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Executive Summary 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 1⁄2 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. 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. 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. 

Close-up photo shows broken cylinder valve and neck area 

of SCUBA cylinder that struck the 33-year old fire fighter.

(NIOSH Photo)
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Contributing Factors • 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.

Key Recommendations

• 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.

The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and 

Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of 

work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the 

NIOSH Fire Fighter Fatality Investigation and Prevention Program, which examines line-of-duty deaths or on-duty deaths of fire 

fighters to assist fire departments, fire fighters, the fire service, and others to prevent similar fire fighter deaths in the future. The 

agency does not enforce compliance with state or federal occupational safety and health standards and does not determine fault or 

assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH 

investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop 

a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and 

interviews are not recorded. The agency's reports do not name the victim, the fire department, or those interviewed. The NIOSH 

report's summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency's 

recommendations and is not intended to be definitive for purposes of determining any claim or benefit.

For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
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2018

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Introduction

On June 24, 2018, a 33-year-old male career part-time fire fighter died after being struck in the head by 

a pressurized compressed-air self-contained underwater breathing apparatus (SCUBA) cylinder. On 

Monday, June 25, 2018, the Director of the Ohio Public Employment Risk Reduction Program 

contacted the National Institute for Occupational Safety and Health and requested NIOSH assistance. 

That same day the fire department directly contacted the NIOSH Fire Fighter Fatality Investigation and 

Prevention Program to request assistance with an investigation. On June 26, 2018, the U.S. Fire 

Administration notified NIOSH of this incident. 

On June 28, 2018, a safety engineer with the NIOSH Fire Fighter Fatality Investigation and Prevention 

Program traveled to Ohio to initiate an investigation and to inspect the incident scene at the fire 

department’s Station 22. The NIOSH investigator met with the fire chief, fire department’s Human 

Resources manager, the fire department’s officer responsible for training activities who was also an 

officer of the International Association of Fire Fighters local union, a representative of the State of 

Ohio Bureau of Workers’ Compensation, Public Employment Risk Reduction Program, and a 

representative of Ohio Department of Commerce, Division of State Fire Marshal. The incident scene 

was inspected and photographed. The NIOSH safety engineer and the two Ohio state employees then 

traveled to the local county sheriff’s office to inspect two cylinders and cylinder valve components 

involved in the incident that were being held in custody by the sheriff’s office.

On July 2, 2018, the safety engineer returned to Ohio to continue the investigation, along with the 

Medical Officer from the NIOSH Fire Fighter Fatality Investigation and Prevention Program Medical 

Component located in Cincinnati, Ohio. The NIOSH investigators obtained copies of the fire fighter’s 

training records, fire department standard operating procedures, the dispatch audio records for the 

incident and county coroner’s reports. Interviews were conducted with the fire fighters directly 

involved in the incident.

Fire Department

This combination fire department provides fire suppression and emergency medical (EMS) services 

across parts of two counties where it serves a population of approximately 41,000 residents across a 

geographical area of about 362 square miles. The daytime population increases to over 75,000.

The fire department operates as a joint emergency medical services (EMS) and fire protection district. 

The joint EMS/fire district is governed by a board of directors. The fire chief, a fiscal officer, and the 

human resources director report to the board of directors. The fire department employs an assistant fire 

chief and a fire safety inspector. The fire department operates three shifts with a minimum staffing 

level of 11 career (full and part-time) fire fighters per shift. Each shift is supervised by a shift captain 
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and a shift lieutenant. The fire department currently operates out of four stations across the district. 

Table One lists the apparatus and equipment housed at each station.

Table One

Station 10 Station 21 Station 22 Station 23

Tender 212

Utility 248

Medic 226

Brush 247

Engine 201

Rescue 234

Medic 220

Medic 221

Engine 202

Medic 222

Brush 245

Boat 200

4-wheel ATV

Engine 203

Tender 214

Rescue 232

Tower 236

Brush 246

Medic 223

Medic 224

Medic 225

UTV 200

FEMA trailer

Utility 249

Table Two highlights the number of emergency calls that the fire department responded to over the 

past three years.

Table Two

Year 2015 2016 2017 2018*

Fire 480 590 557 318

EMS 4,428 4,516 4,870 2,817

Total 4,908 5,106 5,427 3,135

*through 

7/23/2018
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At the time of the incident, the fire department was in the process of re-establishing a fire department 

dive rescue team that had been disbanded under a previous fire chief. The current chief had been 

working with fire department members (both career and volunteer) over the past year to re-establish 

the dive rescue team. In order to be a member of the fire department dive team, the individual fire 

fighter is responsible for obtaining their Open Water certification. After that, the department covers the 

cost for the additional trainings such as Advanced Open Water, Rescue Diver, and Recovery Diver. At 

the time of the incident, the fire department had not established standard operating procedures or 

guidelines covering the dive rescue team. The fire department did have a set of draft standard operating 

procedures that were in the process of being reviewed and adopted as official standard operating 

procedures.

Training and Experience

The state of Ohio has three certification levels for fire fighters: Volunteer, Fire Fighter Level I, and 

Fire Fighter Level II:

• Volunteer Fire Fighter requires 36 hours of training in basic concepts, equipment, and 

techniques. This training does not include live fire training. After successful completion, 

the student may take the state certification examination.

• Fire Fighter I requires a minimum of 156 hours training that includes a comprehensive 

introduction of basic fire-fighting concepts and skills and permits the students to practice 

the skills, including live fire training.

• Fire Fighter II requires a minimum of 104 hours of training that includes additional practice 

of skills on advanced rescue and prevention concepts, including participation in live fire 

training evolutions. Level II certification is required for full-time paid (career) fire fighters.

With the exception of full-time career fire fighters, the state of Ohio permits the authority having 

jurisdiction to determine the level of fire fighter certification. The state also requires continuing 

education credits after certification. For Fire Fighter I and Fire Fighter II, any certification after 2012 

requires 56 hours of continuing education every 3 years.

Fire department records showed that the fire fighter killed during this incident had received state 

certification in Volunteer Firefighter, Firefighter I, Firefighter II, Emergency Medical Technician, 

Advanced Emergency Medical Technician and Fire Instructor. In addition, fire department records 

showed that the fire fighter had 1,555.50 hours of on-duty activity and fire service training from 

December 2015 through June 2018.
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Incident Location

This incident occurred inside the north engine bay at the fire department’s Station 22. In addition to 

existing work benches, fire fighters had set up a table near the Side B wall to hold assorted tools, 

SCUBA cylinders, and cylinder valves (see Photo 1). The fire fighters were also working on the engine 

bay floor. The station did not have a cylinder containment vessel or system to contain cylinders. 

Photo 1: Photo shows the North engine bay at Station 22 where the incident occurred.

Photo courtesy of the State Fire Marshal’s Office.
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SCUBA Cylinder

The cylinder involved in this incident was a U.S. Department of Transportation (DOT)-approved 

model 3AL flat-bottomed aluminum cylinder manufactured in June 1991. The cylinder was designed 

to be filled with compressed gas to a maximum pressure of 3000 pounds per square inch (psi). The 

cylinder was used as a self-contained underwater breathing apparatus (SCUBA) air cylinder by a 

commercial fisherman in saltwater conditions for several years. The cylinder had been hydrostatically 

retested, in accordance with DOT requirements four times with the most recent hydrostatic retest 

conducted in September 2011. Note: Aluminum cylinders including the 3AL model cylinder are 

required to be hydrostatically retested every 5 years per DOT regulations found in Title 49, Code of 

Federal Regulations (CFR) Section 180.205. At the time of this incident, members of the fire 

department’s dive team had recently acquired a lot of 22 used 3AL aluminum cylinders. All the 

cylinders in the lot of 22 had been used for SCUBA diving in salt water conditions. All the cylinders 

had expired hydrostatic test dates so fire fighters were working to remove the cylinder valves from the 

cylinders so that the cylinders could be hydrostatically tested and requalified.

As part of the NIOSH investigation, the cylinder valve was sent to an engineering laboratory for a 

metallurgical analysis to help identify why the cylinder valve was stuck shut. Based upon the 

laboratory’s visual inspection and tests conducted, chloride-induced corrosion was the root cause of the 

failure of the regulator valve’s normal operation. Corrosion locked the regulator valve in the “closed 

positon”, and did not prevent compressed gas escaping elsewhere from the valve body at full pressure. 

See Appendix One for the laboratory conclusions and summary page. The full laboratory investigation 

report is available upon request.

 

Weather Conditions

The weather on June 24, 2018 at approximately 1354 hours (the day and approximate time of the 

incident) was mostly cloudy. The temperature was approximately 78 degrees Fahrenheit with 64 

percent relative humidity and winds from the west / northwest at 13 miles per hour. Barametric 

pressure was recorded at 28.8 inches water column [Weather Underground 2018]. The weather was not 

considered to be a contributing factor in this incident. 

Investigation

On June 24, 2018 at approximately 1410 hours, a 33-year old part-time career fire fighter was critically 

injured when he was struck in the head by a pressurized self-contained underwater breathing apparatus 

(SCUBA) breathing air cylinder. The cylinder experienced an uncontrolled leak and became an 

airborne projectile. 

On the day of the incident, two career fire fighters were working their normal shift at Station 22. Fire 

Fighter 1 was a full time employee of the fire department. Fire Fighter 2 was a 33-year-old career parttime employee. Fire Fighter 1 was also a member of the fire department’s dive rescue team, having just 

joined the dive rescue team in the past year. 
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Members of the fire department’s dive rescue team had recently privately purchased a lot of 22 used 

self-contained underwater breathing apparatus (SCUBA) air cylinders. All of the cylinders had expired 

hydrostatic test dates and all the cylinders were reported to be full of air. NOTE: At the time of this 

investigation, the fire department did not own or supply any dive rescue equipment to the dive rescue 

team members. All dive rescue team members were required to obtain their own protective equipment 

and dive gear.

The fire department’s captain in charge of the dive rescue team (off duty on this day) brought the lot of 

22 cylinders to Station 22 in his personal vehicle so that he could train Fire Fighter 1 on how to inspect 

SCUBA cylinders. Since all of the cylinders had expired hydrostatic test dates and would need to be 

requalified by an authorized test facility, it was decided to drain the air from each cylinder and remove 

the cylinder valve so that the inside of each cylinders could be visually inspected. 

Both Fire Fighter 1 and Fire Fighter 2 assisted the captain in draining the SCUBA cylinders and 

removing the cylinder valves. The ambulance normally parked in the North engine bay was moved 

outside the station so that the captain’s personal vehicle (containing the 22 SCUBA cylinders) could be 

backed into the north station bay (see Photo 1 and Diagram 1). The cylinder examination and 

inspection work was done on a table in the engine bay and also on the engine bay floor. Some of the 

cylinder valves were difficult to remove from the cylinder so the fire fighters would lay a cylinder on 

the engine bay floor so that a fire fighter could hold the cylinder while another fire fighter used 

wrenches to unthread the cylinder valve from the cylinder neck. NOTE: Station 22 did not have any 

type of cylinder containment system to secure compressed gas cylinders. Station 22 also did not have 

a table vise or similar device to securely hold and restrain a cylinder. 

During this process, the fire fighters noticed that a number of the SCUBA cylinders could not be 

drained of air because the cylinder valve hand wheels were stuck and could not be turned to open the 

valves. It was decided to drain the air from the cylinders with non-functioning (stuck) valves by 

loosening the pressure-relief disc plug slightly and allow the air to drain off through the threaded port.

Fire Fighter 1 was instructed to loosen the pressure-relief burst disc plugs on the cylinder valves 

approximately 1 1⁄2 to 2 turns, while Fire Fighter 2 assisted the captain in removing cylinder valves 

from the empty cylinders. Fire Fighter 1 began to drain the cylinders with non-functioning (stuck) 

cylinder valves by loosening the pressure-relief disc plugs with a 3/8-inch socket wrench and turning 

the plug approximately 1 1⁄2 to 2 turns until the air began to bleed off through the treads. Once the 

cylinder began to bleed off air, the cylinder was placed upright on the engine bay floor. Note: 3AL 

cylinders have flat bottoms so the cylinders would stand upright. It was reported that this process took 

60 to 90 seconds for the air to bleed off until the cylinder was empty. SCUBA cylinders do not have 

pressure gauges on the valve body so the exact cylinder pressure was unknown. Three cylinders were 

drained in this manner. During this process, one of the pressure-relief plugs separated from the valve 

body which created an unrestricted orifice through which the cylinder contents (compressed air) 

vented. While working to drain the air from a fourth cylinder, Fire Fighter 1 observed a cylinder begin 

to spin around and bounce on the floor due to the pressure escaping from the burst disc plug port. The 

spinning cylinder struck another empty cylinder (blue in color) that had already been drained of air and 

had its cylinder valve removed. The empty blue cylinder was projected across the engine bay where it 
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struck the passenger side of the engine (see Diagram 1), bounced up toward the ceiling, struck an 

overhead pipe and came to rest on the engine bay floor. 

Diagram 1. Diagram shows the approximate travel paths of the pressurized SCUBA cylinder 

and the empty blue cylinder which became airborne after being struck by the unrestrained 

pressurized cylinder. 

NIOSH Diagram.
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Hearing this commotion, the three fire fighters began to move out of the way to find cover. Fire Fighter 

1 quickly moved to his left away from the cylinders while the captain and Fire Fighter 2 moved to take 

cover behind the brush truck parked behind Engine 22 (see Diagram 1). After striking the empty blue 

SCUBA cylinder, the leaking pressurized SCUBA cylinder was launched in the opposite direction 

across the engine bay and struck the concrete block wall approximately 7 feet above the floor (see 

Photo 2 and Photo 3). When the cylinder struck the wall, the cylinder valve was sheared off at the 

cylinder neck (see Photo 4, Photo 5 and Photo 6). The valve body came to rest on the floor near the 

man door entrance to the engine bay. The valve hand wheel separated from the valve body and came to 

rest on the floor near the work bench. The cylinder was then projected at an angle back across the 

engine bay where it struck the rear corner (passenger side) of Engine 22 before glancing off the engine 

and striking Fire Fighter 2 in the head (see Photo 7 and Diagram 1). The cylinder landed on the engine 

bay floor and continued to expend energy as the remaining air was depleted, before coming to rest near 

exercise equipment located at the rear of the engine bay (see Photo 10).

Photo 2. Hole in engine bay wall caused by SCUBA cylinder (valve end) striking the wall after 

the cylinder became a projectile. 

NIOSH Photo.
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Photo 3. Exemplar SCUBA cylinder valve is held up against wall where the incident SCUBA 

cylinder struck the engine bay wall, creating a hole in the wall. Note how the shape of the 

cylinder valve matches the damaged area on the wall

NIOSH Photo.
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Photo 4. The SCUBA cylinder involved in this incident. Note the scuff marks on the cylinder 

caused by the cylinder striking the engine bay wall (see Photo 2 and Photo 3). The area 

highlighted in red is the area that impacted the wall. 

NIOSH Photo.
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Photo 5. SCUBA cylinder valve involved in the incident. This cylinder valve was broken off 

from the SCUBA cylinder when the cylinder struck the engine bay wall. It is believed that the 

valve handwheel (left side of valve in Photo above) also broke off when the cylinder struck the 

wall. See Photo 4. 

NIOSH Photo.
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Photo 6. Photo shows how cylinder valve broke off the SCUBA cylinder when the cylinder 

impacted the engine bay wall. Also see Photo 2, Photo 3 and Photo 4.

NIOSH Photo.
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Photo 7. Close-up view of the dent on the rear of Engine 22 (officer side) where the pressurized 

cylinder struck the engine before glancing off engine and striking Fire Fighter 2.

NIOSH Photo.
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The Captain and Fire Fighter 1 immediately began to administer first aid to Fire Fighter 2. Fire Fighter 

1 called dispatch for an air medic helicopter and also requested an ambulance. Within minutes, the fire 

fighter was transported via helicopter to a regional trauma hospital where he was pronounced dead. 

Photos 8 through 10 as well as Diagram 1 depict the estimated travel path of the airborne pressurized 

cylinder. State Fire Marshal’s Office investigators and local deputy sheriffs investigated the incident 

scene immediately after the incident and were able to estimate the likely travel path of the cylinder.

Photo 8. Photo depicts estimated path of cylinder after compressed air was released through 

pressure relief burst disc orifice. Cylinder was standing on end at Position 1 when it began to 

spin and rotate due to the escaping air pressure. The orange tape marks the cylinder’s travel 

path estimated by State Fire Marshal’s Office investigators and County Sheriff’s Deputies. 

Cylinder is believed to have become airborne at Position 6 and traveled in a spinning motion 

until it struck the engine bay wall at Position 7. Also see Photo 9 and Photo 10.

NIOSH graphic using photo supplied by State Fire Marshal’s Office.
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Photo 9. 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.
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Photo 10. 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.
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Contributing Factors

Occupational injuries and fatalities are often the result of one or more contributing factors or key 

events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH 

investigators identified the following items as key contributing factors in this incident that ultimately 

led to this fatality:

• 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 cylinder 

• Selection, care and maintenance of SCUBA equipment

• Inadequate risk versus gain analysis.

Cause of Death

According to the County Coroner Office death investigation report, the Fire Fighter 2 died due to blunt 

force trauma to the head and the manner of death was accidental.

Recommendations

Recommendation #1: 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. 

Discussion: 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. NFPA 1500 Standard on Fire Department 

Occupational Safety, Health and Wellness Program [NFPA 2018] outlines the general requirements 

for the safe handling, storage, and use of SCBA cylinders in Chapter 7.15. Fire departments should 

apply these requirements to self-contained underwater breathing apparatus (SCUBA) cylinders as well. 

Chapter 7.15.6 states that during the filling of SCBA cylinders, all personnel and operators shall be 

protected from catastrophic failure of the cylinder, except during specific rapid refilling processes 

which the fire department risk assessment process has identified and for which standard operating 

procedures have been incorporated [NFPA 2018].

There are a number of hazards associated with the handling, use and storage of compressed gases, 

depending upon the type of cylinder and the contents. Some of these hazards include:
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• Pressure Hazards: All compressed gases are hazardous due to the high pressure inside the 

cylinder. Damage to the cylinder valve can result in a rapid release of the high pressure gas 

propelling the cylinder causing personal injury and damage to property.

• Fire and Explosion Hazards: Flammable gases such as acetylene, butane and hydrogen can burn 

or explode under certain conditions. If flammable gases are allowed to accumulate until their 

concentration is between their defined Lower Explosion Limit (LEL) and Upper Explosion 

Limit (UEL), an explosion may occur if there is an ignition source present.

• Health Hazards: Many gases are toxic and can cause serious health problems dependent upon 

the specific gas, its concentration, length of exposure, and route of entry. Health symptoms of 

exposure to gases can be immediate, or delayed.

• Chemical Burn Hazards: Some compressed gases are corrosive. They can burn or damage skin 

on contact, burn the eyes or lungs if inhaled, as well as attack and corrode metals.

• Asphyxiation Hazards: Asphyxiation is the main hazard associated with inert gases such as 

helium, argon, and nitrogen. If these gases escape undetected into the atmosphere, they can 

quickly reduce the oxygen levels below concentrations necessary to support consciousness and 

life.

• Physical Hazards: Compressed gas cylinders are large, heavy and awkward to handle. Improper 

handling, or not properly securing cylinders while in use, can cause cylinders to fall causing 

injury to workers.

Many sources of safe handling procedures for compressed gas cylinders are available through an

internet search. One such example is a fact sheet provided by the Texas Department of Insurance, 

Division of Workers’ Compensation Resource Center. This fact sheet states “The use, storage and

handling of compressed gas cylinders presents two types of hazards. First is the chemical hazard 

associated with the cylinder contents (corrosive, toxic, flammable, etc.). Second is the physical hazard 

represented by the cylinder being under pressure. Mishandled cylinders may rupture violently, release 

their hazardous contents or become dangerous projectiles.” This fact sheet, Compressed Gas Cylinders: 

A 5-Minute Safety Training Aid can be found at the webpage 

https://www.tdi.texas.gov/pubs/videoresource/t5compressedgas.pdf [Texas TDI, 2006]. 

Another source of safe handling procedures is the Texas A & M University at Galveston Compressed 

Gas Safety Program manual [Texas A & M, 2015]. Page 11 of this manual states “If the cylinder’s 

valve does not operate properly, do not attempt to force the valve to turn. The cylinder should be 

returned to the vendor. Employees must not attempt to repair cylinders or cylinder valves or to force 

stuck or frozen cylinder valves.” This Compressed Gas Safety Program manual is available at the 

webpage 

http://www.tamug.edu/EnvironmentalHealthSafety/NO_Menu_Important_Files/Compressed%20Gases

%20Safety%20Program%2010-2015.pdf. 
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A number of additional internet sites devoted to compress gas safety stressed the point that when a 

compressed gas cylinder is encountered having a damaged or corroded valve, the user should contact 

the cylinder supplier or vendor for instructions and not attempt to repair or remove the damaged valve 

themselves.

During this incident, pressurized SCUBA cylinders were being handled in a station that did not have a 

cylinder containment system. Fire department members were in the process of draining the air from 

SCUBA cylinders so that the valves could be removed from the cylinders. Some of the SCUBA 

cylinder valves were stuck and could not be opened. Since the valves were stuck shut, fire fighters 

were loosening the pressure-relief burst disc plugs to allow the compressed air to bleed off. Performing 

this work in a cylinder containment system may have resulted in a different outcome. 

Recommendation #2: 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).

Discussion: NFPA 1852 Standard on Selection, Care, and Maintenance of Open-Circuit SelfContained Breathing Apparatus (SCBA) establishes requirements for the selection, care, and 

maintenance of self-contained breathing apparatus (SCBA) as required by the respiratory protection 

program in NFPA 1500: Fire Department Occupational Safety and Health Program to reduce health 

and safety risks associated with improper maintenance, contamination, or damage [NFPA 2019].

While NFPA 1852 specifically covers self-contained breathing apparatus (SCBA), self-contained 

underwater breathing apparatus (SCUBA) are very similar in function to SCBA. Since many fire 

departments provide public safety dive teams as part of their response coverage, fire departments 

should evaluate the guidelines and requirements found in NFPA 1852 and apply these applicable 

guidelines and requirements to SCUBA equipment.

For example, NFPA 1852, Chapter 7 covers maintenance. Chapter 7.1.3.4 states “Users shall not 

perform work beyond the limits of the organization’s SOPs and their training and shall not exceed 

what is allowed by the manufacturer’s written instructions.” This practice should be applied to both 

SCBA and SCUBA equipment. Chapter 7.2.3.8 states “Cylinder repairs shall be limited to only those 

conditions specified by the SCBA manufacturer. [NFPA 2019]. As noted, these guidelines and 

requirements, while developed for SCBA, could be easily adapted by fire departments to cover 

SCUBA equipment.

NFPA 1852, Chapter 7.3.5 states “Where filling breathing air cylinders during routine maintenance, all 

operators and personnel shall be protected from catastrophic failure of the cylinder by a SCBA fill 

station that meets the requirements specified in Section 24.9 of NFPA 1901 [NFPA 2019]”. NFPA 

1901, Section 24.9 covers SCBA or SCUBA Air Cylinder Fill Station requirements. Additional design 

requirements for SCBA and SCUBA air cylinder fill stations are also included [NFPA 2016]. Note: 

While NFPA 1901, Section 24.9.1.1 which states “The fill station shall fully enclose the cylinder 

during filling to contain the fragments if a cylinder ruptures,” applies to fill systems mounted on fire 
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apparatus, good safety and health practice suggests that all cylinder fill stations should fully enclose 

the cylinder being filled.

During this incident, fire fighters were performing not-routine maintenance on used SCUBA cylinders 

with stuck valves that were pressurized. A cylinder fill station or a means to fully enclose the cylinders 

was not available at the fire station. Non-routine maintenance should only be attempted by qualified 

and trained individuals following the manufacturer’s guidelines and specifications. If fire departments 

do not have the prerequisite training, knowledge, and skills to perform the maintenance required, the 

fire department should seek assistance from the manufacturer or a manufacturer-qualified vendor.

Recommendation #3: Fire departments and authorities having jurisdiction (AHJ) should conduct a 

hazard identification and risk assessment analysis of their response areas and incident scenes to 

determine what resources are needed to conduct technical search and rescue operations in 

accordance with NFPA 1670 and NFPA 1500.

Discussion: Although there is no evidence that the following recommendation would have prevented 

this fatality, it is being provided as a reminder of best safety practice for the fire service. Technical 

rescue incidents are “low frequency/high risk” events. The primary purpose of risk assessment is to 

focus on incidents that might not occur very often (low frequency) but that could have severe 

consequences associated with them (high risk). The reason for the focus on low frequency/high risk 

incidents is that since they do not occur on a frequent basis, responders might not be as prepared to 

deal with them, and the outcomes can be harmful or detrimental to fire fighters (see Diagram 2).

According to NFPA 1670 Standard on Operations and Training for Technical Search and Rescue 

Incidents, Chapter 4.2.1, states, “The AHJ shall conduct a hazard identification and risk assessment of 

the response area and shall determine the feasibility of conducting technical search and rescue 

operations.” Chapter 4.2.2 states, “The hazard identification and risk assessment shall include an 

evaluation of the environmental, physical, social, and cultural factors influencing the scope, frequency 

and magnitude of a potential technical search and rescue incident and the impact they might have on 

the ability of the AHJ to respond to and to operate while minimizing threats to rescuers at those 

incidents” [NFPA 2017b]. 

According to NFPA 1500 Standard on Fire Department Occupational Safety, Health and Wellness 

Program, a risk management plan serves as documentation that risks have been identified and 

evaluated and that a reasonable control plan has been implemented and followed [NFPA 2018]. 

Determining the frequency and severity of occurrence of risks will serve as a method for establishing 

priorities.
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High Frequency

Low Risk

Low Frequency

Low Risk

High Frequency

High Risk

Low Frequency

High Risk

 

FREQUENCY

R

I

S

K 

Diagram 2 

The hazard identification and risk assessment determines “what” can occur, “when” (how often) it is 

likely to occur, and “how bad” the effects could be. In other words, the hazard identification and risk 

assessment is necessary in order for fire departments and AHJs to determine what the hazard is, how 

often it is likely to occur, the location it is likely to occur, and what actions are necessary to mitigate 

the threats. 

Fire departments and authorities having jurisdiction at the local, state and federal level can help ensure 

the safety of emergency responders who must respond to drownings and other incidences where public 

safety dive rescue teams are needed by conducting hazard identification and risk assessment surveys 

within their response areas. These surveys should include both existing water hazards (lakes, rivers, 

streams, reservoirs, and standing bodies of water) and anticipated flood-prone areas based upon 

historical data. The survey should also include flood maps and identify other site-specific hazards. 

These survey plans should also identify the specific personal protective clothing and equipment 

necessary to respond to the different hazards identified by the survey. 

Once the hazard identification and risk assessment is developed, fire departments and AHJs can use 

this information to ensure that all fire fighters and emergency responders are trained and properly 

equipped to address all potentially dangerous areas of concern during dive rescue operations and other 

types of water rescue, following the requirements outlined in NFPA 1670. 
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Recommendation #4: Fire departments and authorities having jurisdiction should ensure that they 

identify the operational level for technical search and rescue they are capable of providing. 

Discussion: Although there is no evidence that the following recommendation would have prevented 

this fatality, it is being provided as a reminder of best safety practice for the fire service. As previously 

noted, fire departments and authorities having jurisdiction are required by NFPA 1670 to identify the 

operational level for technical search and rescue that they are capable of providing, based upon hazard 

identification, risk assessment, training level of personnel, and availability of internal and external 

resources. Fire fighters should be trained to the appropriate operational level based upon the 

requirements of NFPA 1006 Standard for Technical Rescuer Professional Qualifications [NFPA 

2017a]. NFPA 1006, Chapter 18 covers dive rescue operations. Additionally, NFPA 1006, Chapter 16 

covers surface water operations; Chapter 17 covers swiftwater rescue; Chapter 19 covers ice rescue; 

Chapter 20 covers surf rescue; Chapter 21 covers watercraft rescue; and Chapter 22 covers floodwater 

rescue operations. Each rescue discipline is covered at the awareness level, operations level and 

technician level.

The Awareness Level represents the minimum capability of organizations that provide response to 

technical search and rescue incidents. Operations Level represents the capability of organizations to 

respond to technical search and rescue incidents and to identify hazards, use equipment, and apply 

limited techniques specified in this standard to support and participate in technical search and rescue 

incidents. The Technician Level represents the capability of organizations to respond to technical 

search and rescue incidents and to identify hazards, use equipment, and apply advanced techniques 

specified in this standard necessary to coordinate, perform, and supervise technical search and rescue 

incidents” [NFPA 2017b]. NFPA 1670, Chapter 4.1.3, states, “In jurisdictions where identified hazards 

might require a search and rescue capability at a level higher than awareness, a plan to address this 

situation shall be written.” Chapter 4.1.3.2 further states, “Where an advanced level of search and 

rescue capability is required in a given area, organizations shall have a system in place to utilize the 

most appropriate resource(s) available, through the use of local experts, agreements with specialized 

resources, and mutual aid. [NFPA 2017b]”

During this incident, the fire department involved was in the process of re-establishing a fire 

department dive rescue team. At the time of the incident, the fire department had draft standard 

operating procedures covering dive rescue operations. These draft SOPs had not been finalized by the 

fire department. NFPA 1670 requires that rescuers expected to enter water for search and rescue 

operations operate at the technician level and be trained to the requirements of NFPA 1006 Standard 

for Technical Rescuer Professional Qualifications.

Recommendation #5: Fire departments should ensure that fire fighters who engage in water rescue 

operations are properly trained and equipped for the assigned task as outlined by NFPA 1670 

Standard on Operations and Training for Technical Search and Rescue Incidents.

Discussion: Although there is no evidence that the following recommendation would have prevented 

this fatality, it is being provided as a reminder of best safety practice for the fire service. Virtually 
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every jurisdiction in North America has the potential for water rescue and recovery operations. These 

situations can occur in swimming pools, ponds, lakes, rivers, streams, drainage canals and other bodies 

of water [Dodson 2007, IFSTA 2008]. Water, the very ingredient that fire fighters regularly use to 

extinguish fires has caused numerous fire fighter injuries and deaths [Dodson 2007, NIOSH 2002, 

NIOSH 2010, NIOSH 2011].

National Fire Protection Association (NFPA) 1670, Standard on Operations and Training for

Technical Search and Rescue Incidents was developed to define specific levels of preparation and 

operational capability that should be achieved by any authority having jurisdiction (AHJ) who has the 

responsibility for conducting technical rescue operations. The purpose of this standard is to assist the 

AHJ in accessing technical search and rescue hazards within the response area, to identify the level of 

operational capability, and to establish operational criteria [NFPA 2017b]. 

NFPA 1670, Chapter 4.1.1, states, “The authority having jurisdiction (AHJ) shall establish levels of 

operational capability needed to conduct operations at technical search and rescue incidents, based on 

hazard identification, risk assessment, training level of personnel, and availability of internal and 

external resources.” Chapter 4.1.2 states “At a minimum, all technical search and rescue organizations 

shall meet the awareness level for each type of search and rescue incident for which the AHJ has 

identified a potential hazard. Chapter 4.1.4 of NFPA 1670 identifies the following operational levels 

for technical search and rescue and as noted, requires that standard operating procedures be 

established. Quoting NFPA 1670, Chapter 4.1.4:

“The AHJ shall establish written standard operating procedures (SOPs) consistent with one of 

the following operational levels for each of the disciplines defined in this document. 

(1) *Awareness Level. This level represents the minimum capability of organizations 

that provide response to technical search and rescue incidents.

(2) *Operations Level. This level represents the capability of organizations to respond 

to technical search and rescue incidents and to identify hazards, use equipment, and 

apply limited techniques specified in this standard to support and participate in 

technical search and rescue incidents.

(3) Technician Level. This level represents the capability of organizations to respond 

to technical search and rescue incidents and to identify hazards, use equipment, and 

apply advanced techniques specified in this standard necessary to coordinate, 

perform, and supervise technical search and rescue incidents.” [NFPA 2014b].

Chapter 4.1.5 states that it is not the intent of this document to have an organization deem itself 

capable of an advanced skill level in any of the disciplines defined herein simply by training or 

adhering to the requirements set forth. Maintaining an operations- or technician-level capability in any 

discipline shall require a combination of study, training, skill, and frequency of operations in that 

discipline [NFPA 2017b]. 
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Chapter 4.1.6 states that the AHJ shall establish operational procedures consistent with the identified 

level of operational capability to ensure that technical search and rescue operations are performed in a 

manner that minimizes threats to rescuers and others [NFPA 2017b]. 

Chapter 4.1.8 states that operational procedures shall not exceed the identified level of capability 

established in 4.1.4. Annex A of NFPA 1670 contains additional information to clarify this point. 

According to Annex A4.1.4(1), the “awareness level” can involve search, rescue, and recovery 

operations. Members of a team at this level are generally not considered rescuers. Annex A4.1.4(2) 

states the “operations level” can involve search, rescue, and recovery operations, but usually operations 

are carried out under the supervision of technician-level personnel [NFPA 2017b].

Chapter 4.1.10 contains information that fire departments and authorities having jurisdiction can use to 

develop training programs for technical search and rescue operations. This chapter requires that the 

training be commensurate with the operational capability of the organization. Chapter 4.1.10.4 states, 

“The AHJ shall evaluate its training program to determine whether the current training has prepared 

the organization to function at the established operational level under abnormal weather conditions, 

extremely hazardous operational conditions, and other difficult situations” [NFPA 2017b].

NFPA 1670 focuses on water search and rescue that includes six separate water-related disciplines at 

both the operations level and technician level including dive rescue (Chapter 18), as well as surface 

(Chapter 16), swift water (Chapter 17), ice (Chapter 19), surf (Chapter 20), watercraft search and 

rescue (Chapter 21), and flood water (Chapter 22) [NFPA 2017b]. NFPA 1670 includes detailed 

requirements for the standard operating procedures to be developed and implemented and the type of 

personal protective equipment and clothing to be worn during all levels of water search and rescue 

[NFPA 2017b].

At the time this incident occurred, the fire department was in the process of re-establishing a public 

safety dive rescue program. The fire department was in the process of developing standard operating 

procedures (SOPs) and guidelines (SOGs) to cover the public safety dive rescue program. Eight to 10 

fire fighters had expressed an interest in being part of the fire department’s public safety dive rescue 

program. A volunteer fire department member who was also a certified Dive Instructor was 

responsible for providing all dive rescue team training. The fire department’s draft SOPs covering dive 

rescue operations did not address SCUBA equipment maintenance or cylinder safe handling 

procedures. 

Recommendation #6: Fire departments should develop, implement, and enforce standard operating 

procedures for water search and rescue operations including dive rescue operations.

Discussion: Although there is no evidence that the following recommendation would have prevented 

this fatality, it is being provided as a reminder of best safety practice for the fire service. NFPA 1670 

Standard on Operations and Training for Technical Search and Rescue Incidents, Chapter 4.1.4,

requires the authority having jurisdiction (AHJ) to establish standard operating procedures that are 

consistent with each of the awareness, operational, and technician operational levels. Chapter 4.1.6 

states that the AHJ shall establish operational procedures consistent with the identified level of 
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operational capability to ensure that technical search and rescue operations are performed in a manner 

that minimizes threats to rescuers and others. Chapter 4.1.8 states, “Operational procedures shall not 

exceed the identified level of capability established in 4.1.4” [NFPA 2017b].

In addition to other fireground operations, standard operating procedures (SOPs) pertaining to water 

rescues should be developed to standardize practices and techniques used by fire departments. These 

SOPs should also be tailored to meet the specific needs and conditions within a response jurisdiction. 

SOPs should outline, at a minimum, the following: mandatory appropriate PPE, equipment or apparel 

likely to endanger personnel if they fall into the water or attempt a rescue, upstream safety spotters, 

personnel staged at downstream points, only properly trained personnel staged in the danger area,

standard communications, waterway rescue preplans, and safety consideration for rescuers. 

At the time this incident occurred, the fire department was in the process of re-establishing a public 

safety dive rescue program. The fire department was in the process of developing standard operating 

procedures (SOPs) and guidelines (SOGs) to cover the public safety dive rescue program. Eight to 10 

fire fighters had expressed an interest in being part of the fire department’s public safety dive rescue 

program. A volunteer fire department member who was also a certified Dive Instructor was 

responsible for providing all dive rescue team training. The fire department’s draft SOPs covering dive 

rescue operations did not address SCUBA equipment maintenance or cylinder safe handling 

procedures. 

Recommendation #7: Fire departments should recognize public safety SCUBA diving as a high 

risk/low frequency event and ensure that public safety divers are properly trained, equipped, and 

supported to perform public safety diving responsibilities and integrate the training and SOPs with 

regional dive and water rescue team(s) who they regularly respond with.

Discussion: Although there is no evidence that the following recommendation would have prevented 

this fatality, it is being provided as a reminder of best safety practice for the fire service. Fire 

departments should recognize public safety SCUBA diving as a high risk/low frequency event and use 

a risk assessment program to determine the level of involvement they are able to participate in (see 

Diagram 2). During this assessment, departments can decide if they want to accept the risk (fully 

committed to equipping and training their own team), share the risk (integrate with other teams in a 

mutual aid or regional team) or decline the risk (using a program risk analysis to transfer SCUBA 

duties to other agencies). 

There is no standard scale to measure and evaluate frequency and severity of risk for the fire service. It 

is imperative that a fire department develop a risk management program that is based upon the process 

of identifying, evaluating, prioritizing, and controlling risk. The risk management plan incorporates a 

full range of control measures that may be used to limit, reduce, or eliminate the probability that an 

undesirable outcome will occur. 

An important factor is that the fire department should prepare and maintain a written statement or 

policy that establishes the existence of the fire department, the services the fire department is 

authorized and expected to perform, and the basic organizational structure. This will be basis for the 
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development of the risk management program. The frequency and severity of risk starts with a 

thorough community risk assessment [NFPA 2018]. 

Some fire departments will have a greater or lesser degree of tolerance for risk than others. The intent 

of the risk management process is for a fire department to develop a standard level of safety. This 

standard level of safety defines the parameters of the acceptable degree of risk for which members 

perform their job functions. There is no single method or solution for effectively managing risk. 

Determining how to manage risk is a decision each individual fire department must make based on the 

risk management model [VBFD 2016]. 

A fire department’s leadership should have a covenant with their public safety dive team through the 

governing body’s risk manager (or risk management structure) to make diver safety their top priority 

by managing the risk. The risk manager should focus on sound resources based on research, training 

and experience. The leadership should consider sound risk management if they are going to commit 

their people to an underwater environment. The department has an ethical, moral, and legal duty to 

prepare them to be effective public safety divers. There is no greater responsibility [in public safety 

SCUBA diving] than safety [Orusa 2017]. 

Fire departments should prepare and maintain written policies and standard operating procedures that 

document the organization structure, membership, roles and responsibilities, expected functions, and 

training requirements, including the following:

• The types of standard evolutions that are expected to be performed and the evolutions that must 

be performed simultaneously or in sequence for different types of situations

• The minimum number of members who are required to perform each function or evolution and 

the manner in which the function is to be performed

• The number and types of apparatus and the number of personnel that will be dispatched to 

different types of incidents

• The procedures that will be employed to initiate and manage operations at the scene of an 

emergency incident [NFPA 1500].

Fire departments that decide they want to accept the risk and perform technical rescue water 

operations, including SCUBA diving and water rescue, need to ensure that personnel receive the 

proper initial training, advanced training, repetitive skills training and interagency training with mutual 

aid or regional dive teams that they regularly respond with. Fire departments must also understand that 

the commitment will involve a continuing commitment to advanced and recurrent training and also 

equipment and marine apparatus purchasing and maintenance.

Managing risk includes mandatory continuing education and skills documentation programs. Steve 

Orusa, Fire Chief of Fishers Indiana Fire Department and national expert and author of Dive Rescue 

Specialist, Operational Training for Public Safety Divers [Orusa 2007] notes a lack of basic diving 
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skills has been statistically identified as one of the leading causes of public safety diving fatalities. 

With 86% of the fatalities occurring in training and recovery modes (as was this incident), managing 

the components of rescue and recovery mode and the risk/benefit analysis in water rescue operations 

and training are critical. There is overwhelming documentation that provides evidence of serious safety 

concerns when relying solely on recreational training for public safety dive teams [Orusa 2017].

The advanced SCUBA training needs to be consistent with national consensus standards and agencies 

that provide recognized, advanced levels of certification to safely perform this level of emergency 

service capability. Although recreational SCUBA diving certification programs provide a level of 

training that is fine for the recreational SCUBA diving community, these programs are not commonly 

designed for the extreme hazards regularly encountered with public safety water rescue and diving. 

According to NFPA 1006 Standard for Technical Rescuer Professional Qualifications, 2017 edition, 

Annex A [NFPA 2017a], 

“The committee is of the opinion that Advanced Open Water certification provided by 

most nationally recognized certifying agencies (agencies associated with the Recreational 

SCUBA Training Council) build an acceptable foundation for the basic SCUBA skills 

required for dive technical rescuer. These courses do not, however, offer all of the skills 

required to meet these standards, and further training and experience in special hazards 

expected to be encountered in the AHJ’s territory should be sought.”

Chief Orusa has taught the importance of advanced repetitive skill dive training beyond recreational 

dive skills for many years. Public safety SCUBA diving is a technical skill that greatly exceeds 

recreational SCUBA certification levels. He notes: “Recreational diving agencies provide safe and 

effective dive training for the enjoyment of the public. The business model of a recreational SCUBA 

agency is to teach the client to have fun underwater. John Q. Public is not performing dives in zero 

visibility, dives with prolonged bottom times, dives with entanglement hazards, dives requiring heavy 

physical exertion, dives at all times of the day and night, and dives in extreme weather conditions. That 

is public safety diving.” [Orusa 2017].

In his book Chief Orusa notes: “Inadequate SCUBA skills may be the leading cause of public safety 

diver accidents. In many cases, a problem developed that the diver was unable to solve due to a basic 

skill level. In most cases, divers had received either insufficient or nonexistent SCUBA skills refresher 

training after initial certification.” Public safety divers should have training and experience in a variety 

of environments likely to be encountered in rescue operations, such as deep water complex dives, 

limited visibility, cold water diving, ice, current, contamination and hazardous materials, dry suit, and 

lifting operations.

Annual confirmation of these skills should be performed to ensure continued competency. Dive 

team(s) need to stay current on training and annual skills evaluation. An example of an evaluation form 

to assess skills of public safety divers is provided in Figure 1.

The level of knowledge, skills, ability, equipment and support required for a public safety SCUBA 

diver are outlined in NFPA 1006 [NFPA 2017a] and NFPA 1670 Standard on Operations and 

Training for Technical Search and Rescue Incidents [NFPA 2017b]. Throughout NFPA 1006 and 
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1670, hazard analysis and risk assessment is addressed. One of the most hazardous events a diver can 

encounter is not being able to solve problems or make decisions underwater. The typical chain of 

events in a public safety diving accident is as follows:

• The public safety diver becomes cold and/or tired

• Their stress level which is already high under such circumstances, increases

• The public safety diver encounters a problem or makes a mistake they cannot solve

• Panic ensues

• Death or serious injury results [Orusa 2017].

Public safety diving requires emergency response teams with specific knowledge, skills, ability, 

equipment and continued support beyond basic fire fighter or emergency responder requirements to 

resolve unique or complex rescue situations. Additionally, when the team is faced with complex, deep, 

highly technical recovery dives, it is important to realize the team’s limitations and when the team 

needs assistance and call additional resources (mutual aid). Some jurisdictions utilize regional teams to 

meet the goals of risk management for a specific risk (shared risk). 

A key part of an overall rescue strategy should be mutual aid. The use of formal or informal mutual aid 

can help share the risk by providing additional experience, equipment, personnel and other resources to 

a public safety diving event. Other benefits include, greater levels of coverage and redundancy, 

building trust between organizations and leadership benefits that can ultimately make for a safer dive 

environment. Additionally it can remove destructive competitiveness and rivalries between 

departments and/or agencies. 

Since the resource requirements and commitments are very high, a shared risk approach may work for 

some jurisdictions. Regional or mutual aid teams need to train together (if they are going to work 

together) so they can recognize and work together and have a level of coverage and/or redundancy that 

they may not have otherwise. If regional teams are going to work and train together, they should 

consider integrating their standard operating procedures (SOPs) and standard operating guidelines 

(SOGs). The difference between SOPs and SOGs is the difference between a procedure, which must be 

followed, and a guideline, which is more flexible and allows the responder to tailor his/her actions to 

fit the situation. A set of SOPs would include any rules that should be inviolable. For example, a public 

safety diver should always end his/her dive with 1,000 psi remaining for emergency reserve air (3,000 

psi per 80-cubic-foot cylinder). The 1,000 psi rule should not be broken and is a good example of an 

SOP [Hendrick et al. 2000].

Fire department SCUBA dive teams need to stay current on new equipment available such as “in 

mask” air supply status or heads up display (HUD), communications and protective gear such as dry 

suits and redundant air supply options. Also, new high definition sonar systems are available that can 

reduce a dive teams exposure to blind diving, by working to locate and isolate a dive target to within 

feet. Blind underwater searches using search ropes and gridding-off areas are very task-oriented and 
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time-consuming (underwater time) and therefore could require a significantly greater resource 

commitment for a significantly longer period of time. Reducing your exposure to the hazard is a 

recognized risk management principal. Dive teams should consider reducing the risk by reducing the 

exposure to the hazard (underwater) by spending more time and resources when they can on surface 

operations and technology to locate and mark targets with extreme accuracy.

Continued support for the team is an important component of the leadership of technical rescue teams. 

Once a team is properly trained and equipped, the organization must continue to provide support to 

maintain the technical rescue team’s operational readiness through continued training and review of 

program goals and needs. Inadequately trained divers should not be allowed to participate in technical 

rescue SCUBA diving incidents beyond their level of training (see Figure 1).

Recommendation #8: Federal, state, local, and municipal governments, standard-setting 

organizations, and authorities having jurisdiction should consider developing and adopting a 

national standard on public safety dive teams and public safety dive operations.

Discussion: This recommendation focuses on the need for a national standard covering public safety 

dive rescue operations. Currently, a national standard covering public safety dive rescue operations 

does not exist. 

“We should require standards that increase the safety and effectiveness of fire department public safety 

SCUBA operations. A root cause analysis identifies that public safety dive-specific training and 

equipment, standardization of training and equipment, SOPs, skills maintenance requirements, best 

practices, and consistency must be implemented. The result of these professional qualifications will be 

the prevention of injuries and the loss of personnel in the line of duty [Orusa 2019].” 
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Figure 1. Sample SCUBA basic skills evaluation checklist.

(International Association of Dive Rescue Specialists: www.IADRS.org.)
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http://www.tamug.edu/EnvironmentalHealthSafety/NO_Menu_Important_Files/Compressed%20Gases

%20Safety%20Program%2010-2015.pdf. 

VBFD [2016]. Risk management plan. Virginia Beach, VA: Virginia Beach Fire Department, 

https://www.vbgov.com/government/departments/fire/Pages/default.aspx.

Weather underground [2018]. Historical weather data for June 24, 2018. Date accessed: July 2018. 

Investigator Information

This incident was investigated by Timothy R. Merinar, Safety Engineer, with the Fire Fighter Fatality 

Investigation and Prevention Program, Surveillance and Field Investigations Branch, Division of 

Safety Research, NIOSH located in Morgantown, West Virginia. Dr. Wendi Dick, Medical Officer, 

with the NIOSH Fire Fighter Fatality Investigation and Prevention Program, Medical Component, in 

Cincinnati, Ohio assisted with the interview process. An expert technical review was provided by Fire 

Chief Steven Orusa, Fishers Fire Department, Fishers, Indiana. A technical review was also provided 

by the National Fire Protection Association, Public Fire Protection Division. 

NIOSH acknowledges the assistance and cooperation of employees with the Ohio Bureau of Workers’ 

Compensation, Public Employee Risk Reduction Program and the Ohio Department of Commerce, 

Division of State Fire Marshal, Fire & Explosion Investigations Bureau during this investigation.
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Report # F2018-10

Career Part-Time Fire Fighter Dies After Being Struck by Pressurized 

SCUBA Cylinder — Ohio

Disclaimer

Mention of any company or product does not constitute endorsement by the National Institute for 

Occupational Safety and Health (NIOSH). In addition, citations to websites external to NIOSH do not 

constitute NIOSH endorsement of the sponsoring organizations or their programs or products. 

Furthermore, NIOSH is not responsible for the content of these websites. All web addresses referenced 

in this document were accessible as of the publication date.
Page 34

Report # F2018-10

Career Part-Time Fire Fighter Dies After Being Struck by Pressurized 

SCUBA Cylinder — Ohio

Appendix One

Laboratory Analysis of SCUBA Cylinder Valve

NIOSH Investigation F2018-10 OH 

Based upon the laboratory’s visual inspection and tests conducted, chloride-induced corrosion was the 

root cause of the failure of the regulator valve’s normal operation. Corrosion locked the regulator valve 

in the “closed positon”, and did not prevent compressed gas escaping elsewhere from the valve body at 

full pressure. 

The full laboratory investigation report is available upon request.