapid Intervention Team (RIT) should respond to every working structure fire. The team should report to the IC and remain at the staging area until an intervention is required to rescue a fire fighter. The RIT should have all the tools necessary to complete the job–e.g., a search rope, rescue rope, first-aid kit, and a resuscitator to use in case a fire fighter needs assistance. These teams can intervene quickly to rescue fire fighters who become disoriented, lost in smoke-filled environments, trapped by fire, involved in structural collapse, or run out of air.
Recommendation #3: Fire Departments should ensure that the incident command system is fully implemented at the fire scene. 6
Discussion: The Incident Command System (ICS) defines the roles and responsibilities to be assumed by personnel and the operating procedures to be used in the management and direction of emergency incidents and other functions. The Incident Commander (IC) is the individual with overall responsibility to implement and oversee the system.
The following functions are the responsibility of the IC, which include, but are not limited to
Assumption, confirmation, and position of command. After the IC arrives on the fireground and assumes command, a stationary command post on the exterior of the fire building should be established. Command positioning becomes a critical factor in the overall effectiveness of the incident. A strategic level of command can only be produced if the IC is in a stationary command-post position. The command post should be situated in a conspicuous location which affords the IC a good view of the fire building and surrounding area. Ideally, it would offer a view of two sides of the fire building. Advantages of a command post are (1) stationary position, (2) a relatively quiet place in which to think and make decisions, and (3) a vantage point to oversee the operation. A stationary command post also offers the potential for improved lighting, protection from weather, space for additional staff, and access to more powerful mobile radios, reference and preplanning materials, and portable computers (in some instances).
Situation evaluation. The IC is the only person who has the exterior, stationary, command-post-position advantage that allows current and forecasted information to be received, processed, evaluated, and then translated into a series of decisions that control the position and function of the fire fighters working in and around the hazard zone. This information management function becomes a major reason why the IC should stay at the command post. It is difficult for an IC to receive, decipher, and then react effectively to reports from all over the incident site if he/she is moving around, in proximity to operational noise, distracted by direct face-to-face communications with fire fighters, and limited to a portable radio as opposed to a more powerful mobile radio.
Initiate, maintain, and control communications. It is the IC’s responsibility to initiate, maintain, and control effective incident communications. This communications function is critical to safe and effective incident operations because it is the means by which the IC and all the other incident participants stay connected. Being able to effectively communicate becomes the major tool the IC uses to exchange information and to create effective action. The IC should use the stationary command-post advantage to maintain continuous and clear communications.
Deployment. The deployment function requires the IC to provide and manage a steady, adequate, and timely stream of appropriate resources. Typically, the IC logs the arriving units into the inventory and tracking system on a tactical worksheet in the stationary command post. The IC also enters the units into a standard accountability system that tracks where companies/crews are located in the hazard zone.
Strategy/incident action planning. A critical responsibility of the IC is to identify and manage the overall incident strategy (offensive or defensive). The IC must continually evaluate the relationship between the level of hazards present and the basic capability of the safety system to protect fire fighters from those hazards. The hazards present at structural fires involve structural collapse, thermal and toxic insult, becoming trapped and running out of air, and becoming disoriented, lost, and running out of air. The conditions present at this incident included a seemingly vacant building with two levels, very few accessible openings to the outside, energized overhead power lines impeding access to the second level from the rear, and holes in the second-level floor. These conditions, combined with an active fire, created an environment with numerous hazards.
Recommendation #4: Fire departments should ensure that fire fighters, when operating on the floor above the fire, have a charged hoseline. 7
Discussion: It is a good practice to have a charged hoseline when operating on the floor above the fire. Where there is risk of extension to concealed spaces and attics, additional precautionary lines are needed at each of these areas. Backup lines may also be needed in other areas above the fire. In this incident, several fire fighters made it to the second floor to perform truck operations (ventilate and search for fire extension) above the fire and were not equipped with a charged handline.
Recommendation #5: Fire departments should instruct and train fire fighters on manually activating their PASS device when they become lost, disoriented, or trapped. 1
Discussion: When a fire fighter becomes lost or disoriented, a few simple steps can facilitate a rescue and reduce the chance of injury. The first step is the radio transmission of the Mayday situation, followed by the fire fighter providing the RIT and IC with clues as to his last known location. The fire fighter’s second step involves manually activating the PASS device. The final step requires the fire fighter to remain calm (conserving air), stay in radio contact with command and the RIT, and to survey the surroundings in an attempt to gain a bearing of direction or potential escape routes. It is important that if the fire fighter is not in immediate danger of fire impingement or collapse, that he remains in the safe area and moves as little as possible. This will conserve air and possibly help the RIT find the fire fighter more quickly than if the fire fighter is constantly moving. These steps should be incorporated into the department’s standard operating procedures with fire fighters trained on those procedures. Although fire fighters identified the fact that Victim #1’s PASS was activating, investigators were unable to determine, through interviews or equipment examination, whether Victim #2’s PASS device had gone into alarm mode.
Recommendation #6: Fire departments should ensure that a separate Incident Safety Officer (ISO), independent from the Incident Commander, is appointed. 8-11
Discussion: According to NFPA 1561, paragraph 4-1.1, "the Incident Commander (IC) shall be responsible for the overall coordination and direction of all activities at an incident. This shall include overall responsibility for the safety and health of all personnel and for other persons operating within the incident management system. While the IC is in overall command at the scene, certain functions must be delegated to ensure adequate scene management is accomplished." According to NFPA 1500, paragraph 6-1.3, "as incidents escalate in size and complexity, the IC shall divide the incident into tactical-level management units and assign an ISO to assess the incident scene for hazards or potential hazards." The most effective ISOs are those who operate as a consultant to the IC. The ISO establishes a relationship with the IC by asking what the action plan is, followed by a summary of the current situation status and resource status. With this information, the ISO can collect more information in the form of a reconnaissance or 360-degree size-up of the incident. With this additional information, the ISO can report concerns and possible solutions to the IC. During this incident, the IC was also acting as the Safety Officer and thus was limited in being able to perform the additional functions of a separate ISO.
Recommendation #7: Fire departments should ensure that Standard Operating Procedures (SOPs) and equipment are adequate and sufficient to support the volume of radio traffic at multiple-alarm fires. 9
Discussion: At times, fireground communications become ineffective because of congested radio traffic and inadequate radio equipment on the fireground. Although the IC had Central Dispatch clear the radio channel for emergency traffic, most radio operators continued to use the same channel. Standard operating procedures (SOPs) should be written and implemented, and communications equipment should be of sufficient quantity and quality to support the volume of communications encountered at the fire scene. In the event of Maydays or emergencies on the fireground, all fire fighters should switch radio operations to a new frequency or other channels. This would open the main channel for communication in case of an emergency or lost fire fighters. In this case, some fire fighters switched channels and others did not.
Recommendation #8: Fire departments should ensure that self contained breathing apparatus (SCBAs) are properly inspected, used, and maintained to ensure they function properly when needed. 12, 13
Discussion: It is rare for a SCBA respirator performance evaluation, in and of itself, to point to causes of a fatality. In this case, it was not possible to determine if the deficiencies discovered during the testing of the Unit #2 SCBA existed prior to the victim’s death or were sustained subsequent to his death from fire or recovery efforts, or handling of the equipment prior to and during shipping to NIOSH. Regardless, NFPA 1404 contains general guidelines that all fire departments should follow to ensure that all in-service SCBAs are in good working order and will function properly when needed. An SCBA will only provide the highest level of protection when it is properly serviced and maintained. Both NFPA 1404, (Chapter 5-1.4) and the Occupational Safety and Health Administration (OSHA) Respirator Standard (29CFR 1910.134(h)(3)(i)(A) require the SCBA to be inspected prior to use. This inspection should include a functional check to ensure that the regulator, low-air alarm, bypass valve, and other features of the SCBA are working properly. Additionally, NFPA 1404, Chapter 6-2.1, and OSHA 29CFR 1910(c)(1)(v) require a preventive maintenance program to be in place to prevent SCBA malfunction and equipment failure during use.
REFERENCES
INVESTIGATOR INFORMATION
This investigation was conducted by Robert Koedam, Chief of the Trauma Investigations Section, and Safety and Occupational Health Specialists Mark McFall and Jay Tarley, Surveillance and Field Investigations Branch, Division of Safety Research.
Photo 1. A-Side
Photo 2. C-Side
Photo 3. D-Side
Diagram 1. First Level
Diagram 2. Second Level
APPENDIX I: NIOSH SCBA Test Report
Status Investigation Report of Two
Self-Contained Breathing Apparatus
Missouri
NIOSH Task No. TN-12448
December 11, 2002
Disclaimer
The purpose of Respirator Status Investigations is to determine the conformance of each respirator to the NIOSH approval requirements found in Title 42, Code of Federal Regulations, Part 84 (42 CFR 84). A number of performance tests are selected from the complete list of Part 84 requirements and each respirator is tested in its "as received" condition to determine its conformance to those performance requirements. Each respirator is also inspected to determine its conformance to the quality assurance documentation on file at NIOSH. In order to gain additional information about its overall performance, each respirator may also be subjected to other recognized test parameters, such as National Fire Protection Association (NFPA) consensus standards. While the test results give an indication of the respirator’s conformance to the NFPA approval requirements, NIOSH does not actively correlate the test results from its NFPA test equipment with those of the NFPA. Thus, the NFPA test results are provided for information purposes only. Selected tests are conducted only after it has been determined that each respirator is in a condition that is safe to be pressurized, handled, and tested. Respirators whose condition has deteriorated to the point where the health and safety of NIOSH personnel and/or property is at risk will not be tested. |
Investigator Information
The SCBA inspections were conducted by and this report was written by Vance Kochenderfer, Quality Assurance Specialist, Respirator Branch, National Personal Protective Technology Laboratory, National Institute for Occupational Safety and Health, located in Bruceton, Pennsylvania.
Status Investigation Report of Two
Self-Contained Breathing Apparatus
Missouri
NIOSH Task No. TN-12448
Background
As part of the National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program, the Respirator Branch agreed to examine and evaluate two Survivair 4500 psi, 30-minute, self-contained breathing apparatus (SCBA). The Fire Department reported that the SCBA were last used during interior firefighting operations at a structure fire on May 3, 2002.
This SCBA status investigation was assigned NIOSH Task Number TN-12448. The Fire Department was advised that NIOSH would provide a written report of the inspections and any applicable test results.
The SCBA, sealed in corrugated cardboard boxes, were delivered to the NIOSH Appalachian Laboratory for Occupational Safety and Health (ALOSH) in Morgantown, West Virginia on May 7, 2002. Upon arrival, the sealed packages were taken to the Firefighter SCBA Evaluation Lab (Room 1520) and stored under lock until the time of the evaluation.
SCBA Inspection
The first package from the Fire Department was opened, and the SCBA inspection was initiated on May 9, 2002, in Room 1520 of the ALOSH Building. The inspection of Unit #1 was completed that same day. Unit #2 was inspected on May 16, 2002. The SCBA were inspected by Vance Kochenderfer, Quality Assurance Specialist, of the Respirator Branch, National Personal Protective Technology Laboratory (NPPTL), NIOSH. The SCBA were examined, component by component, in the condition as received to determine their conformance to the NIOSH-approved configuration. The entire inspection process was videotaped. The SCBA were identified as the Survivair Panther™ model.
An unusual observation made for both units was that the fabric components (hood, head harness, and neck strap) of the facepiece were damp. The facepieces were allowed to dry before testing was performed. The facepiece lens of Unit #1 had an inch-long crack. In addition, the backframe of Unit #1 was severely cracked. Discussions with the Fire Department indicate that this may have occurred during attempts to rescue the wearer.
Personal Alert Safety System (PASS) Device
A Personal Alert Safety System (PASS) device was incorporated into the pneumatics of each SCBA. During the inspection, the PASS devices were activated both manually and automatically. Although the units appeared to function normally, they were not tested against the requirements of NFPA 1982, Standard on Personal Alert Safety Systems (PASS), 1998 Edition. Because NIOSH does not certify PASS devices, no further testing or evaluations were conducted on the PASS units.
SCBA Testing
The purpose of the testing was to determine the SCBA’s conformance to the approval performance requirements of Title 42, Code of Federal Regulations, Part 84 (42 CFR 84). Further testing was conducted to provide an indication of the SCBA’s conformance to the National Fire Protection Association (NFPA) Air Flow Performance requirements of NFPA 1981, Standard on Open-Circuit Self-Contained Breathing Apparatus for the Fire Service, 1997 Edition.
The following performance tests were conducted on the SCBA:
NIOSH SCBA Certification Tests (in accordance with the performance requirements of 42 CFR 84):
1. Positive Pressure Test [42 CFR 84.70(a)(2)(ii)]
2. Rated Service Time Test (duration) [42 CFR 84.95]
3. Gas Flow Test [42 CFR 84.93]
4. Exhalation Breathing Resistance Test [42 CFR 84.91(c)]
5. Static Facepiece Pressure Test [42 CFR 84.91(d)]
6. Remaining Service Life Indicator Test (low-air alarm) [42 CFR 84.83(f)]
National Fire Protection Association (NFPA) Tests (in accordance with NFPA 1981, 1997 Edition):
7. Air Flow Performance Test [NFPA 1981, Chapter 6, 6-1]
Testing of Unit #1 was initiated on May 13, 2002. Five performance tests were completed that day. The Exhalation Breathing Resistance Test and Static Facepiece Pressure Test were conducted on May 14, 2002. Testing of Unit #2 was initiated on May 21, 2002. Five performance tests were completed that day. The Exhalation Breathing Resistance Test and Static Facepiece Pressure Test were conducted on May 22, 2002. All testing was videotaped with the exception of the Exhalation Breathing Resistance Tests and Static Facepiece Pressure Tests.
Unit #1 met the requirements of all tests. However, while the low-air warning bell functioned properly during the Remaining Service Life Indicator Test, it did not ring during the Rated Service Time test. While this does not constitute a failure, it may indicate that maintenance is required.
Unit #2 failed the Rated Service Time Test and Positive Pressure Test. In addition, the low-air gauge warning light did not activate during any tests, failing the Remaining Service Life Indicator Test.
When Unit #2 was initially subjected to the Rated Service Time Test/Positive Pressure Test, the exhalation valve was stuck closed. The valve was then freed by manually opening the valve and the test re-run. Early in the Rated Service Time Test, the low-air warning bell began sounding abnormally, making a buzzing noise. Later, at the time when it was expected to activate, the bell sounded normally but erratically.
Summary and Conclusions
Two SCBA were submitted to NIOSH by the Fire Department for evaluation. The two SCBA were delivered to NIOSH on May 7, 2002. Unit #1 was inspected on May 9, 2002. Unit #2 was inspected on May 16, 2002. The two units were identified as Survivair Panther™, 30-minute, 4500 psi, SCBA (NIOSH approval number TC-13F-284). Both were labeled as compliant to the 1997 edition of NFPA 1981. Despite damage to the backframe of Unit #1, both SCBA were determined to be in a condition safe for testing.
The two units were each subjected to a series of seven performance tests. Testing began on May 13, 2002, and was completed on May 22, 2002. Unit #1 met the requirements of all six selected NIOSH tests performed. Unit #1 also met the facepiece pressure requirements of the NFPA Air Flow Performance Test. No maintenance or repair work was performed on Unit #1 at any time. Initially, the exhalation valve of Unit #2 was stuck closed. Testing was resumed after the valve was freed. Unit #2 failed to meet the requirements of the Rated Service Time Test and Positive Pressure Test, and the gauge light failed the Remaining Service Life Indicator Test. Unit #2 met the facepiece pressure requirements of the NFPA Air Flow Performance Test.
In light of the information obtained during this investigation, the Institute has proposed no further action at this time. Following inspection and testing, the SCBA were returned to the packages in which they were received and stored under lock in Room 1520 at the NIOSH facility in Morgantown, West Virginia. The packages were moved to Building 108 at the NIOSH facility in Bruceton, Pennsylvania, in connection with the transfer of the National Personal Protective Technology Laboratory to that location. They were secured there pending return to the Fire Department.
If the SCBA are to be placed back in service, they should be repaired, inspected, and tested by a qualified service technician. In particular, Unit #2 is non-conforming and cannot be used unless it is restored to proper performance. Special attention should be paid to the low-air warning bells of both units. The facepiece lens of Unit #1 should also be replaced. While in storage, the cylinders of both units have become due for inspection and hydrostatic testing by a Department of Transportation authorized retester before the cylinders can be returned to service.
National Personal Protective Technology Laboratory/Respirator Branch/Quality Assurance Section
Respirator Field Problem
Incoming Inspection Report Summary - Unit #1
Task Number: | TN-12448 | ||
Date Received: | 7 May 2002 | ||
Date Inspected: | 9 May 2002 | Description: | Fatality |
Manufacturer: | Survivair | Inspected by: | Vance Kochenderfer |
Approval Number: | TC-13F-284 | SCBA Type: | Open Circuit, Pressure-Demand |
Components and Observations - Unit #1
NOTE: All references to “right” or “left” are from the user’s perspective.
National Personal Protective Technology Laboratory/Respirator Branch/Quality Assurance Section
Respirator Field Problem
Incoming Inspection Report Summary - Unit #2
Task Number: | TN-12448 | ||
Date Received: | 7 May 2002 | ||
Date Inspected: | 16 May 2002 | Description: | Fatality |
Manufacturer: | Survivair | Inspected by: | Vance Kochenderfer |
Approval Number: | TC-13F-284 | SCBA Type: | Open Circuit, Pressure-Demand |
Components and Observations - Unit #2
NOTE: All references to "right" or "left" are from the user’s perspective.
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