A Summary of a NIOSH fire fighter fatality …Residential Structure Fire Claims the Life of One...

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F2000 Death in the line of duty...26

Residential Structure Fire Claims the Life of One Career Fire Fighter�Alabama

August 3, 2001A Summary of a NIOSH fire fighter fatality investigation

SUMMARYOn April 20, 2000, a 33-year-old male career firefighter was fatally injured while battling aresidential structure fire. At approximately 1630hours, Central Dispatch was notified of a reportedstructure fire at a single family residence. At 1631hours, Central Dispatch notified the local firedepartment of the reported structure fire. Car 12(captain/incident commander [IC]), Engine 1(lieutenant, engine operator, and fire fighter[FF#1]), Engine 2 (lieutenant, fire fighter [FF#2],and engine operator/fire fighter [victim]), Rescue52 (two fire fighter/paramedics [FF#3 and FF#4]),Car 14 (air supply van, two fire fighters [FF#5and FF#6]), and Rescue 50 (two fire fighter/paramedics [FF#7 and FF#8]) responded to thescene. At 1633 hours, a captain arrived on thescene and established incident command (IC). Heconducted a scene size-up, including a walk-around of the structure, and confirmed to CentralDispatch that there was a working structure firewith thick black smoke emitting from the garage/basement. As Engine 1 was approaching thescene, the IC instructed the crew to stop and

connect to the hydrant. Rescue 52 met up withEngine 1 at the hydrant and assisted them inmaking the connection. Engine 1 connected theirsupply line to the hydrant and proceeded to thescene as Rescue 52 finished making the hydrantconnection. The IC radioed that the fire was inthe garage/basement. Rescue 52 arrived on thescene. The lieutenant from Engine 1 instructedFF#1 to pull a 1¾-inch handline off of Engine 1and proceed with him into the garage/basementof the structure. At approximately the same time,FF#5 and FF#6 arrived on the scene in Car 14(air supply van). They reported to the IC andwere instructed to pull a 1¾-inch handline andenter through the front door of the structure withthe victim. They walked into the structure andimmediately dropped to their knees due to heatand lack of visibility. They made their way intothe structure, moving to their left approximately10 feet. The victim was on the nozzle and FF#5and FF#6 served as backup. Heavy smoke madeit impossible to see, so they exited the structureto get a positive pressure fan (PPV) to aid inventilation. As they exited, FF#4 was setting upthe fan at the front door of the structure. The

The Fire Fighter Fatality Investigation and PreventionProgram is conducted by the National Institute forOccupational Safety and Health (NIOSH). The purpose ofthe program is to determine factors that cause or contributeto fire fighter deaths suffered in the line of duty.Identification of causal and contributing factors enableresearchers and safety specialists to develop strategies forpreventing future similar incidents. The program does notseek to determine fault or place blame on fire departmentsor individual fire fighters. To request additional copies ofthis report (specify the case number shown in the shieldabove), other fatality investigation reports, or furtherinformation, visit the Program Website at

www.cdc.gov/niosh/firehome.htmlor call toll free 1-800-35-NIOSHIncident Scene

Residential Structure Fire Claims the Life of One Career Fire Fighter� Alabama

Investigative Report #F2000-26Fatality Assessment and Control Evaluation


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victim and FF#5 and FF#6 reentered the structurethrough the front door and made their way to theright and into the living room. FF#5, FF#6, andthe victim were near the bathroom of the residencewhen FF#6 heard a loud crack. It is believed thatat this time the victim fell through the bathroomfloor into the basement. The engine operatorfrom Engine 1 went into the basement bedroom,entering from the garage through the utilityroom into the downstairs bedroom. The engineoperator from Engine 1, with the help of FF#1and FF#4, removed the victim from thestructure. The victim was flown by anemergency-transport helicopter to a regionaltrauma center where he was pronounced dead.

NIOSH investigators concluded that to minimizethe risk of similar occurrences, fire departmentsshould

� ensure that fire fighters performing firefighting operations under or above trussesare evacuated as soon as it is determinedthat the trusses are exposed to fire

� ensure that a rapid intervention team isestablished and in position upon arrival

� ensure that fireground communication ispresent through both the use of portableradios and face-to-face communications

� ensure that exterior fire attack is at aminimum during search and rescue

� ensure fire fighters are trained to recognizethe danger of searching above a fire

Although there is no evidence that it contributedto this fatal event, the following recommendationis being provided as a reminder of good safetypolicy.

� ensure consistent use of personal alert safetysystem (PASS) devices at all incidents andconsider providing fire fighters with a PASSintegrated into their self-containedbreathing apparatus

INTRODUCTIONOn April 20, 2000, a career fire departmentresponded to a residential structural fire at a localresidence. The victim was part of an interiorattack crew who was killed when he fell throughthe upstairs floor while trying to locate the fire.The fire originated in the basement wiring directlyunder the section of the floor that collapsed(Figure 1). On April 21, 2000, the United StatesFire Administration (USFA) notified the NationalInstitute for Occupational Safety and Health(NIOSH) of this incident. On June 5-7, 2000,two safety and occupational health specialistsfrom the Division of Safety Research, Fire FighterFatality Investigation and Prevention Programinvestigated this incident. Interviews and meetingswere conducted with the chief of the department,fire fighters who were on the scene of this incident,a representative from the International Associationof Fire Fighters (IAFF), and the State FireMarshal. The incident site was visited andphotographs of the fire scene were reviewed.Copies of witness statements, training records,standard operating procedures (SOPs), the deathcertificate, and a map of the fire scene were reviewed.An inspection of the victim�s self-contained breathingapparatus (SCBA) was conducted by the NIOSH,Division of Respiratory Disease Studies, RespiratorBranch (see Attachment).

This career department consists of 85 uniformedfire fighters. The department serves a populationof 60,000 in an area of 60 square miles. Thestructure involved in this incident was a one-storywood frame house, with a one car garage and apartial basement under the living area.





The State of Alabama requires all fire fighters tobe NFPA Level I certified. The victim wascertified at the NFPA Fire Fighter Level I and II.Additionally, the victim had the followingcertifications: Driver Operator, EMT, Haz-Mat,Apparatus Operation, First Aid, CPR, RopeRescue, and Public Safety Telecomm. At the timeof the incident, the victim was wearing a full arrayof personal protective clothing and equipment,consisting of turnout gear (coat and pants),helmet, gloves, boots, Nomex® hood and a self-contained breathing apparatus (SCBA) with amanual personal alerting safety system (PASS)device.The victim had 8 years of experience.

INVESTIGATIONOn April 20, 2000, at approximately 1630 hours,Central Dispatch was notified of a reportedstructure fire. At 1631 hours, Central Dispatchnotified the fire department, and the followingunits were dispatched to the scene:

Car 12�captain/incident commander (IC)

Engine 1�lieutenant, engine operator, and firefighter (FF#1)

Engine 2�lieutenant, fire fighter (FF#2), andengine operator/fire fighter (the victim)

Rescue 52�two fire fighter/paramedics (FF#3 andFF#4)

Car 14 (Air Supply Van)�two fire fighters (FF#5and FF#6)

Rescue 50�two fire fighter/paramedics (FF#7 andFF#8)

At 1633 hours, the Captain arrived on the sceneand established incident command (IC). Heconducted a scene size-up, including a walk-

around of the structure, and confirmed to CentralDispatch that there was a working structure firewith thick, black smoke emitting from the garage/basement area (Photo 1). As Engine 1 wasapproaching the scene, the IC instructed the crewto stop and connect to the hydrant. Rescue 52met up with Engine 1 at the hydrant and assistedthem in making the connection. Engine 1connected their supply line to the hydrant andproceeded to the scene as Rescue 52 finishedmaking the hydrant connection.

Engine 2 arrived on the scene with a lieutenant,the engine operator/fire fighter (victim), and FF#2.The lieutenant from Engine 1 approached the ICto determine the location of the fire. The IC statedthat the fire was in the basement. Rescue 52 (FF#3and FF#4) arrived on the scene. The lieutenantfrom Engine 1 instructed FF#1 to pull a 1¾-inchhandline off of Engine 1 and proceed with himinto the structure through the garage/basementdoor (Figure 1).

At approximately the same time, FF#5 and FF#6arrived on the scene in Car 14 (air supply van).They reported to the IC and were instructed topull a 1¾-inch handline and enter through the frontdoor of the structure, along with the victim. FF#5,FF#6, and the victim pulled the handline into thestructure and immediately dropped to their kneesbecause of heat and lack of visibility. They madetheir way into the structure, moving to their left,for approximately 10 feet. The victim was on thenozzle and FF#5 and FF#6 served as backup. Dueto poor visibility, they exited the structure to geta positive pressure fan (PPV) to aid in ventilation.As they exited, FF#4 was already setting up thefan at the front door of the structure. The victim(nozzleman) and FF#5 and FF#6 reentered thestructure, with a 1¾-inch handline, through thefront door, made their way to the right, andcontinued into the structure to the bathroom area





(Figure 1). FF#3 proceeded into the garage/basement of the structure, entering through thegarage door, and made his way into the basementabout 10 feet and met up with the lieutenant fromEngine 1 and FF#1. Note: At this point, therewas zero visibility in the garage/basement. Thelieutenant from Engine 1 and FF#1 and FF#3attacked the fire with a 1¾-inch handline, but wereforced to exit due to the extreme heat. Afterexiting the structure, FF#3 went to the rear of thestructure to check for fire extension and for abetter path to attack the fire.

The lieutenant from Engine 1 and FF#1 reenteredthe garage/basement area to attack the fire for asecond time. They again were forced to exit dueto extreme heat. The lieutenant from Engine 2placed a PPV fan in front of the garage door, thenwent into the basement with FF#1 to continuesuppression activities. They opened the nozzleto suppress the fire, and the heat and steam thatwas created forced them to drop to the floor.FF#3 reentered the garage and met up with thelieutenant from Engine 2 and FF#1. The lieutenantfrom Engine 1 proceeded to the rear of thestructure and noticed an opening approximatelyin the middle of the foundation wall, covered byplywood. He cleared the opening and saw�blowtorch-like� fire conditions coming from theopening. The lieutenant from Engine 1 then wentto the front of the structure (garage area) andretrieved a 1¾-inch handline. He and FF#1proceeded to the rear of the structure with thehandline to hit the fire through the opening in thefoundation at the rear of the structure. FF#5,FF#6, and the victim continued their search forthe fire inside the structure. At this time FF#6heard a loud crack, and saw the victim had fallenthrough the bathroom floor into the basementarea. FF#5 and FF#6 crawled to the area wherethe victim fell through the floor and saw flames inthe basement. They dropped to their stomachs

to distribute their weight on the floor and yelledto the victim to protect himself from the fire byopening his nozzle and hitting the flames. Theyreached into the opening of the floor, grabbed thevictim�s hands, and tried unsuccessfully to pullthe victim back up to them.

The lieutenant from Engine 2 and FF#3 werecontinuing suppression activities in the garage andmade it approximately 5 feet through the doorwayleading into the downstairs utility room. As theyentered the doorway, they saw the glow from thefire. FF#3�s low-air alarm was sounding and hewas forced to exit. The IC made his way to therear of the structure to assess the conditions. Atthis time FF#3, with a fresh bottle, was instructedby the lieutenant from Engine 1 to enter the frontdoor and meet up with the crew from Rescue 52.He made his way into the structure approximately6 feet and noticed that the floor felt spongy. Thelieutenant from Engine 1 and FF#1 and FF#4opened the nozzle and sprayed water into theopening in the rear (vent) of the structure forapproximately 1 minute when they heard someoneyelling from the upstairs of the structure. Theyshut the handline down so they could hear whowas yelling and what was being said. They heardthe interior crew yell �man down� and �get ascuttle-hole ladder.� FF#3 then exited thestructure to get the scuttle-hole ladder to assist inthe removal of the victim. After several attemptsby FF#5 and FF#6 to pull the victim up throughthe hole, FF#6 exited the structure to inform theIC of the situation and retrieve a scuttle-holeladder to aid in removal of the victim from thebasement. FF#5 stayed inside the structure to tryto aid in the removal of the victim. FF#6 was metat the front door by FF#3 with the scuttle-holeladder. FF#3 and FF#6 took the ladder into thestructure. After several attempts to place theladder, FF#5, FF#6, and FF#3 exited the structureto find a better way to reach the victim. Note:





The ladder was very hard to maneuver and setinto place due to the confined area of the hallwayof the structure. The IC instructed FF#3 to switchduties with the engine operator from Engine 1.The IC then pulled a 2½-inch hoseline off ofEngine 1 and instructed FF#5 to go to thebasement with the engine operator from Engine1 to aid in suppression and search efforts. FF#6reentered the structure through the garage door,took the 2½-inch line from FF#5, and sprayedwater as long as he could before exiting. Note:FF#6 did not have an air pack on at this time.FF#5 went in to assist in rescue operationsbecause he knew the general area where thevictim could be located. FF#5 crawled into thebasement bedroom entering from the garage throughthe utility room into the downstairs bedroom. Theengine operator from Engine 1 made his way intothe structure, crawling on his knees, following FF#5and a handline. The engine operator from Engine 1heard FF#5 yell that he found the victim. The engineoperator went to FF#5 and, with the help of FF#1and FF#4, removed the victim from the structure.The victim was flown by emergency-transporthelicopter to a regional trauma center where he waspronounced dead.

CAUSE OF DEATHAccording to the medical examiner�s report, thecause of death is listed as thermal injuries (full-thickness burns to roughly one-third of bodysurface area).

RECOMMENDATIONS AND DISCUSSIONRecommendation # 1: Fire departments shouldensure that fire fighters performing fire fightingoperations under or above trusses are evacuatedas soon as it is determined that the trusses areexposed to fire.1

There is no specific time limit on how long firefighters should operate under or on truss systems

that are exposed to fire. A time limit is oftenused by fire departments as a guide for operationunder or on truss systems. Even though standardfire-engineering calculations show that lightweighttrusses may be expected to collapse after about10 minutes in a fully developed fire, it is notrecommended to set a time limit. As stated inBuilding Construction For the Fire Service,1

�under fire conditions, truss failure isunpredictable.� When fire fighters arrive on thescene of a building with trusses exposed to fire, itis virtually impossible to identify how long thetrusses have been exposed to fire and consequentlyset a time limit for fire suppression. When it isdetermined that the building�s trusses have beenexposed to fire, any fire fighters operating underor above them should be immediately evacuated.If it is not clear that the building�s trusses havebeen exposed to fire, a defensive attack shouldtake place until the conditions can be verified.

Fire fighters may have difficulty finding the exactlocation of fire in a building, even though heavysmoke makes it clear that fire is present. The firecould be in a void or concealed area. For example,a floor truss can span great lengths with no breaksor fire stops, creating a void space that can concealthe fire, allowing it to grow rapidly. The term�fire-rated� should not be misinterpreted. It doesnot provide any fire resistance, but merely meetsfire code requirements for rate of flame spread.The design of floor trusses provides a void to hidethe fire and allow carbon monoxide to accumulate.If the floor truss would collapse while fire fighterswere under or on them, the fire fighters couldbecome trapped inside the structure. In thisincident the floor trusses were exposed to fire,causing the structural members to weaken.

Recommendation #2: Fire departments shouldensure that a rapid intervention team isestablished and in position upon arrival.2





A rapid intervention team (RIT) should respondto every major fire. The team should report tothe officer in command and remain at thecommand post until an intervention is required torescue a fire fighter(s) or civilians. The RIT shouldhave all tools necessary to complete the job (e.g.,a search rope, first-aid kit, and a resuscitator) touse if a fire fighter becomes injured. Many firefighters who die from smoke inhalation, from aflashover, or from being caught or trapped by fireactually become disoriented first. They are lostin smoke and their SCBAs run out of air, or theycannot find their way out through the smoke,become trapped, and then fire or smoke kills them.The primary contributing factor, however, isdisorientation. The RIT will be ordered by theIC to complete any emergency searches orrescues. They will provide the suppressioncompanies the opportunity to regroup and take aroll call instead of performing rescue operations.When the RIT enters to perform a search andrescue, they should have full cylinders on theirSCBAs and be physically prepared. When a RITteam is used in an emergency situation, anadditional RIT team should be put into place incase an additional emergency situation arises. Thisadditional RIT team should be comprised of fresh,well-rested fire fighters.

Recommendation #3: Fire departments shouldensure that fireground communication ispresent through both the use of portable radiosand face-to-face communications.3,4

During the course of the fireground operations,the IC must be heard and also must hear everyoneon the scene. All members should follow radiocommunications guidelines, keeping transmissionsshort, specific, and clear. However, these areascannot be completed if electronic problems occur,or not all fire fighters are equipped with portablecommunication equipment. Therefore, fire

departments should implement a backupcommunications plan to avoid a communicationbreakdown on the fireground. The plan shouldinclude backup electronic equipment, additionalchannels, training, and consideration of face-to-face communications, or the utilization of runnersto communicate an important message if radiocommunication fails.

Recommendation #4 : Fire departments shouldensure that exterior fire attack is at a minimumduring search and rescue.5

Once search and rescue operations are in place,fire departments should ensure that the fire fighterscompleting the search and rescue are not placedin danger by the fire attack. It is a complicatedprocedure to determine the position of the firefighters completing search and rescue operationsin the interior, from an exterior position. If anexterior fire attack is being performed while theinterior search and rescue operations are takingplace, there is a possibility that the fire could shiftand place the interior fire fighters conductingsearch and rescue operations in an unsafe position.Additionally, the use of an exterior hoseline todirect water through a window could possiblycause a collapse, placing the interior fire fightersin a dangerous position. Command and operationsmust be in communication at all times on thefireground to ensure coordination of tactics.

Recommendation #5: Fire Departments shouldensure fire fighters are trained to recognize thedanger of searching above a fire.6

The danger of being trapped above a fire is greatlyinfluenced by the construction of the burningbuilding. Of the five basic building constructiontypes�fire resistive, noncombustible, ordinaryconstruction, heavy timber, and wood frame�thegreatest danger to a fire fighter who must search





above the fire is posed by wood frameconstruction. Vertical fire spread is more rapid inthis type of structure. Flames may spreadvertically and trap fire fighters searching abovethe fire in four ways: up the interior stairs,windows (autoexposure), concealed spaces, andflame spread up the combustible exterior siding.

Although there is no evidence that it contributedto this fatal event, the following recommendationis being provided as a reminder of good safetypolicy.

Recommendation #6: Fire departments shouldensure consistent use of personal alert safetysystem (PASS) devices at all incidents andconsider providing fire fighters with a PASSintegrated into their self-contained breathingapparatus.

PASS devices are electronic devices worn by thefire fighter, which will emit a loud and distinctivealarm if the fire fighter becomes motionless formore than 30 seconds. Fire fighters enteringhazardous areas should be equipped with a PASSdevice. There are several types of PASS devicesavailable. One device that could be used is a PASSthat is integrated into the SCBA. PASS devicesintegrated into the SCBA will be activated whenthe SCBA air cylinder is turned on. Manual PASSdevices are also used throughout the fire service.These devices require the fire fighter to manuallyturn on the device each time they use it.

REFERENCES1. Brannigan FL [1999]. Building constructionfor the fire service. Quincy, MA: National FireProtection Association.

2. National Fire Protection Association [1997].NFPA 1500, standard on fire departmentoccupational safety and health program. Quincy,MA: National Fire Protection Association.

3. Dunn V [1998]. Collapse of burning buildings,a guide to fireground safety. Saddle brook, NJ:Fire Engineering Books and Videos.

4. NFPA [1995]. NFPA 1561, Standard on firedepartment incident management system. Quincy,MA: National Fire Protection Agency.

5. Coleman J [1997]. Incident management forthe street-smart fire officer. Saddle Brook, NJ:Fire Engineering MA: National Fire ProtectionAssociation.

6. Dunn V [1992]. Safety and survival on thefireground. Saddle Brook, NJ: Fire EngineeringBooks and Videos.

INVESTIGATOR INFORMATIONThis investigation was completed by, Thomas P.Mezzanotte and Kimberly L. Cortez, Safety andOccupational Health Specialists, Division ofSafety Research, Surveillance and FieldInvestigations Branch.





Photo 1. Points of Entry of Fireground Personnel for Fire Suppressionand Rescue Crews

Door thevictim’s crew

enteredGarage door where

interior suppression andrescue crews entered





Photo 2. Rear of the Structure, Bathroom Area

Bathroom Vent inrear of thestructure





Figure 1. Aerial View of First Floor

BedroomBedroom

Bedroom

Living Room Bedroom

BathroomKitchen

Hallway

Area in whichthe victim fellthrough the floor

Initial entry ofvictim’s crew

Second entry ofvictim’s crew

KEY

Not To Scale





Garage Utility Room Bedroom

Retaining Wall

Area wherevictim was

found

Opening in rearof the strucutre

Path of Rescue Teams

Not To Scale

Figure 2. Aerial View of Basement





ATTACHMENTThe following is a summary of NIOSH Task No. TN-11541. For a full report, including attachments, photos,and tables, contact NIOSH, Division of Respiratory Disease Studies, Respirator Branch at (304) 285-5907.

NIOSH Reference: TN-11541

Phone: (304) 285-5907Fax: (304) 285-6030October 10, 2000

John S. Robison,State Fire MarshalState of AlabamaDepartment of Insurance201 Monroe Street, Suite 1780P. O. Box 303352Montgomery, Alabama 36130-3352

Dear Sir:

The National Institute for Occupational Safety and Health (NIOSH) has concluded itsinvestigation conducted under NIOSH Task Number TN-11541. This investigation consistedof the inspection and performance-testing of one self-contained breathing apparatus (SCBA)shipped to NIOSH by your office on May 25, 2000. The primary purpose of this investigationwas to determine the SCBA�s conformance to the NIOSH certification requirements of Title42, Code of Federal Regulations, Part 84 (42 CFR 84). Six selected performance tests wereconducted in accordance with these NIOSH approval requirements. In order to provide youwith additional information about the SCBA�s performance, the National Fire ProtectionAssociation (NFPA) Air Flow Performance test, was also conducted. The NFPA Air FlowPerformance test was conducted in accordance with NFPA 1981, Standard on Open-CircuitSelf-Contained Breathing Apparatus for the Fire Service - 1997 Edition. Our inspectionreport and results of all tests are contained in a detailed Status Investigation Report which isenclosed.

Inspection of the SCBA shipped to NIOSH by the Alabama State Fire Marshal was completedon July 31, 2000. The NIOSH approval label is damaged but readable. The label indicatesthat the SCBA is a Mine Safety Appliances (MSA) Ultralite II, 30-minute, 2216 psi, SCBA

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Controland Prevention (CDC)

National Institute for OccupationalSafety and Health - ALOSH1095 Willowdale RoadMorgantown, WV 26505-2888





ATTACHMENT (continued)

(NIOSH approval number TC-13F-138). The SCBA is worn and has the appearance ofhaving seen considerable use. The facepiece lens is considerably dirty. The visibility throughthe lens is very poor.

The compressed air cylinder shipped with the SCBA is a Survivair 2216 psi cylinder. It isimportant to note that the NIOSH regulations listed in Subpart D of Title 42, Code ofFederal Regulations (CFR), Part 84, Section 84.30 (a) and (b) state:

(a) The Institute shall issue certificates of approval pursuant to the provision of thissubpart only for individual, completely assembled respirators which have beenexamined, inspected, and tested, and which meet the minimum requirements set forthon subparts H through L of this part, as applicable.(b) The Institute will not issue certificates of approval for any respirator componentor for any respirator subassembly.

While the Survivair cylinder shipped with the MSA SCBA is approved for use on severalSCBA with certificates of approval held by Survivair, this cylinder is not a part of any ofMSA�s NIOSH-approved configurations. Therefore, the MSA SCBA with the Survivaircylinder attached, is not considered to be a NIOSH-approved SCBA configuration.

The SCBA was thoroughly inspected and determined to be in a condition safe for testing.The Survivair cylinder from the Center Point Fire Department was used during the perfor-mance testing even though the use of a Survivair cylinder on an MSA SCBA represents anunapproved configuration. Performance testing was initiated on August 1, 2000, and wascompleted on August 2, 2000. The SCBA met the requirements of five of the six NIOSHperformance tests conducted. The SCBA failed to meet the requirements of the NFPA AirFlow Performance Test. The complete SCBA test report with results of all performancetesting conducted on the SCBA is presented in Attachment Three of the enclosed report.

While the SCBA was tested with the cylinder shipped with the unit, this is not meant tocondone the use of a Survivair cylinder with an MSA SCBA. In fact, this SCBA configura-tion is not approved by NIOSH.

During the Static Facepiece Pressure test, the facepiece pressure was found to be slightlyhigher than the NIOSH limitation. Excessive static facepiece pressure could potentiallyshorten the duration time of the SCBA air supply due to air leakage through the facepieceexhalation valve. However, this SCBA met the requirements of the Rated Service Time Test.While the unit failed to maintain positive pressure during the NFPA Air Flow PerformanceTest, the possibility of inward leakage into a firefighter�s facepiece would be dependant upon





ATTACHMENT (continued)

the face to facepiece seal, the ventilation rate at the time of use, as well as other factors suchas age, weight, and the physical condition of the firefighter. Test results indicate that air wasflowing to the facepiece in a sufficient quantity to meet the NIOSH requirements. It shouldbe noted that the SCBA facepiece pressure remained positive throughout the NIOSH RatedService Time Test. It is also important to note that the SCBA was evaluated in the �asreceived� condition. The condition of the SCBA prior to the incident cannot be determined.

It is strongly recommended that this SCBA be inspected and serviced by an authorized MSAservice technician, all necessary overhaul and repair work be completed, and the SCBAreturned to a NIOSH-approved configuration by incorporating a proper MSA compressed aircylinder before placing the unit back into service. It is also recommended that all SCBAinspection, handling, use, and maintenance procedures be reviewed with regard to activitiesand practices that could impact the safe use of all SCBA.

No further action will be taken by NIOSH and the investigation of Task Number TN-11541will be considered closed. The SCBA will be stored under lock in room H-178A of theNIOSH Appalachian Laboratory for Occupational Safety and Health (ALOSH) pendingreturn to your office.

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 ScientistQuality Assurance TeamRespirator BranchDivision of Respiratory DiseaseStudies

A Summary of a NIOSH fire fighter fatality …Residential Structure Fire Claims the Life of One...

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