# Two Career Lieutenants Killed and Two Career Fire Fighters Injured Following a Flashover at an Assembly Hall Fire—Texas/Appendix I

Appendix I
Status Investigation Report of Four Self-Contained Breathing Apparatus Submitted by the NIOSH Division of Safety Research on behalf of the this Texas Fire Department NIOSH Task Number 18986 (Note: The full report is available upon request.)
Background
As part of the National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program, the Technology Evaluation Branch agreed to examine and evaluate four SCBA identified as Scott Health and Safety model AirPak 4.5, 4500 psi, 30-minute, selfcontained breathing apparatus (SCBA).
This SCBA status investigation was assigned NIOSH Task Number 18986. The NIOSH Division of Safety Research (NIOSH/DSR) and this Texas Fire Department was advised that NIOSH would provide a written report of the inspections and any applicable test results. The SCBA units, contained within cardboard boxes, were delivered to the NIOSH facility in Bruceton, Pennsylvania on March 12, 2013. After their arrival, the packages were taken to building 20 and stored under lock until the time of the evaluations.
SCBA Inspection
The packages were opened initially in the General Respirator Inspection Area (building 20) on March 27, 2013 and an initial visual inspection was conducted by Tom Pouchot, General Engineering NPPTL. The SCBAs were inspected extensively on successive dates of April 2, 3, 4 and 5, 2013. The SCBA identified as FF#1 was labeled by NPPTL as SCBA Unit #1. The SCBA identified as Victim #1 was labeled by NPPTL as SCBA Unit #2. The SCBA identified as FF#2 was labeled by NPPTL as SCBA Unit #3. The SCBA identified as Victim #2 was labeled by NPPTL as SCBA Unit #4. These SCBA units were extensively examined, component by component, in the condition received to determine the conformance of the unit to the NIOSH-approved configuration. The units were identified as the Scott Health and Safety Company model AirPak 4.5, 30 minute, 4500 psi units, NIOSH approval numbers TC-13F-0076 for Unit # 3, TC-13F-0076CBRN for Unit #2 and unknown for Units #1 (label shows TC-13F-0080, a 2216 PSIG unit, but the unit is a 4500 PSIG SCBA) and #4 as the NIOSH label was covered. The visual inspection process was documented photographically.
Also on June 14, 2013 Scott Health and Safety conducted a down loading of the data logger for SCBA #2. Once all inspections were completed, the SCBA units were repackaged and placed back in building 20 under lock. The complete SCBA inspections are summarized in Appendix I of the NPPTL report. The condition of each major component of each of the SCBA’s that were photographed with a digital camera is contained in Appendix III of the NPPTL report. ​It was judged that only Unit #3 of the 4 SCBA units could be safely pressurized and tested using a substitute cylinder provided by the Texas Fire Department and a substitute facepiece from NIOSH. Unit #3 was tested on April 18, 2013.
SCBA Testing
The purpose of the testing was to determine the conformance of the SCBA 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 conformance of each SCBA 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.
NIOSH SCBA Certification Tests (in accordance with the performance requirements of 42 CFR 84):
    1. Positive Pressure Test [§ 84.70(a)(2)(ii)]
    2. Rated Service Time Test (duration) [§ 84.95]
    3. Static Pressure Test [§ 84.91(d)]
    4. Gas Flow Test [§ 84.93]
    5. Exhalation Resistance Test [§ 84.91(c)]
    6. Remaining Service Life Indicator Test (low-air alarm) [§ 84.83(f)]
National Fire Protection Association (NFPA) Tests (in accordance with NFPA 1981, 1997 Edition):
    7. Air Flow Performance Test [Chapter 5, 5-1.1]
Unit #3 was the only unit in a condition to be tested. This unit was tested on April 18, 2013 using a substitute cylinder and facepiece. NIOSH was unable to perform the NFPA test as the test set up was inoperable.
Appendix II of the NPPTL report contains the complete NIOSH test reports for the SCBA. Tables One and Two summarize the NIOSH and NFPA test results.
Summary and Conclusions
Four SCBA units were submitted to NIOSH by the NIOSH Division of Safety Research for this Texas Fire Department for evaluation. The SCBA units were delivered to NIOSH on March 12, 2013 and initially inspected on March 27, 2013. The units were identified as a Scott Health and Safety model AirPak 4.5, 4500 psi, 30-minute, SCBA (NIOSH approval numbers TC-13F-0076, Unit #3 and TC13F-0076CBRN, Unit #2). Scott Health and Safety performed a downloading of the Unit #2 data logger on June 14, 2013. The complete inspections of the SCBA units were conducted on April 2, 3, 4 and 5, 2013. The units suffered varying levels of heat damage, exhibited other signs of wear and tear and the units were covered generally with dirt, grime, some foreign material and soot. The cylinder valves as received on Unit #1, #2, #3 and #4 were in the closed position. The cylinder gauge could not be read on Unit #1 from the front. The cylinder gauge on Unit #2 read 0 psig. The cylinder gauges on Unit #3 and #4 could not be read due to heat damage. The cylinder valve hand-wheels could be ​turned. The regulator and facepiece mating and sealing areas on Units #1, #2, #3 and #4 were relatively clean and there was minimal debris on the inside of the facepieces. All the units had varying degrees of lens damaged due to heat. The lens on Units #2 and #4 had holes. The facepiece head harness webbing on the Units #1, #2 and #3 were in fair condition with dirt present and only some evidence of wear or damage. Unit #4 had the left side straps not attached to the facepiece as the attachment hardware was damaged and the hairnet was black. Only the PASS on Unit #3 functioned. The NFPA approval labels on Units #2, #3 and #4 were present and readable. Unit #1 did not have a NFPA label visible. Visibility through all the facepiece lenses was poor as the lenses had heat damage.
The air cylinder on Unit #2 had a manufactured date of 01/04. The air cylinder on Unit #1 had a partial date visible of 2003. Under the applicable DOT-E-10945-4500 exemption, the air cylinder is required to be hydro tested every 5 years. For the air cylinder on Unit #2, a retest date before the last day of 01/09 is required. No retest labels were readable on Unit #2, therefore it is not possible to determine if the cylinder was within the hydro certification when last used. The Unit #1 cylinder also could not be determined if the cylinder was within hydro certification when last used. The Unit #3 and Unit #4 cylinders could not determine a manufacturer date or re-hydro date. Therefore, it could not be determined if the cylinders were within hydro certification when last used. All the cylinders were mostly black. The fiber wrap on the cylinder of Unit #4 was exposed and damaged. No air was remaining in any of the cylinders.
A replacement air cylinder with a current hydrostatic re-test qualification was supplied by the Texas Fire Department. This cylinder was substituted for all Unit #3 tests. In addition, the facepiece on Unit #3 was damaged and this facepiece was replaced by a facepiece supplied by NIOSH. No other maintenance or repair work was performed on the units at any time.
SCBA Unit #3 met the requirements of the NIOSH Positive Pressure Test, with a minimum pressure of 0.05 inches of water. Unit #3 met the requirements of all of the other NIOSH tests.
In light of the information obtained during this investigation, NIOSH has proposed no further action on its part at this time. Following inspection and testing, the SCBAs were returned to storage pending return to the Texas Fire Department.
If some of the units are to be placed back in service, the SCBA's must be extensively repaired, tested, cleaned, damaged components replaced and inspected by a qualified service technician, including such testing and other maintenance activities as prescribed by the schedule from the SCBA manufacturer. Typically a flow test is required on at least an annual basis.