On June 24, 2018, a 33-year-old male career part-time fire fighter (Fire Fighter 2) died after being struck in the head by a pressurized compressed-air self-contained underwater breathing apparatus (SCUBA) cylinder. Fire Fighter 2 was working his regular shift at Station 22 and was assisting Fire Fighter 1 and an off-duty captain with the inspection of a lot of 22 used SCUBA cylinders.
The SCUBA cylinders had been recently privately purchased by members of the fire department’s dive rescue team. The cylinders were all used and all had expired hydrostatic retest dates stamped on the cylinders. The fire fighters were draining the air from the cylinders and removing the cylinder valves so that the cylinders could be sent out to be hydrostatically retested and requalified.
Some of the cylinder valves were stuck shut preventing the fire fighters from bleeding off the cylinders’ contents through the cylinder valve. In order to bleed off the cylinder contents from the cylinders with the stuck valves, Fire Fighter 1 was instructed to loosen the pressure-relief burst disc plugs on the cylinder valves approximately 1 ½ to 2 turns, while Fire Fighter 2 assisted the captain in removing cylinder valves from the empty cylinders.
During this process, one of the pressure-relief plugs separated from the valve body which created an unrestricted oriface through which the cylinder contents vented.
The unsecured cylinder began to spin, rotate and bounce off the engine bay floor until it became an airborne projectile. The airborne cylinder struck a concrete block wall, causing the cylinder valve body to shear off, resulting in a larger oriface for the cylinder contents to vent through.
Photo shows estimated travel path (estimated by State Fire Marshal’s Office investigators and County Sheriff’s Deputies) of the cylinder after it struck wall and the cylinder valve broke off. This caused the air to escape the cylinder at an increased rate. The cylinder bounced off the wall and was projected across the engine bay where the cylinder struck the right rear corner of Engine 22 (Position 8), then struck the Fire Fighter 2. The step ladder at Position 9 marks the approximate location of Fire Fighter 2 who was moving to take cover behind the brush truck. After striking Fire Fighter 2, the SCUBA cylinder fell to the floor and continued moving along the path indicated by the orange tape from Position 10 to Position 15 where the cylinder came to rest near the exercise weight equipment. Also see Photo 8 and Photo 10. (Photo courtesy of State Fire Marshal’s Office)
The cylinder was projected off the concrete block wall diagonally across the engine bay where it struck the right rear corner (officer side) of the engine, then glanced off the engine striking Fire Fighter 2 in the head.
Photo shows estimated travel path (estimated by State Fire Marshal’s Office investigators and County Sheriff’s Deputies) of the cylinder after it struck the rear corner of Engine 22 (point 8), then struck the fire fighter at approximately Point 9 before falling to the engine bay floor (point 10) and expending energy as it moved across the engine bay floor before coming to rest at Point 15 near the exercise weight equipment. Also see Photo 8 and Photo 9. (Photo courtesy of State Fire Marshal’s Office)
The other two fire fighters immediately began to administer first aid to the fallen fire fighter. Fire Fighter 1 called dispatch for an air medic helicopter and an ambulance. Within minutes, Fire Fighter 2 was transported via helicopter to a regional trauma hospital where he was pronounced dead.
- Unsecured pressurized SCUBA cylinder
- Unknown hazards associated with old, out-of-date cylinders with stuck valves
- Limited training and experience on the task
- Non-routine maintenance on pressurized SCUBA cylinders
- Selection, care and maintenance of SCUBA equipment
- Inadequate risk versus gain analysis.
- Fire departments should ensure that pressurized cylinders of all types are properly stored, handled and maintained in a safe manner following the manufacturer’s recommendations and industry best practices by qualified and properly trained individuals.
- Fire departments should follow guidance provided by NFPA 1852 Standard on Selection, Care, and Maintenance of Open-Circuit Self-Contained Breathing Apparatus (SCBA) and apply it to self-contained underwater breathing apparatus (SCUBA).
Additionally, federal, state, local, and municipal governments, standards-setting organizations and authorities having jurisdiction should:
- Consider developing and adopting a national standard on public safety dive teams and public safety dive operations including guidelines for the selection, care and maintenance of SCUBA equipment.