Are we learning from others mistakes? 
    Warehouse Fire Claims the Life of a Battalion Chief - Missouri 
    ATTACHMENT 1  
    (This attachment was originally sent as an official letter summarizing the results of a NIOSH inspection and testing of a self-contained breathing apparatus.) 

    DEPARTMENT OF HEALTH & HUMAN SERVICES 
    Public Health Service  
    Centers for Disease Control and Prevention (CDC) 
    National Institute for Occupational Safety and Health - ALOSH 
    1095 Willowdale Road 
    Morgantown, WV 26505-2888 

    NIOSH Reference: TN-11336 

    Phone: (304) 285-5907  
    Fax: (304) 285-6030 
    February 1, 2000 

    Dear Chief: 

    The National Institute for Occupational Safety and Health (NIOSH) has concluded its investigation conducted under NIOSH Task Number TN-11336. This investigation consisted of the inspection and testing of one self-contained breathing apparatus (SCBA) shipped to NIOSH by the Fire Department on January 3, 2000. Our inspection report and results of all tests are contained in a detailed Status Investigation Report which is enclosed. 

    Inspection of the SCBA was completed on January 4, 2000. The SCBA was worn and had the appearance of having seen considerable use. Although the NIOSH approval label was missing, and component part numbers could not be identified on a few component parts, the SCBA appeared to be in the approved condition for a Mine Safety Appliances (MSA) Ultralite, 30-minute, 2216 psi, SCBA (NIOSH approval number TC-13F-138). 

    The SCBA was thoroughly inspected and determined to be in a condition safe for testing. However, a current hydrostatic test date was not identified on the fiberglass-wrapped composite aluminum cylinder shipped with the SCBA. The cylinder was also found to contain a substantial amount of fluid. It was subsequently learned that the SCBA was left at the fire scene for several days following the fire incident and was immersed in several inches of water. The fluid inside the cylinder is believed to be water which seeped through the pneumatic system of the SCBA and into the cylinder. The cylinder shipped with the SCBA was determined to be unsafe for refilling. A substitute cylinder was obtained from MSA for use during the testing of the SCBA. 

    The SCBA was tested in the condition as received from the Fire Department (except for the replacement cylinder). The purpose of the testing was to determine the SCBA’s conformance to the approval performance requirements of Title 42, Code of Federal Regulations (CFR), Part 84, Subpart H. Further testing was conducted to determine conformance to the National Fire Protection Association (NFPA) Air Flow Performance requirements of NFPA 1981, 1997 Edition. A series of tests utilizing a Biosystems PosiChek3 computerized SCBA performance tester was also conducted. 

    Of the six selected NIOSH tests performed, the unit failed the Rated Service Time Test and the Remaining Service Life Indicator Test. The SCBA also failed to meet the minimum facepiece pressure requirements of the NFPA Air Flow Performance Test. When performance tested using the Biosystems PosiChek3, the unit failed the Alarm Accuracy portion of the Complete SCBA Test. 

    During the inspection of the SCBA, it was noted that paper fibers were adhered to the facepiece exhalation valve diaphragm. At the time, no effort was made to remove these fibers. During the Rated Service Time Test, the sound of air escaping from the exhalation valve was observed after the cylinder valve was opened, but prior to the start-up of the breathing machine. The unit failed to meet the requirements of the Rated Service Time Test. After the performance testing was completed, the exhalation valve was purged with compressed air to remove the visible paper fibers. The Rated Service Time Test was then repeated. This time, no air was observed to be leaking from the exhalation valve, and the unit met the requirements of the test. 

    Internal inspections of other individual components requiring disassembly (such as the low air alarm assembly) were not performed. 

    The status of the SCBA with regard to its conformance to the performance standards prior to the incident cannot be determined. It is quite possible that the test failures observed during this evaluation are a result of damage sustained by the SCBA after the firefighter succumbed to his injuries while fighting the fire on December 18, 1999. For example, the paper fibers affecting the operation of the exhalation valve could have been deposited when the SCBA was submerged in water after the incident. It is also not known what effects, if any, non-conforming SCBA performances would have had at the fire scene. While the unit failed to maintain positive pressure during the NFPA Air Flow Performance Test, the possibility of inward leakage into a firefighter’s facepiece would be dependant upon the face to facepiece seal, the ventilation rate at the time of use, as well as other factors such as age, weight, and the physical condition of the firefighter. Test results indicate that air was flowing to the facepiece in a sufficient quantity to support moderate ventilation requirements. It is also important to note that the SCBA facepiece pressure remained positive throughout the NIOSH Rated Service Time Test. 

    The Personal Alert Safety System (PASS) device shipped with the SCBA was not evaluated by NIOSH. The Institute does not have criteria for testing these units. During the inspection, the PASS unit was manually activated and appeared to operate properly. 

    It is strongly recommended that this SCBA be inspected and serviced by an authorized MSA service technician, and all necessary overhaul and repair work be completed before placing the unit back into service. It is also recommended that all SCBA inspection, handling, use, and maintenance procedures be reviewed with regard to activities and practices that could impact the safe use of all SCBA. 

    It is important to note that this SCBA is reported to have been left in standing water at the fire scene for several days following the fire incident. Paper fibers were found adhered to almost every component of the SCBA. Water was found in the pneumatic assemblies and inside the SCBA cylinder. It is believed that this contamination occurred after the victim was removed from the incident scene. It is probable that the paper fibers and water had an effect on the SCBA’s performance during the testing sessions at NIOSH and compromised the value of this physical evidence. 

    Therefore, the Institute recommends that the Fire Department review its policies and procedures to ensure the use of proper methods for maintaining the integrity of physical evidence collected during fire investigations. Care should be taken to protect the value of physical evidence from the time of its initial discovery and collection to its subsequent examination and testing. Guidelines for the proper handling of physical evidence can be found in NFPA 921, Guide for Fire and Explosion Investigations, 1998 Edition, Chapter 9 - Physical Evidence. 

    No further action will be taken by NIOSH and the investigation of Task Number TN-11336 will be considered closed. The SCBA will be stored under lock in room 178A of the NIOSH Appalachian Laboratory for Occupational Safety and Health (ALOSH) pending return to the Fire Department.  

    I trust this information is satisfactory to meet your needs. If you require further assistance, please contact me at (304) 285-6337. 

      

    Sincerely yours, 

    Thomas W. McDowell, 
    Physical Scientist 
    Quality Assurance Team 
    Respirator Branch 
    Division of Respiratory Disease Studies 
      

    ATTACHMENT 2 
    (This attachment was originally sent as an official letter summarizing the results of a NIOSH evaluation of the fire department's SCBA maintenance program.)  

    DEPARTMENT OF HEALTH & HUMAN SERVICES 
    Public Health Service  
    Centers for Disease Control aand Prevention (CDC) 
    National Institute for Occupational Safety and Health - ALOSH 
    1095 Willowdale Road 
    Morgantown, WV 26505-2888 

    NIOSH Reference: TN-11336 

    Phone: (304) 285-5907  
    Fax: (304) 285-6030 
    February 1, 2000 

    Dear Chief : 

    During our visit to the Fire Department on January 19, 2000, Tim Merinar and I had the opportunity to evaluate your fire department’s self-contained breathing apparatus (SCBA) maintenance program. The objectives of our visit were to evaluate your SCBA maintenance program and to make recommendations for improvement. This evaluation consisted of visiting the SCBA maintenance area, interviewing fire department personnel associated with the maintenance of SCBA, reviewing SCBA maintenance records and procedures, evaluating the compressed-air cylinder refilling station located at your training facility, examining Air Truck 1, and evaluating the compressed-air and oxygen cylinder refilling stations located at Stations 4, 10, and 18. Our evaluation process benefitted substantially from the cooperation of your staff. Their cooperation was instrumental in providing us with information necessary for the evaluation of your SCBA maintenance program. 

    Your current SCBA maintenance program was evaluated and compared to the respirator and SCBA maintenance requirements listed in the following recognized national standards: 

    Title 29, Code of Federal Regulations (CFR) Part 1910.134 known as The OSHA Respirator Standard. 

    National Fire Protection Association (NFPA) 1404, Standard for a Fire Department Self-Contained Breathing Apparatus Program, 1996 Edition. 

    National Fire Protection Association (NFPA) 1500, Fire Department Occupational Safety and Health Program,1997 Edition 

    American National Standards Institute, Inc. (ANSI), American National Standard for Respiratory Protection, ANSI Z88.2-1992. 

    These standards specify the minimum benchmark requirements that all fire department respirator programs should strive to meet or exceed. Compliance with these standards is considered to be essential to maintain SCBA in a condition meeting the certification requirements of the National Institute for Occupational Safety and Health (NIOSH) found in Title 42, Code of Regulation, Part 84, Subpart H, as well as the National Fire Protection NFPA 1981 Standard on Open-Circuit Self-Contained Breathing Apparatus for the Fire Service, 1997 Edition. Failure to maintain your SCBA in an approved condition voids the NIOSH approval until such time as each affected SCBA can be inspected, serviced, and returned to an approved condition. 

    The following areas were identified within the Fire Department SCBA maintenance program as areas where improvement is needed in order to comply with the referenced national standards: 

    1) The SCBA maintenance program should be under the direct control of one designated individual who is a Fire Department employee and who has no other fire fighting or administrative responsibility. In general, this individual’s area of responsibility could be tailored to meet the department’s needs, but should include supervision and control of all aspects of the program including the SCBA preventive maintenance program, repair, testing, record keeping, and auditing. Our evaluation revealed that personnel currently responsible for the SCBA maintenance program have responsibilities in other areas. 

    Title 29, Code of Federal Regulations (CFR), Part 1910.134 (the OSHA Respirator Standard) at 1910.134(c) requires each respirator program to be administered by a suitably trained program administrator. 

    It was also noted that several persons had access to the SCBA repair and spare parts storage areas. This situation could lead to untrained and unauthorized individuals performing SCBA repair, as well as producing problems with maintaining an accurate inventory of replacement parts. 

    2) A preventive maintenance program should be established to ensure regularly scheduled preventative maintenance is conducted on each SCBA at least annually. It is noted that the Fire Department does not operate a preventive maintenance program but rather attempts to repair defective SCBA on an as-needed basis. 

    The OSHA Respirator Standard 29 CFR 1910.134(c)(1)(v); 1910.134(c)(1)(vi); and 1910.134(h) require the employer to develop and implement a written respiratory protection program that includes specific procedures and schedules for cleaning and disinfecting, storage, inspection, maintenance, and repair of respirators used by employees. 

    NFPA 1404, Chapter 6-1.2 and 6-1.3 require annual inspection and servicing of SCBA by qualified personnel. Chapter 6-1.3 requires annual servicing to be conducted following the manufacturer’s recommendations and should include : 

    a) Disassembly of the SCBA into major components 

    b) Flow testing of the regulator 

    c) Disassembly and cleaning of the regulator 

    d) Replacement of worn parts, or those recommended by the manufacturer in the regulator assembly. 

    e) Disassembly of the low-air alarm and cleaning and replacement of component parts as necessary. 

    f) Cleaning and replacement of components of the facepiece and harness assembly, and replacement of component parts as necessary. 

    g) Reassembly of the entire SCBA and testing for proper operation of all components. 

    h) Proper recording of all performed maintenance on record keeping forms. 

    NFPA 1404, Chapter 6-2.1 specifies that a preventative maintenance program shall be established by the authority having jurisdiction for all SCBA used in the organization. 

    NFPA 1404, Chapter 6-2.2 specifies that the SCBA preventative maintenance program shall be conducted in order to prevent SCBA malfunction and failures of equipment during use. 

    NFPA 1500, Chapter 5-3.1 specifies the fire department shall adopt and maintain a respiratory protection program that addresses the selection, inspection, safe use, and maintenance of respiratory protection equipment, training in its use, and the assurance of air quality testing. 

    NFPA 1404, Appendix A, A-6.2 states that an SCBA should be rebuilt by its manufacturer or by a person trained and certified by the manufacturer at intervals as recommended by the manufacturer. 

    Specific guidelines for determining and scheduling preventive maintenance actions can best be compiled with assistance from your SCBA manufacturer. Frequency of complete SCBA overhaul should be based on the manufacturer’s recommendation. If no manufacturer’s recommendation is provided, NIOSH recommends that rebuilding of SCBA assemblies be performed every 3 years. 

    It is apparent that in order for the Fire Department to establish a comprehensive preventive maintenance program, the department will need to acquire additional resources. It would be impossible for your current SCBA maintenance staff to continue to complete repairs as well as perform all tasks necessary for comprehensive preventive maintenance for nearly 300 SCBA. 

    3) Records should be maintained for each SCBA, facepiece, and cylinder at the department. During our visit, we were shown a card filing system where repair and testing information was maintained for each SCBA and filed according to company assignment. An electronic file had also been developed to help track cylinder hydrostatic test schedules and service life dates. NIOSH recommends that the computerized records system be expanded to address the following standard excerpts: 

    NFPA 1404, Chapter 2-2.3 specifies that an individual record of each SCBA regulator and harness assembly shall be maintained. This record shall include the inventory or serial number, date of purchase, date of manufacture, date placed into service, location, maintenance and repairs, replacement parts used, upgrading, and test performance. 

    NFPA 1404, Chapter 2-2.4 specifies that an individual record of each SCBA cylinder shall be maintained. This record shall include the inventory or serial number date of purchase, date of manufacture, date placed into service, location, hydrostatic test pressure and dates, and any inspection and repairs. The hydrostatic test dates shall appear on each cylinder according to the manufacturer’s instructions and applicable government agencies. 

    NFPA 1404, Chapter 2-2.5 specifies that an individual record of each SCBA facepiece shall be maintained. This record shall include the inventory or serial number, date of purchase, location, maintenance and repairs, replacement parts, upgrading, and test performance. 

    NFPA 1500, Chapter 2-7.5 specifies that each fire department shall assure that inspection, maintenance, repair, and service records are maintained for all vehicles and equipment used for emergency operations and training. 

    The American National Standard for Respiratory Protection, ANSI Z88.2-1992, Chapter 10.2 specifies that inspection records be maintained for each respirator. 

    The OSHA Respirator Standard 29 CFR 1910.134(c); 1910.134(h)(3)(iv)(A and B); and 1910.134(m) specify general requirements for record keeping within a respirator program. 

    4) A program should be developed to ensure that all SCBA cylinders meet the US Department of Transportation (DOT) standards for periodic requalification and service life limitations. These standards are listed in Title 49, Code of Federal Regulations (CFR), Part 173.34(e). During our visit to Station 18, we observed several SCBA cylinders in service with expired hydrostatic test dates. A review of the records kept at the Training Center verified that several in-service cylinders had past-due hydrostatic test dates. DOT requirements for the composite aluminum, fiberglass-wrapped cylinders utilized by the Fire Department require that each cylinder be submitted every three years to a DOT-certified retester for inspection and hydrostatic testing. The DOT requirements limit the service life for these cylinders to 15 years from the date of manufacture, regardless of the last date of requalification. 

    NFPA 1500, Chapter 5-3.8 specifies that SCBA cylinders shall be hydrostatically tested within the periods specified by the manufacturers and the applicable governmental agencies. 

    NFPA 1404, Appendix A, A-6.2 specifies that breathing gas cylinders be tested as prescribed in Title 49, Code of Federal Regulations (CFR), Part 178, Shipping Container Specification Regulations. 

    Title 42, Code of Federal Regulations (CFR), Part 84.81(a), NIOSH Requirements for Respiratory Protection Devices requires cylinders used on NIOSH-approved SCBA to meet the minimum DOT requirements. 

    5) The Fire Department should establish a written standard operating procedure for managing SCBA found to be defective or non-functioning. If a firefighter finds an SCBA in need of service during use or inspection, the SCBA should be identified with a tag displaying SCBA identification, information regarding the defect found or performance problem observed, and appropriate contact information for the SCBA user. This procedure should also cover the methods to be used to remove the SCBA from service and to refer the problem to the appropriate SCBA maintenance personnel. All service performed on the SCBA should then be documented in the records system. 

    The OSHA Respirator Standard 29 CFR 1910.134(c)(1)(v) and 1910.134(h)(4) require the employer to develop schedules and procedures for inspecting respirators and ensuring that respirators that fail inspection or are otherwise found to be defective are removed from service. 

    6) Inspections should be conducted at least weekly and preferably at the beginning of each work shift and after each use to ensure that each SCBA is checked for proper function. During our visit, you indicated that each SCBA is inspected at the beginning of each work shift but that a written record detailing cylinder pressure, hardware condition, name, date, and other pertinent information regarding the inspection of each SCBA is not kept. 

    The OSHA Respirator Standard 29 CFR 1910.134(h)(3) lists the requirements for respirator inspections. 1910.134(h)(iv)(A and B) list the requirements for documenting each inspection. 

    NFPA 1404, Chapter 5-1.2 specifies that where fire apparatus is in daily use, an inspection of all respiratory protection equipment and reserve cylinders on each apparatus shall be conducted at least daily. 

    The American National Standard for Respiratory Protection, ANSI Z88.2-1992, Chapter 10.2 specifies that the SCBA user shall inspect the respirator, and that a record of inspection dates shall be kept for each respirator. 

    7) Annual evaluations of the SCBA Maintenance Program should be conducted to monitor and evaluate the effectiveness of the overall SCBA maintenance program. 

    The OSHA Respirator Standard 29 CFR 1910.134(h)(3)(1)(ix) requires the employer to develop and maintain as part of the overall written respiratory protection program, procedures for regularly evaluating the effectiveness of the program. 

    NFPA 1404, Chapter 8-1.1 specifies that the authority having jurisdiction shall review the organization’s respiratory protection program annually for the purposes of determining the need to upgrade or change various aspects of the program. 

    These recommendations are based upon the premise that all SCBA are life-saving devices which will only perform as well as they are maintained. Since they are expected to function and perform properly each time they are used, it is important that SCBA maintenance and inspection be given the utmost priority at the department level. 

    During our visit, we provided your SCBA maintenance personnel with a copy of the peer-reviewed document Respirator Maintenance Program Recommendations for the Fire Service developed by NIOSH and published in the Journal of the International Society for Respiratory Protection. We also provided draft copies of generic standard operating procedures and record keeping forms that may assist you in developing improvements to your overall SCBA maintenance program. 

    During our visit, we also inspected and evaluated three oxygen cylinder refilling stations located at Stations 4, 10, and 18. Oxygen cylinders are typically refilled for use in oxygen resuscitators and other emergency medical equipment used to administer oxygen therapy. The OSHA Respirator Standard 29 CFR 1910.134 as well as the NFPA 1404 Standard for a Fire Department Self-Contained Breathing Apparatus Program, do not specifically address these types of medical devices. However, safe handling practices dictate that oxygen refilling systems as well as oxygen equipment be stored in a clean, dry, air-conditioned location that is locked to limit access only to those individuals who have been properly trained and qualified to work with oxygen equipment. All cleaning, repair, and refilling operations should be conducted using the appropriate special tools which are cleaned, maintained, and dedicated only for use on oxygen equipment. The oxygen cylinder refilling stations that we examined failed to meet the above requirements. 

    The NIOSH Fire Fighter Injury Investigation Report 98F-23, Oxygen Regulator Flash Severely Burns One Fire Fighter - Florida, and the joint FDA and NIOSH Public Health Advisory: Explosions and Fires in Aluminum Oxygen Regulators both contain a number of recommendations on safe handling procedures for handling and filling portable oxygen cylinders. Both documents address special precautions which should be taken for oxygen cylinder filling stations. A copy of each document is enclosed. 

    The Compressed Gas Association pamphlet CGA G-4 (1996 revision) Oxygen (especially chapter 4) and the NFPA 53 Guide on Fire Hazards in Oxygen-Enriched Atmospheres, 1994 Edition are also excellent sources of information on oxygen cylinder storage and safe handling procedures. 

    I trust this information is beneficial to your needs. If you have any questions or require additional information, please contact me at (304) 285-6337. 

    Sincerely yours, 

    Thomas W. McDowell 
    Physical Scientist 
    Respirator Branch 
    Division of Respiratory Disease Studies

 
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