HETA 99-0062-2804

Newark Fire Department

Newark, New Jersey

Kevin C. Roegner, M.P.H.

Joel E. McCullough, M.D., M.P.H., M.S.

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally

applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.

Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally

applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.

Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally

applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.

applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.

Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports
ii

PREFACE

The Hazard Evaluations and Technical Assistance Branch (HETAB) of the National Institute for Occupational

Safety and Health (NIOSH) conducts field investigations of possible health hazards in the workplace. These

investigations are conducted under the authority of Section 20(a)(6) of the Occupational Safety and Health

(OSHA) Act of 1970, 29 U.S.C. 669(a)(6) which authorizes the Secretary of Health and Human Services,

following a written request from any employer or authorized representative of employees, to determine

whether any substance normally found in the place of employment has potentially toxic effects in such

concentrations as used or found.

HETAB also provides, upon request, technical and consultative assistance to Federal, State, and local

agencies; labor; industry; and other groups or individuals to control occupational health hazards and to prevent

related trauma and disease. Mention of company names or products does not constitute endorsement by

NIOSH.

ACKNOWLEDGMENTS AND AVAILABILITY OF REPORT

This report was prepared by Kevin Roegner and Joel McCullough of HETAB, Division of Surveillance,

Hazard Evaluations and Field Studies (DSHEFS). Field assistance was provided by Greg Kinnes, DSHEFS.

Desktop publishing was performed by Denise Ratliff. Review and preparation for printing were performed

by Penny Arthur.

Copies of this report have been sent to employee and management representatives at the Newark Fire

Department; the International Association of Fire Fighters (IAFF), Department of Occupational Health and

Safety; IAFF Local 1860; and the New Jersey Public Employees Occupational Health and Safety Program.

This report is not copyrighted and may be freely reproduced. Single copies of this report will be available

for a period of three years from the date of this report. To expedite your request, include a self-addressed

mailing label along with your written request to:

NIOSH Publications Office

4676 Columbia Parkway

Cincinnati, Ohio 45226

800-356-4674

After this time, copies may be purchased from the National Technical Information Service (NTIS) at

5825 Port Royal Road, Springfield, Virginia 22161. Information regarding the NTIS stock number may be

obtained from the NIOSH Publications Office at the Cincinnati address.

For the purpose of informing affected employees, copies of this report shall be posted

by the employer in a prominent place accessible to the employees for a period of 30

calendar days.
iii

Highlights of the NIOSH Health Hazard Evaluation

Evaluation of American Ref-fuel Incident

In December of 1998, 37 Newark Fire Department (NFD) fire fighters were exposed to irritant gasses during

a response to a fire at American Ref-fuel (AR). Following the incident, the IAFF asked NIOSH to investigate

the events leading to fire fighters’ exposures, and to review the medical care received by the fire fighters after

the incident.

What NIOSH Did

# Interviewed fire fighters who responded to AR

about the response and their symptoms.

# Looked at medical records, radio

communication logs, fire fighter incident

reports, and NFD procedures.

# Went to AR to see the area where the incident

occurred.

What NIOSH Found

# Most fire fighters at the scene had some degree

of irritation to their eyes, throat, or lungs. 

# Fire fighters were likely exposed to chlorine gas

and nitrogen trichloride, and possibly very low

levels of phosgene.

# Fire fighters were initially provided with wrong

information about the contents of the fire.

# The hazardous materials (HAZMAT) company

was committed to the incident in fire mode, so

no HAZMAT response could be made. 

# Not using self-contained breathing apparatus

(SCBA) all the time, poor communications, and

poor building ventilation made exposures

worse.

# The treating physicians in the hospital

emergency rooms were aware of the fire fighter

chemical exposure, but did not know the

specific substances.

# The number of medical tests varied among

hospitals, but this difference did not appear to

cause worse health outcomes.

What the Newark Fire Department

Can Do

# Better enforce SCBA use at the scene of a fire.

# Minimize gaps in HAZMAT coverage.

# Improve communication with local hospitals.

# Better educate fire fighters on decontamination

procedures.

# Better integrate surveillance medical records

with acute occupational health services.

What the Newark Fire Department

Fire Fighters Can Do

# Use better judgement when removing SCBA at

the fire scene.

# Follow two-in, two-out rule.

CENTERS FOR DISEASE CONTROL

CDC

AND PREVENTION

What To Do For More Information:

We encourage you to read the full report. If you

would like a copy, either ask your health and

safety representative to make you a copy or call

1-513/841-4252 and ask for

 HETA Report # 99-0062-2804
iv

Health Hazard Evaluation Report 99-0062-2804

Newark Fire Department

Newark, New Jersey

February 2000

Kevin C. Roegner, M.P.H.

Joel E. McCullough, M.D., M.P.H., M.S.

SUMMARY

On December 22, 1998, the National Institute for Occupational Safety and Health (NIOSH) received a request

for a health hazard evaluation (HHE) from the International Association of Fire Fighters (IAFF) on behalf of

fire fighters from the Newark Fire Department (NFD) to assess the incident response procedures followed

during a fire in a refuse waste-to-energy facility (American Ref-fuel) on December 17,1998, in Newark, New

Jersey. The IAFF indicated that several of the fire fighters responding to the incident were subsequently

hospitalized due to smoke and chlorine gas inhalation. 

NIOSH investigators conducted a site visit to the NFD on April 12-13, 1999, and again on June 24, 1999.

NIOSH personnel conducted private interviews with several NFD fire fighters who responded to the incident

and reviewed several incident-related records provided by the NFD, including the department’s standard

operating procedures (SOPs) and medical records. Self-administered questionnaires were distributed to fire

fighters who were not present on the days of the NIOSH investigation. In addition to the medical interviews

and questionnaires, medical records were reviewed from five hospitals where the fire fighters received

medical care, and from the occupational medicine provider for the NFD. NIOSH investigators also visited

American Ref-fuel.

On December 17, 1998, the NFD received a report of a fire in the refuse pit of American Ref-fuel. The fire

was declared a hazardous materials incident as information became known that the fire had involved chlorine

bleach cleaner which, according to the product’s material safety data sheet, would liberate chlorine and

phosgene as decomposition products. Fire fighters used the plant’s showering facilities for decontamination

purposes before all of the 37 responding fire fighters were sent to area hospitals for evaluation.

The medical survey showed that most fire fighters at the scene experienced some degree of acute upper

respiratory tract irritation, and many experienced lower respiratory tract irritation as well. Fifteen had

persistent symptoms at 24 hours, and 13 had symptoms at the time of the NIOSH investigation. Based on the

combustion of chlorine-containing cleaner, the fire fighters’ exposures probably consisted primarily of irritant

gases, such as chlorine and nitrogen trichloride. 

Medical records revealed that the treating physicians were aware that the fire fighters were exposed to

chemicals at a fire and were concerned about the inhalation of toxic fumes and smoke. However, neither fire

fighters nor treating physicians knew what specific toxins were present. The symptoms of the fire fighters

were consistent in the different hospitals, however the diagnostic tests performed differed. The universitybased hospital performed the most diagnostic tests on the fire fighters. The other hospitals performed fewer

tests, but this did not appear to result in a greater rate of adverse health outcomes.
v

The elements leading to fire fighter exposures at the waste-to-energy plant on December 17, 1998, are

complex and multi-factorial in nature. Clearly, fire fighters did encounter exposures to irritant gasses at

the scene. The NFD approached the incident in fire mode, when in fact, a hazardous materials

(HAZMAT) response approach would have been more appropriate. 

Most fire fighters suffered irritant symptoms that were the result of exposures to irritant gases at

American Ref-fuel. For those fire fighters who had recovered at the time of the NIOSH investigation or

did not develop symptoms, it is unlikely that this exposure will result in further health problems. Those

who developed more significant respiratory symptoms were being evaluated by health care providers.

Several recommendations are offered for improving fire fighter health and safety, including

recommendations for better integration of fire fighter medical surveillance information with acute care

occupational medicine providers, better personal protective equipment (PPE) usage, and filling gaps in

HAZMAT coverage.

Keywords: SIC 9224 (Fire Protection), fire fighters, firefighters, incident command system, ICS,

self–contained breathing apparatus, SCBA, hazardous materials
TABLE OF CONTENTS

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii

Acknowledgments and Availability of Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii

Highlights of the NIOSH Health Hazard Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Introduction ......................................................................... 1

Background ......................................................................... 1

Methods ............................................................................ 2

Evaluation Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Smoke Inhalation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Chlorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Phosgene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Nitrogen Trichloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Incident Command System (ICS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Findings and Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Preplanning and Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Incident Command System (ICS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Hazardous Materials Response Unit ................................................... 8

Safety Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Respiratory and Other Personal Protective Equipment (PPE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Glossary of Medical Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Health Hazard Evaluation Report No. 99-0062-2804 Page 1

INTRODUCTION

On December 22, 1998, the National Institute for

Occupational Safety and Health (NIOSH) received

a request for a health hazard evaluation (HHE)

from the International Association of Fire Fighters

(IAFF). This HHE request was submitted on

behalf of fire fighters from the City of Newark

Fire Department (NFD) to assess the incident

response procedures used during a fire in a refuse

waste-to-energy facility (American Ref-fuel) on

December 17, 1998, in Newark, New Jersey. The

IAFF reported that 37 fire fighters responded to

the incident, and that several of the responders

were subsequently hospitalized due to smoke and

chlorine gas inhalation. The IAFF requested that

NIOSH review the response procedures used

during this incident, investigate the potential

chemical exposures that may have occurred, and

determine the health effects that fire fighters may

experience from the exposure.

In response to this request, NIOSH investigators

conducted a site visit to the NFD on April 12-13,

and again on June 24, 1999. On April 12, an

opening conference was held to discuss the

incident and the nature of the request with

representatives of the NFD and IAFF Local 1860.

During the remainder of the site visit, private

interviews were held with NFD fire fighters and

command staff who responded to the incident, and

copies of several NFD standard operating

procedures (SOPs) and other pertinent records

were obtained for review. 

This report summarizes response procedures as

they affected the health and safety of the fire

fighters, including the Incident Command System

(ICS) and safety management. This report also

discusses decontamination of fire fighters, assesses

the level of care received by fire fighters at area

hospitals, and provides recommendations.

BACKGROUND

The NFD employs 735 uniformed fire fighters, and

serves a geographic area of 23 square miles. The

department operates four shifts (tours), and is

divided into four battalions. Each tour works an

average of 42-hours per week on a schedule of

two, 10-hour shifts on duty followed by a day off,

then two, 14-hour shifts, followed by three days

off. Shift changes occur at 0800 hours (hrs) and

1800 hrs. In 1992, the NFD initiated a policy of

rotating four apparatus companies (one from each

battalion) out of service on each tour. Truck 8 was

retired from service in 1997, and the number of

companies rotating out of service was reduced to

three. In response to a working structural fire, the

NFD will dispatch four engines, two trucks, a

Battalion Chief (BC), a Deputy Chief (DC), a

Safety Officer (SO), a rescue unit, and a rapid

intervention team to the fire scene. 

On December 17, 1998, the NFD responded to a

fire alarm at the eleven-story, American Ref-fuel

plant located in an industrial area outside of

downtown Newark. The facility was constructed

in 1990, and is segmented into several areas, each

designed to play a role in converting nonhazardous waste into energy (Figure 1). At the

west end of the facility is a large, open tipping

hall, where trucks enter to deposit loads into the

refuse pit. The refuse pit measures 280 feet (ft.)

across, by 90 ft. front to back, by 45 ft. deep. The

open space above the refuse pit spans several

stories and is occupied by two 20-ton grappling

cranes. The cranes, which are remotely operated

from each of two control rooms that overlook the

pit, homogenize the waste and move it from the pit

and drop the waste into the waste charging hopper

(7th story). Once in the hopper, refuse is fed into

the furnace. Heat generated by the combusting

solid waste produces steam in a waterwall boiler,

the pressure from which is used to drive a turbine

generator. The plant is licensed to accept nonhazardous waste.
Page 2 Health Hazard Evaluation Report No. 99-0062-2804

At 2008 hrs, December 17, 1998, the NFD

received a 9-1-1 telephone call reporting a fire in

the refuse pit of the waste-to-energy facility. A

full assignment, consisting of four engine

companies, two truck companies, a rescue

company, a BC, a DC, and an SO was dispatched

to the scene. Engine Company 16 (EC16) was the

first to arrive at 2012 hrs. In fire fighter interviews

it was reported that plant employees indicated to

arriving fire fighters that there were two fires: a

fire on the seventh floor and a fire in the refuse pit.

Truck one, the company which is also the

hazardous materials (HAZMAT) unit company,

was the second due truck for the response, and it

arrived on site early in the incident. Several

companies ascended the stairs and elevators to

search for the reported fire on the seventh floor.

They were, however, unable to locate a fire on the

seventh floor. The BC arrived at the scene at 2017

hrs. The DC arrived at the scene at 2025 hrs, at

which time he established a command post on the

first floor. During most of the incident, it was unclear what was burning in the pit. When the BC

and DC inquired about what was burning, plant

employees indicated that it was garbage. Several

fire fighters reported that the incident was

complicated by an intermittent heavy smoke

condition, which limited visibility into the refuse

pit and across the upper floors. Fire fighters

indicated that the smoke appeared white to

yellowish-green, and would ebb and bank with the

intermittent performance of ceiling exhaust fans

located above the pit. The fire was declared under

control at 2238 hrs, at which time it was declared

a hazardous materials incident as information

became known that the fire had involved chlorinecontaining cleaner. The cleaner had been sent to

the facility for disposal. The product’s material

safety data sheet, which reportedly was made

available late into the incident, indicated that the

cleaner would liberate chlorine and phosgene as

decomposition products. Fire fighters used the

plant’s showering facilities for decontamination

purposes before all of the 37 responding fire

fighters were sent to area hospitals for evaluation.

METHODS

NIOSH investigators visited the NFD on two

occasions, and the waste-to-energy plant to obtain

information. During the first visit, NIOSH investigators held an opening conference with the local

IAFF representative and representatives of the

NFD. This meeting was arranged to discuss the

structure and staffing of the NFD, review the

incident chronology and the procedures used

during the response, and review actions of the fire

department subsequent to fire fighters raising

concerns about possible exposures to chlorine and

phosgene. The NIOSH investigators spent additional time during the two days interviewing fire

fighters and command personnel who responded to

the incident and reviewing incident-related records

provided by the NFD. These records included the

incident chronology report, transcripts of radio

communications during the incident, SOPs

followed by the NFD, and various other records

pertaining to this incident. The NIOSH

investigators also requested copies of the

command reports submitted by each apparatus

captain and others who assumed command

functions to the NFD. During the second visit,

NIOSH investigators inventoried the hazardous

materials response unit and spoke with the on-duty

captain of that unit. This meeting was followed by

a visit to American Ref-fuel where NIOSH

investigators met with the plant manager and

viewed the area where the incident occurred.

Telephone interviews were conducted with NFD

personnel not available during our site visit. The

incident response reports, transcripts from NIOSH

interviews with fire fighters, and other pertinent

information were used to reconstruct events and

procedures used during the incident.

On April 12-13, confidential interviews were

conducted with fire fighters who were present at

the scene of the incident. The fire fighters who

responded to the incident and were at work on the

days of the NIOSH investigation were interviewed

by NIOSH investigators. Also, self-administered

questionnaires (accompanied with NIOSH-
Health Hazard Evaluation Report No. 99-0062-2804 Page 3

addressed and postage-paid envelopes) were

distributed by a union representative to fire

fighters who were not present on the days of the

NIOSH investigation. The fire fighters were asked

about their job activities at the scene, their use of

personal protective equipment (PPE),

decontamination procedures, the amount of time at

the scene spent with and without PPE, health

symptoms that began at the scene, persistent health

symptoms, and the medical care they received. In

addition to the medical interviews and

questionnaires, medical records from the five

hospitals where the fire fighters received medical

care, and from the occupational medicine provider

for the department, were reviewed.

EVALUATION CRITERIA

Fire fighters work in varied and complex environments that increase their risk of on–the–job death

and injury. Every day, fire fighters in the United

States are injured in the line of duty.1

 According

to the IAFF, 45 professional fire fighters died in

the line of duty in 1998, and an additional 39

professional fire fighters died as a result of

occupational diseases directly related to fire

fighting.2

 When compared to data compiled for

private industry by the Bureau of Labor Statistics

(BLS), the incidence of fire fighter job-related

injury is nearly 4.5 times that of workers in private

industry; 32.4 percent (%) of fire fighters were

injured in 1998 compared to only 7.1% of private

industry workers.2

 In terms of severity, fire fighter

injuries caused 4,342 lost work hours per 100

workers.2

 Fire fighters face many health hazards,

including: inhalation of a wide variety of toxic

combustion products; chemical exposures by

direct skin and eye contact; physical hazards,

including heat, cold, noise, and falling objects; and

exposure to carcinogenic chemicals or combustion

products. The hazardous exposures most relevant

to the American Ref-fuel incident are discussed in

further detail below.

Smoke Inhalation

Smoke is the volatilized product of combustion. It

varies according to temperature, oxygen availability, and composition of the material being

burned.3

 The inhalational toxins in smoke are

chemicals in the form of gases, vapors, aerosols,

particulate, and fumes.4

 Upon combustion,

synthetic and natural polymers may produce

respiratory irritants (nitrogen and sulfur oxides,

aldehydes, halogenated compounds, and organic

acids), simple asphyxiants (carbon dioxide,

oxygen-deficient atmospheres), and cellular

asphyxiants (carbon monoxide, hydrogen

cyanide).5

 

Each component of smoke may contribute to

respiratory damage in different ways. Although

smoke inhalation is often referred to as a

pulmonary burn, true thermal injury to the lower

respiratory tract appears to be unusual. The upper

airway is very effective in protecting against injury

by heat below the tongue (the trachea and

bronchial tubes). Even in the absence of

recognizable symptoms or disease, fire fighters

often have subclinical effects that may persist for

weeks or months, as evidenced by both restrictive

and obstructive lung changes on spirometry

testing.6

The irritant gases and asphyxiants generated

during combustion account for virtually all of the

clinically recognized respiratory effects of smoke

inhalation. Most of the irritant gases that cause

direct pulmonary injury are highly reactive acids

or bases which, upon inhalation and hydration

within the lung, result in the denaturation or

oxidation of cellular components.5, 6 Highly watersoluble agents, such as ammonia, sulfur dioxide,

hydrogen fluoride, or acrolein, cause injury to the

proximal airway and mucosa, and their noxious

nature is more likely to be recognized by exposed

persons. By contrast, agents with intermediate or

lower water solubilities (e.g., phosgene or nitrogen

oxides) are more likely to result in subtle

presentations, with delayed onset of respiratory

damage. In this instance, fewer warning symptoms
Page 4 Health Hazard Evaluation Report No. 99-0062-2804

may result in prolonged exposures and damage to

distal airways and alveolar membranes.5, 6 

The vast majority of inhalation victims (90% to

95%) acutely complain of shortness of breath,

cough, or hoarseness. Symptoms such as cough,

sore throat, or hoarseness suggest upper airway

injury and the potential for life-threatening airway

obstruction. Shortness of breath and wheezing

suggest lower respiratory tract damage. Headache,

nausea, vomiting, dizziness, confusion, chest pain,

palpitations, and loss of consciousness may

suggest systemic poisoning or simple asphyxiant

effects. The age of the victim and past medical

history are important risk factors for the

development of inhalation injury. Those with

asthma or chronic respiratory diseases may be

more susceptible to the effects of irritant gas

inhalation.3

All victims of smoke inhalation should begin

treatment with supplemental oxygen, which should

be adjusted based on arterial blood gases and

clinical history. The observation period for

asymptomatic patients without significant risk

factors for chronic obstructive pulmonary disease

or coronary artery disease is 4 to 6 hours. Those

who remain asymptomatic during the observation

period can be discharged from the health care

facility with appropriate follow-up instructions.7

If initial clinical findings are minimal, but there is

a history of smoke inhalation, arterial blood gases

(ABGs) should be obtained. ABGs, which usually

include carboxyhemoglobin levels, are an essential

early part of nearly every evaluation of a fire

fighter with smoke inhalation.8

 Although pulse

oximetry is a convenient way to continuously

monitor oxygenation in patients, it is unreliable or

falsely normal in patients who have

dyshemoglobinemias (e.g.,

carboxyhemoglobinemia or methemoglobinemia)

because it measures only oxygen dissolved in the

blood and not the status of tissue oxygenation. In

patients who have altered hemoglobin, the pulse

oximetry does not reflect the impaired oxygen

carrying or delivery capacity of the red cells.

Pulse oximetry does not distinguish between

carboxyhemoglobin (COHb) and oxyhemoglobin

(O2Hb). In these situations, a Co-oximeter should

be used to measure specific levels of hemoglobins

that are unable to transport oxygen efficiently.9

A thorough eye exam in the emergency department

is indicated for those suspected of having smoke

inhalation injury or exposure to corrosive

substances. Eyes contaminated by smoke,

aerosols, and particulates should be treated

similarly to splash injuries and liberally irrigated

with plain water or normal saline. A thorough eye

exam should be performed following irrigation.

Ophthalmologic consultation is indicated in those

presenting with more than minor complaints or

physical findings.8

Chlorine

Chlorine is a yellow-green gas with a sharp or

pungent odor at room temperature. Chorine is

only slightly soluble in water, but on contact with

moisture it forms hypochlorous acid (HClO) and

hydrochloric acid (HCl). The unstable HClO

readily decomposes, forming oxygen-free radicals.

Because of these reactions, water substantially

enhances chlorine’s oxidizing and corrosive

effects.10

Chlorine’s odor and irritant properties generally

provide adequate warning of hazardous concentrations. However, prolonged, low-level exposures

can lead to olfactory fatigue and tolerance of

chlorine’s irritant effects. Mucous membrane

irritation may occur at 0.2 to 16 parts per million

(ppm); eye irritation occurs at 7 to 8 ppm, throat

irritation at 15 ppm, and cough at 30 ppm.11

Inhalation of high concentrations of the gas causes

necrosis of the lining of the trachea and bronchi as

well as pulmonary edema, emphysema, and

damage to the pulmonary blood vessels. Exposure

to 500 ppm can be lethal over 30 minutes, while

1000 ppm can be lethal within a few minutes.12 

The severity of the damage to the respiratory tract

is determined by the concentration and duration of
Health Hazard Evaluation Report No. 99-0062-2804 Page 5

exposure. With high exposures, laryngeal edema

with signs of obstruction of the breathing

passages, acute tracheobronchitis, and chemical

pneumonitis have been described. Following

acute exposure to chlorine gas, both obstructive

and restrictive lung disease may occur.11 Moderate

to severe exposure often results in residual

pulmonary dysfunction, most notably

hyperreactive airways and low residual volumes.

The pulmonary function usually returns toward

baseline within 7 to 14 days. Although complete

recovery generally occurs, symptoms and

prolonged pulmonary impairment may persist,

especially after massive chlorine exposures.13,14

Reactive airways dysfunction syndrome (RADS)

may occur. Chronic exposure may cause moderate

reduction in pulmonary function and corrosion of

the teeth.14

Chlorine may irritate the skin and can cause

burning pain, inflammation, and blisters. Direct

contact with liquid chlorine or concentrated vapor

causes severe chemical burns. Low concentrations

in air can cause burning discomfort, spasmodic

blinking or involuntary closing of the eyelids,

redness and tearing of the eyes. Corneal burns

may occur at high concentrations.10, 15

Exposure to elevated levels of chlorine should be

terminated as soon as possible by removal to fresh

air. The skin, eyes, and mouth should be washed

with large amounts of water.15 A 15- to 20-minute

wash may be necessary. If irritation, pain, swelling, or tearing persists, medical care should be

sought as soon as possible. Contaminated clothing

should be removed and isolated. Contact lenses

should be removed to avoid prolonged chemical

contact with the eyes.12

Phosgene

Phosgene is a colorless gas with an odor similar to

musty hay. It may be formed by the “cracking” of

chlorinated hydrocarbon molecules at high

temperature. Phosgene may be a decomposition

product of other chlorinated chemicals. Phosgene

reacts with moisture and slowly forms HCL and

carbon dioxide.16

Inhalation is the major route of phosgene

exposure. The onset of severe respiratory distress

may be delayed for up to 72 hours depending on

the concentration and duration of exposure.

Olfactory fatigue may occur.17 The low irritant

properties of phosgene are not sufficient to warn

individuals of toxic concentrations. This allows

deep inspiration of high concentrations, causing

HCl to form in the lower respiratory tract.18 HCl

can damage surface cells and cause cell death in

the bronchi and bronchioles. This causes

congestion and pulmonary edema, which may be

quickly fatal. Direct toxicity to the cells leads to

an increase in capillary permeability, resulting in

large shifts of body fluid and decreasing plasma

volume. Early symptoms of overexposure include

chest constriction, painful breathing, and bloody

sputum. Respiratory and circulatory failure are the

common clinical findings in cases of phosgene

poisoning that result in death.16, 17

If the patient survives the initial 48 hours after

exposure, recovery is likely. Sensitivity to irritants

may persist, resulting in bronchospasm and

chronic inflammation of the bronchi. Lung tissue

destruction and scarring may lead to chronic

dilation of the bronchi and increased susceptibility

to infection (bronchiectasis). Also, pulmonary

fibrosis and emphysema may develop after chronic

exposure.18

Phosgene may also damage the skin and eyes.

When phosgene gas contacts moist or wet skin, it

may cause irritation and erythema. High air concentrations can also cause corneal inflammation

and cloudy vision. Eye damage beyond the initial

irritation is uncommon in vapor exposure.16, 17

Treatment measures would include moving the

patient to fresh air and monitor for respiratory

distress. Monitoring for 12 to 24 hours after

exposure has been recommended. Exposed areas
Page 6 Health Hazard Evaluation Report No. 99-0062-2804

should be washed thoroughly with soap and water.

Exposed eyes should be irrigated with copious

amounts of tepid water for at least 15 minutes. If

irritation, pain, swelling, lacrimation, or photophobia persists, the patient should be seen in a

health care facility.16, 17 There is no evidence that

phosgene is either carcinogenic or teratogenic.17

Nitrogen Trichloride

Nitrogen trichloride (NCl3) is a brownish-yellow

gas with a pungent, offensive chlorine-like odor.

It is the most irritating of the chloramines and can

impart an odor at concentrations above 0.02 ppm.19

It is the by-product of several reactions, including

the reaction between chlorine and nitrogenated

substances. NCl3 decomposes to ammonia and

hypochlorous acid. Hypochlorous acid reacts

rapidly with ammonia to form monochloramine.20

NCl3 is a strong irritant, but little else is known

about its toxicology. Exposure to its fumes produces excess tearing, irritation of the mucous

membranes of the respiratory tract, and nausea.

The acute inhalation toxicity of NCl3 is similar to

that of chlorine.20

Animal studies have found that the respiratory

tract is the primary site of damage in rats exposed

to NCl3. Rats exposed for prolonged periods to

concentrated NCl3 died of pulmonary edema. No

chronic health effects have been demonstrated in

humans exposed to these fumes.21

Incident Command System

(ICS)

Management of fire department day–to–day

activities is usually vested in a Fire Chief or other

titled person who serves as the commander of the

fire suppression forces and their activities,

including the safety of the fire fighters.22 To assist

in the management (especially in the operation,

coordination, and effectiveness) of wide–scale fire

suppression activities, a system has been

developed for controlling personnel, facilities,

equipment, and communications. This system is

known as the ICS.23 This is a system of unified

command and control designed to assure the

smooth implementation of operational procedures

by all agencies on scene in a coordinated manner.24

A further refinement of the ICS by fire service

organizations addresses all types of emergency

incidents and includes performance criteria for the

components of a system that incorporates specific

safety and health objectives. This has been

developed into a nationally recognized standard

known as the Incident Management System

(IMS).25 Some common components of an IMS

are: modular organization, integrated

communications, common terminology, unified

command structure, and consolidated action

plans.26 The National Fire Protection Association

has documented the consequences of operating

without such an IMS which have resulted in

numerous deaths and injuries of fire fighters.27

The National Fire Service has also published

model procedures for an IMS that is specific for

high–rise fire fighting.28

In establishing and utilizing the IMS, the first

priority must be life safety.29 The responsibility

for this priority issue is that of the officer in

command of the emergency incident.27,29 The

incident commander is responsible for the overall

safety of all members and all activities occurring

at the scene. The Fire Chief, however, bears the

ultimate responsibility for the safety and health of

all members of the department.

FINDINGS AND

DISCUSSION

Preplanning and Information

First due companies (companies who respond first)

commented in their interviews with NIOSH that

they had previously been to American Ref-fuel for

preplanning exercises. Through this preplanning
Health Hazard Evaluation Report No. 99-0062-2804 Page 7

they were familiar with the facility. Some fire

fighters indicated that the plant’s management had

always been very accommodating during such

visits and forthcoming with information about the

process and facility. One fire fighter indicated that

a trust had been fostered through these visits. It

was also suggested that second and third due

companies did not have this preplanning at the

facility, and extending preplanning to include

second and third due companies in light of

companies rotating out of service would be

beneficial. 

Under Title III of the Superfund Amendments

Reauthorization Act (SARA), the owner or

operator of a facility is required to disclose the

presence of hazardous chemicals if they are kept

on the property at greater than a threshold

quantity. This reporting is to be carried out

annually through Tier I or Tier II reporting as

indicated in 40 CFR part 370 of the Code of

Federal Regulations (CFR). SARA Title III, Tier

II reporting is retrospective; facility operators are

required to report quantities of hazardous materials

on site during the preceding year. The cleaner

present in American Ref-fuel’s refuse pit would

need to be reported under Tier II, but not until

March 1999. Although the reporting requirements

are a good means for emergency response

personnel to receive information about chemicals

at a facility, the reporting system would typically

not provide responders with such information

about chemicals that are on site for the first time.

This system, though beneficial, would not have

been effective for preplanning in this case.

Although the main ingredient of the cleaner,

sodium dichloroisocyanurate, would be classified

as a hazardous waste, the composite mixture does

not meet the definition. The material reportedly

meets the definition of a non-hazardous waste.

This may have been a source of miscommunication between plant employees and fire

fighters as to the contents of the fire.

Based on fire fighters’ reports, there seemed to be

confusion throughout the incident as to the

location and contents of the fire. Much of the

confusion stemmed from misinformation provided

by employees of American Ref-fuel. When the

first engine arrived on the scene, fire fighters noted

that employees of the facility had begun to apply

water to the refuse pit with a 1-inch hose line.

They prepared to augment this effort with a 2 1⁄2-

inch hose line. While they were preparing for this,

the BC arrived on the scene and reportedly was

informed by an American Ref-fuel employee that

there was a fire on the seventh floor rack. The BC

asked the employee what was burning and was told

that it was just garbage; however, several fire

fighters reported that they had smelled a chlorinelike odor during the incident. One fire fighter

remained with the engine to man the hose line

while the other fire fighters and the BC proceeded

to the seventh floor in search of the fire that was

reported there. Fire fighters were unable to locate

a fire on the seventh floor. 

Incident Command System

(ICS)

The NFD operates under the ICS. Department

programs reviewed by NIOSH are consistent with

the ICS. The department’s SOPs indicate that the

NFD has established a succession of command

based on rank. That is, command is initially

assumed by the first ranking person/officer on

scene. A command post is set up and its location

and the incident commander are identified to the

dispatcher. Command is passed along to the next

higher ranking officer that arrives, including the

deputy fire chief and fire chief. According to

reports, this system was followed during the

incident. 

When the BC arrived at the scene he assumed a

mobile command. This allowed the BC to operate

in the command role while he moved around the

scene to size up the incident. Reportedly this

approach is commonly used in the NFD for full

alarm responses. When the DC arrived on the

scene, he established the command post in an

office area on the first floor. The DC indicated
Page 8 Health Hazard Evaluation Report No. 99-0062-2804

that he particularly liked this location because the

office had a telephone system which he could use

to communicate with fire fighters in various

locations in the facility. At some point into the

incident, the BC recommended that the DC

relocate the command post to the seventh floor.

The rationale for this recommendation is unclear.

The DC started to the seventh floor to determine if

a relocation of the command post would be

beneficial. As the DC ascended the stairs he

reportedly encountered a strong chlorine odor on

the third floor. At this time, the DC decided to

stop, and to keep the command post at the groundfloor office location.

Interviewed fire fighters indicated that they were

always aware of who was in command during the

incident. One fire fighter further indicated that the

DC takes a strong command and that it is clear that

he is making the decisions.

Hazardous Materials

Response Unit

The HAZMAT response unit consists of a four- or

five-person company and two apparatus (a

response apparatus and spill/decontaminaton

apparatus). This unit is housed at the fire station

located at 188 Mulberry Street. Two persons bring

the spill/ decontamination apparatus, and two or

three persons bring the response apparatus to

HAZMAT scenes. The HAZMAT team is

augmented with a rescue unit (Rescue 1), which

responds to all full alarms, and a fire company

trained to conduct the decontamination. In

addition to being the designated HAZMAT

response, the HAZMAT company responds to fire

calls. The company will respond to a fire in a

ladder truck (truck 1), as they responded to this

incident. This approach leaves a two-fold gap in

HAZMAT response coverage. First, the

HAZMAT response team, while occupied fighting

the fire, is unavailable to efficiently respond to a

concurrent HAZMAT incident at a different

location within the city. Second, as was the case

at American Ref-fuel, if the incident commander

at the scene of the fire determines that the hazards

of the incident dictate a change in response

approach from fire mode to HAZMAT mode, the

HAZMAT team may already be

committed/contaminated. The former Captain of

the HAZMAT company indicated that there have

been situations where the company was enroute (in

fire mode) and has had to turn truck 1 back and get

the HAZMAT apparatus.

Gaps in HAZMAT coverages were compounded

during the American Ref-fuel incident due to the

NFD’s policy of rotating companies out of service.

In January of 1997, truck 8 went from being

rotated out of service on the second tour to being

retired from service. Having a truck company out

of service increases the area that the other truck

companies, including truck company 1, are

expected to cover. A full alarm will trigger two

truck companies to respond. Interviewed fire

fighters indicated that, given the location of

American Ref-fuel, truck company 8 would have

been the second due to the incident scene.

Because, however, truck company 8 is out of

service, truck company 1 became second due. The

result of this is the latter of the two gaps in

coverage discussed above; a HAZMAT response

was compromised when the company was

committed to the incident scene in fire mode.

Although the incident was declared HAZMAT

only at the very end, any attempts to make the

declaration sooner would have been complicated

by the fact that the HAZMAT company was

already committed to the scene and potentially

contaminated with the chemicals involved. This

deficiency was manifest in the make-shift

decontamination procedures used at the incident.

The Newark Hazardous Materials Annex indicates

that the NFD is the lead agency for hazardous

materials emergency responses, and that the NFD

will handle the initial response to HAZMAT

incidents. Meeting this responsibility requires the

NFD to be fully prepared to respond to a

HAZMAT incident at any time. Ideally, this

requirement would be met by providing fire

companies solely dedicated to hazardous materials
Health Hazard Evaluation Report No. 99-0062-2804 Page 9

response, rather than a company that responds in

either fire mode or HAZMAT mode, depending

upon early indications about the incident. Accordingly, incident commanders would have the option

to change from a fire to HAZMAT mode without

the logistical concerns of having no HAZMAT

team readily available.

Safety Management

The IMS encourages the delegation of authority,

but not responsibility, for the safety function at an

incident to a fire fighter or other competent person,

who is specially trained and knowledgeable in safe

emergency operations.30 The failure to delegate

may cause conflict between the positions of

command and safety. IMS guidelines generally

recommend that the command officer, who is

responsible for managing the incident on the

strategic level, establish and operate from a

stationary command post as soon as possible after

arriving on the scene.29 In contrast, the delegated

SO must routinely observe operations at the scene

of an incident. This means he must have full

authority to move around the incident scene (fire

ground) to observe and control safety concerns.29

This safety officer would also have the emergency

authority to stop and/or prevent unsafe acts. If the

department safety officer is also routinely

responsible for other tasks, an assistant SO may

need to be designated to address incident safety

functions.

The NFD has a policy for dispatching an incident

safety officer to all full alarm fires. The policy

gives the SO the authority to correct safety and

health hazards, immediately if they are deemed to

be an imminent hazard to personnel, and through

the incident commander if they are not deemed to

be an imminent hazard. Consistent with National

Fire Protection Association (NFPA) 1500

standard, the NFD places general responsibility for

fire fighters’ safety and health with the Fire Chief

or incident commander. 

An SO was dispatched to this incident. There is

not much documentation indicating what actions

the SO took during the incident. The SO’s

incident report indicates that he worked to assure

that companies remained intact. NIOSH

investigators interpret this to indicate that the SO

was working to keep companies accountable for

their members. It was indicated to NIOSH through

interviews that some fire fighters roamed free

during the incident and were isolated from their

company. The recent revision of the Occupational

Safety and Health Administration’s (OSHA)

respiratory protection regulation (29 CFR

1910.134), as adopted by the New Jersey Public

Employees Occupational Safety and Health

(PEOSH) program, includes measures designed to

protect fire fighters while working inside burning

buildings.31 The rule, referred to as a “double

buddy system” or more commonly the 2 in/2-out

rule, states that whenever fire fighters enter a

burning structure, they must do so in teams of at

least two and remain in direct voice or visual

contact with each other at all times. Also, at least

two other fully equipped and trained fire fighters

must remain outside the structure to monitor those

inside and be prepared to rescue them. This

regulation was not in effect at the time of the

incident, but the practice is a good safety

precaution that has been followed by many fire

departments prior to the date on which the

regulation came into enforcement. 

Training

The training requirements for persons who will

engage in hazardous materials response activities

are outlined in 29 CFR 1910.120 (q).32 This

paragraph states that the training shall be based on

the duties and the functions to be performed by

each responder of an emergency response

organization. Five levels of training are outlined

in the paragraph: 1) first responder awareness

level, trained to initiate an emergency response

sequence by notifying the proper authorities of the

release; 2) first responder operations level, trained

to protect persons, property or the environment
Page 10 Health Hazard Evaluation Report No. 99-0062-2804

from the effects of a hazardous material release;

3) hazardous materials technician, trained to

assume an offensive role in stopping the release;

4) hazardous materials specialist, provide support

to hazardous materials technicians; 5) on scene

incident commander, assume control of the

incident beyond the first responder awareness

level. Trainers who teach any level of training

shall have satisfactorily completed a training

course for teaching the subjects they are expected

to teach, such as the course offered by the National

Fire Academy. 

Communications

Fire department communications can be

ineffective or even completely unusable in a

high–rise building.28 At some locations within a

high–rise building it is difficult to send or receive

messages using portable radios. Successful radio

transmission may become intermittent as the

sender or receiver of a radio message moves

within the building.28

The NFD used portable radios during the incident.

They also had the use of an on-site telephone

system that was used to call to the seventh floor

from the command post. It was indicated to

NIOSH investigators that portable radio communications were poor at times during the incident.

This was evidenced in radio transcripts when the

BC attempted to communicate information about

the contents of the fire to the DC. Reportedly,

about 25 minutes into the incident, an employee of

the plant approached the BC on the seventh floor

and indicated to the BC that the plant had received

a shipment of Drano® that day and that this was

the material that was burning. At this time, the BC

attempted to notify the DC of this information via

portable radio. At 2030 hrs, 18 minutes after the

first company had arrived on site, the BC indicated

to the DC, “One of the workers reports they had a

load of Drano® come in today”......no response

from the DC. “One of the workers reports that the

substance was Drano®, a large amount came into

the plant today.”....no response from the DC. The

radio transcripts show no further mention of the

Drano®. Transcripts documenting telephone

communications were not available.

Respiratory and Other

Personal Protective

Equipment (PPE)

Because the smoke was not very dense at times

during the incident, and the crane operation rooms

seemed to be isolated from the smoke, a few fire

fighters at the scene reported that they felt

comfortable removing their self–contained breathing apparatus (SCBA) in certain areas of the

facility. While a properly operating SCBA worn

by a well-trained individual offers adequate

protection against smoke and chemical inhalation,

even brief exposure without respiratory protection

may present a health hazard. Fire fighting requires

strenuous physical exertion, which increases

oxygen demand and respiratory rate and thus

increases the risk of exposure to inhalational

toxins and hypoxia.33 Although fire fighters are

equipped with respiratory protective equipment, it

is not always used, especially during the final

extinguishment or overhaul phases, when smoke

intensity and assumed exposures are thought to be

low. Inadequate respiratory protection at the fire

scene is an important risk factor in the

development of toxicity from smoke inhalation.34

One study reported that 70% of fire fighters

remove their mask at some time during knockdown

and that as many as 30% wear their masks less

than half the time.35

A fire fighter’s complete turnout gear typically

worn during a fire incident consists of a helmet,

hood, turnout coat, turnout pants, boots, gloves,

and a SCBA with a personnel alert safety system

(PASS) device. SCBA’s provide the highest level

of protection against inhalation exposures, even in

atmospheres considered immediately dangerous to

life and health. Turnout gear is made of fireresistant material that will provide protection

against flashover temperatures up to 1500 degrees

Fahrenheit (°F) for brief periods. Although

turnout gear has the ability to withstand some
Health Hazard Evaluation Report No. 99-0062-2804 Page 11

types of chemical contact, during a chemical fire

it may not provide protection against chemical

exposure. Skin exposure is very likely because

turnout gear material is not impermeable to many

chemicals. Currently, PPE made of a material that

is both fire- and chemical-resistant does not exist.

Following the incident, turnout gear was tested for

surface contamination by wetting the surface and

using litmus paper. This would indicate if there

was surface contamination present on the gear that

was either an acid or a base. The tests indicated

that the surfaces were neither acidic nor basic.

According to interviewed fire fighters, the gear

was placed in truck one after the incident and

returned to the fire stations the following morning.

Reportedly, the gear was replaced with clean

turnout gear a few days later. Some fire fighters

indicated they had worn the turnout gear in the

interim. The use of chemically-contaminated gear

may result in skin irritation when worn by fire

fighters at other fire scenes.36 The NFD uses a

Quartermaster system to supply fire fighters with

their gear. Elements of a Quartermaster system

should include the replacement, repair, laundering,

and decontamination of turnout gear. If feasible,

an adequate supply of replacement turnout gear

should be made available to fire fighters while

necessary replacement, repairs, or laundering is

rendered.

Medical

 

Confidential interviews were obtained from 20 fire

fighters, and self-administered questionnaires were

completed by an additional 8 fire fighters (37 fire

fighters were at the scene). The average amount of

time spent at the scene was 3.7 hours (range: 2 - 6

hours). The average amount of time spent at the

scene without respiratory protection was 2 hours

(range: 0.25 to 5.50). Twenty-one fire fighters

(75%) reported that they smelled a chlorine-like

odor while they were at the scene. All reported

that they wore SCBA for some amount of time at

the scene. The most common symptom reported

was burning or irritation of the eyes (18

participants, 64%). The next most common

symptoms were throat irritation or hoarseness (15,

54%) followed by cough (12, 43%). Eight fire

fighters (29%) reported a burning sensation in

their chest. Three fire fighters (11%) reported that

they began wheezing at the scene. Five fire

fighters (18%) reported that they developed no

symptoms at the scene or afterward.

Decontamination of the fire fighters occurred after

it was determined that the scene was a hazardous

materials incident. Decontamination took place in

the shower facilities of American Ref-fuel. All

fire fighters reported that they decontaminated

themselves by showering with water from 2 to 10

minutes. In addition to showering, 7 (25%)

reported that they flushed their eyes with water

while in the shower. There were complaints that

the water was too cold and this decreased the

decontamination time. They also reported that

there was an inadequate number of towels to dry

themselves and inadequate clothing to protect

against the cold weather. Many fire fighters

continued to wear their under garments while in

the shower.

The 37 fire fighters were transported to five local

hospitals. Most were transported by emergency

medical services (EMS), but others drove

themselves to the hospital. Twenty-two hospital

medical records from the five hospitals were

reviewed. The number of medical records

received from each hospital ranged from three to

five. These records revealed that the treating

physicians were aware that the fire fighters were

exposed to chemicals at a fire, and the physicians

were concerned about the inhalation of toxic

fumes and smoke. However, it was unclear to the

treating physicians in most circumstances what

specific toxins were present at American Ref-fuel.

Several medical records specifically mentioned

“possible phosgene” and “possible chlorine gas

exposure.” 

Fire fighters’ symptoms were consistent in the

different hospitals; however, the extent of

diagnostic testing differed. The university-based

hospital performed the most diagnostic tests on the
Page 12 Health Hazard Evaluation Report No. 99-0062-2804

fire fighters. The tests included chest x-rays

(CXR), electrocardiograms (EKG), arterial blood

gases (ABG), pulse oximetry, carboxyhemoglobin

levels, methemoglobin levels, serum electrolyte

levels, and complete blood counts (CBC).

Pulmonologists were also consulted for further

evaluation of the fire fighters’ pulmonary status.

The fire fighters were monitored for a median of

24 hours to assess late pulmonary effects of the

inhaled exposures.

The other hospitals performed consistently fewer

tests. One hospital performed only pulse

oximetry, while others performed pulse oximetry

plus carboxyhemoglobin level or chest x-ray.

Some hospitals contacted the New Jersey Poison

Control Center, while others did not. These

hospitals did not perform prolonged monitoring to

assess the late pulmonary effects of the inhalation

exposures. In the non-university hospitals, the fire

fighters were monitored a median of 3.75 hours.

Two of the 37 fire fighters were admitted to

separate hospitals from the emergency

departments. The hospitalizations were reported

to be the result of the inhalation exposure at the

scene. One of the fire fighters was hospitalized for

five days and the other for six days. A third fire

fighter had persistent respiratory symptoms, and

he was placed on limited duty for 3 weeks and

continued to take medications for his respiratory

condition at the time of the NIOSH interview (4

months later).

Several fire fighters had persistent symptoms for

several days to weeks. The most common persistent symptom was burning eyes. Several reported

that they saw an ophthalmologist for their eyes and

were given antibiotic drops. One fire fighter

reported that he did not remove his contact lenses

at the scene and his eye symptoms persisted up to

the time of the NIOSH interview. Others

complained of persistent burning in their chests

and coughing, which lasted a few days to a week

after the incident.

Seven fire fighters made an appointment to be seen

at the occupational medicine provider for the NFD.

Five medical records were reviewed from this

clinic. Chest x-ray and pulmonary function tests

(PFT) were ordered on all five fire fighters. Two

of the PFT’s showed evidence of mild obstructive

disease, and the others were normal. There were

no comparison PFT’s that were available.

Surveillance examinations, including PFT’s, are

performed at another clinic and not at this clinic.

Three fire fighters had more severe lower

respiratory tract injury. One of these fire fighters

had a severe viral infection on the day of the

incident, and perhaps this illness could have made

his respiratory tract more vulnerable to the irritants

that were present. The reason the other two

developed more severe symptoms is unclear. They

may have received a higher dose of the irritant

gases, but their description of their job activities,

PPE, and location does not differ significantly

from those with less severe pulmonary injury.

The medical evaluation of fire fighters differed by

hospital. The university-based hospital performed

consistently more tests than the other hospitals.

The evaluations at the university-based hospital

were consistent with recommendations and

guidelines on medical evaluation of fire fighters

after exposure to toxic substances and smoke.5,

6,7,8,9,10, 15,34 However, from our interviews and

review of the medical records, it appears that the

differences in the medical evaluations did not

result in worse clinical outcomes among the fire

fighters receiving fewer tests. Thus, it is likely

that most fire fighters did not receive sufficient

doses of the toxins to cause significant pulmonary

or systemic health effects; however, this

information was not known at the time of the

hospital evaluations.

Appropriate diagnostic studies for symptomatic

patients with smoke inhalation and asymptomatic

patients with significant risk factors (from history

of exposure and past medical history) include

pulse oximetry, arterial blood gas (ABG) analysis,

chest x-ray, electrocardiogram and cardiac
Health Hazard Evaluation Report No. 99-0062-2804 Page 13

monitoring, and carboxyhemoglobin (COHb)

level.6

 Carboxy-hemoglobin level is important

because it is the most direct biological measure of

exposure to carbon monoxide (CO). COHb levels

should be measured in all patients with smoke

inhalation and cannot be inferred reliably from

clinical signs and symptoms. Elevated COHb

level should raise the concern for CO poisoning as

well as potential exposure to other smoke

inhalation toxins, such as coexisting asphyxiants

and irritants.4

Chest radiographs are a low-yield procedure and

are commonly normal in the early course of smoke

inhalation.5, 6 Most often, abnormal findings such

as local, patchy, or diffuse infiltrates are not

evident until 24 to 36 hours after exposure.37

Subtle findings such as perivascular haziness, peribronchial cuffing, bronchial wall thickening, and

subglottic edema may be apparent within 24 hours

of exposure. Serial chest x-rays may be useful in

monitoring severe smoke inhalation.38

Pulmonary function testing can aid in the medical

evaluation of patients with toxic pulmonary

insults. Pulmonary function testing is an

informative but underutilized source of diagnostic

information in the acute setting. Obstructive

ventilatory defects, characterized by reduced

expiratory flow volumes and flow rates are early

findings that are related to primary airway injury.

Also, these abnormalities generally precede chest

x-ray findings or arterial blood gas alterations and

permit early identification of patients at increased

risk for more severe subsequent pulmonary

disease.5, 6

In 1992, University of Medicine and Dentistry of

New Jersey (UMDNJ) Robert Wood Johnson

Medical School, in conjunction with U.S. Public

Health Service, Division of Employee

Occupational Health, and the New Jersey

Department of Health, produced “Guidelines for

the Emergency Management of Firefighters.”39

These guidelines were produced to assist

emergency departments and other health care

providers to recognize and treat various conditions

for which a fire fighter is occupationally at risk.

These guidelines were written because toxic

exposures in fire fighters are not often recognized,

and morbidity and mortality may be lessened

through early recognition and treatment of medical

problems.

Subsequent to the testing performed in the acute

care setting, few fire fighters had additional

medical tests performed to assess the long term

health effects of their exposures at American Reffuel. Seven fire fighters reported that they were

evaluated by the department’s occupational health

provider. The most persistent health concern was

burning eyes which lasted several weeks after the

incident. Also, a few fire fighters had persistent

pulmonary symptoms. However, the surveillance

medical evaluations were performed by another

health care provider. This information was not

available to the occupational medicine provider

when they were evaluated after the American Reffuel incident because the two providers do not

routinely share medical records unless requested.

The surveillance information would be helpful to

determine if there were differences between

current and previous evaluations, such as

pulmonary function tests.

The decontamination procedures at American Reffuel were not consistent with guidelines. It was

fortunate that the shower facilities were available

at the facility. Skin decontamination was

acceptable in most cases, but there was inadequate

flushing of the eyes in most cases. Most fire

fighters reported that they were not aware that they

should flush their eyes with water. Guidelines

recommend flushing the eyes for at least 15

minutes after such exposure, and this may take

place during showering or at other early phases of

the delivery of health care.10, 15

CONCLUSIONS

The elements leading to fire fighter exposures at

American Ref-fuel on December 17, 1998, are

complex and multi-factorial in nature. Clearly,
Page 14 Health Hazard Evaluation Report No. 99-0062-2804

fire fighters did encounter exposures to irritant

gasses at the scene. The NFD approached the

incident in fire mode, when in fact, a hazardous

materials response approach would have been

more appropriate. The reasons for using a fire

mode at the scene stem largely from

misinformation provided to the arriving fire

fighters about the true nature of the materials

involved. Early into the incident, the BC was

provided information about the chemical nature of

the fire. This information would have provided

justification for revising the strategy employed.

Efforts by the BC to communicate this information

to the DC via portable radio were unsuccessful. It

is not known if this information was

communicated in person or via the American Reffuel telephone system. Controls, which should

have limited exposures, either failed or were

circumvented. Exhaust ventilation at the plant was

reported to have operated only intermittently,

occasionally allowing the smoke and gas to

concentrate in the areas where fire fighters were

working. This intermittent smoke condition,

coupled with several reports of fire fighters

removing their respiratory protection during the

incident, ultimately led to the inhalation of

harmful concentrations of smoke and gas. 

Most fire fighters suffered irritant symptoms that

were the result of their exposures to irritant gases

at American Ref-fuel. Those fire fighters who did

not develop symptoms or who had recovered are

unlikely to develop health problems in the future

because of this exposure. These irritant gases may

produce chronic respiratory diseases, but only in

those with high exposures and severe acute

symptoms. The fire fighters who suffered more

severe injuries continued to receive medical care

at the time of the NIOSH investigation. 

Health care providers were uncertain of the

specific exposures of the fire fighters, even when

they were discharged from the emergency

departments. Obtaining fewer medical tests did

not appear to adversely affect the health outcome

of the fire fighters who received care at those

hospitals. However, following the guidelines

developed by the New Jersey Department of

Health for evaluating fire fighters after acute

respiratory exposures would be preferable in the

future. Decontamination procedures were less

than optimal at the scene. Inadequate flushing

may have resulted in persistent irritation of the

eyes in some fire fighters. Also, the persistent

irritation may be due to the initial chemical injury

to the mucous membranes of the eye.

RECOMMENDATIONS

The following recommendations are based on the

findings of this survey, previous HHEs, and the

current scientific literature. These recommendations are intended to reduce the potential for

work-related injuries and illnesses to fire fighters

of the NFD. 

1. The NFD should ensure personnel are trained

to handle the duties and functions they may be

called upon to perform in a hazardous materials

response. These training requirements are outlined

in 29 CFR 1910.120 (q). At a minimum, all members of the fire department should be trained to the

first responder awareness and operations level.

Members of the HAZMAT team should be trained

to the hazardous materials technician level.

Anyone who may be called upon to assume

incident command over a hazardous materials

response should be trained to the on scene incident

commander level. This should include all captains

of the HAZMAT unit and chiefs. This training

should be followed up with annual refresher

training as indicated in 29 CFR 1910.120 (q). 

2. Department records indicated that the

responsibility for HAZMAT operations did not

consistently fall with one person. Rather, responsibility for HAZMAT operations and/or training

appears to have shifted among a few different

persons. There should be a clear line of command

for the administrative aspects of the HAZMAT

operation. This person should have ultimate

responsibility for assuring that the HAZMAT unit

is stocked with appropriate and operational
Health Hazard Evaluation Report No. 99-0062-2804 Page 15

equipment, which is maintained in good working

order. Clear command over all HAZMAT tours

should be established to assure consistent and

adequate training beyond the training provided by

the individual HAZMAT captains. 

3. Fire fighters may often face chemical

exposures when responding to incidents such as

the American Ref-fuel chemical fire because they

lack appropriate protective equipment. No PPE

currently exists that will protect against both fire

and the chemical exposures associated with such

an incident. To reduce the likelihood of fire

fighters sustaining undue chemical exposures

during these types of incidents, all fire fighters

should properly wear all PPE while in established

hazard zones (i.e., hot, warm, and cold).

4. The Newark Hazardous Materials Annex

indicates that the NFD is the lead agency for

hazardous materials emergency responses. Ideally

this requirement would be met by providing fire

companies who are solely dedicated to hazardous

materials response, rather than a company that

responds in either fire mode or HAZMAT mode,

depending upon early indications about the

incident. An increase in resources would need to

be directed to HAZMAT in order to meet the

increased staffing a dedicated unit would require.

Short of providing a fully dedicated HAZMAT

unit, the NFD should consider modifying response

protocol so that HAZMAT companies are less

likely to be occupied by fire calls. For example,

not having truck company 1 respond as first or

second due to a fire would offer the IC the option

to change from a fire mode without having

compromised the HAZMAT company. 

5. Reports indicate that some fire fighters were

alone at times during the incident. The SO’s

report suggests that he was trying to follow a

double buddy system or some other form of

accountability. The NFD should implement and

enforce a fire fighter accountability consistent with

PEOSH’s two-in-two-out rule.

6. Immediately following fire suppression and

overhaul activities involving chemical fires, all

potentially contaminated PPE should be

thoroughly inspected, tested, and laundered in a

timely fashion. Fire fighters should also be

instructed to promptly discontinue the use of any

potentially contaminated PPE and equipment.

Whether a Quartermaster system or an Allowance

system is used, an adequate supply of backup

equipment should be available to fire fighters.36

7. Since fire fighting is a highly hazardous

occupation, safe work habits and use of PPE is

strongly emphasized. During a fire incident, the

assigned Safety Officer must have full authority to

move around the scene to observe and address

safety and health hazards, including such unsafe

practices of not wearing respiratory protection in

hot and warm zones. At future fire incidents, the

Safety Officer should enforce the use of all

necessary PPE in hot and warm zones and also

identify other unsafe practices on the fireground.

8. The NFD should consider issuing a written

“Alert” to small businesses to inform them about

fire protection issues, including emergency

response preplanning and the importance of

reporting any chemical storage and use at their

facility to the fire department. Businesses should

be encouraged to report the initial or intermittent

use of chemicals, which the NFD would be

unaware of until the subsequent SARA III

reporting period. 

9. Communication between the NFD and local

emergency departments and hospitals should be

improved. At this point there is no standard

procedure to relate fire fighter exposure

information from the NFD to local hospitals. This

could be accomplished by assigning a liaison

between the fire department and the hospital(s).

10. Fire fighter medical surveillance information

should be better integrated with acute care

occupational medicine services. The medical surveillance examinations will have baseline health

results. Acute changes in health conditions may
Page 16 Health Hazard Evaluation Report No. 99-0062-2804

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Washington, DC: International Association of

Fire Fighters.

3. Nelson GL [1987]. Regulatory aspects of fire

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4. Lui D, Olson KR [1991]. Smoke inhalation.

CMCC Crit Care Toxicol 1:203-24.

5. Orzel RA [1993]. Toxicological aspects of

firesmoke: polymer pyrolysis and combustion.

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7. Teixidor HS, Rubin E, Novick GS, Alonzo

DR [1983]. Smoke inhalation: radiographic

manifestations. Radiol 149:383-7.

8. Gochfeld M, Szenics J, Boesch R, Fontus H

[1992]. Guidelines for the emergency

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Occupational Health, UMDNJ- Robert Wood

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13. Parkes WR [1994]. Non-metallic gases,

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be noticed more readily if this information is

available to the acute care provider. This could be

accomplished by making surveillance information

readily available to the occupational medicine

provider who provides acute medical care.

11. Decontamination procedures stress the importance of flushing the eyes and other exposed

mucous membranes when exposed to contaminants

capable of causing damage in those parts of the

body.

12. In the aftermath of acute chemical exposure,

fire fighters should undergo exams to determine if

they have any acute health effects related to that

exposure. The components of the exams should be

determined by the nature of the chemical exposure.

13. Although the NFD conducted an internal audit

of their communications systems in 1997, which

determined that the portable radios used by the fire

department were “state of the art” and that there

was “little that could or should be done to improve

their performance,” the NFD should periodically

review the radio technology available that may

serve to improve communications in high-rise

structures and update the departments communications equipment as more effective radios become

available. 

REFERENCES
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15. Poisindex® [1999]. Toxicological Management: Chlorine gas. Micromedex Inc. Englewood,

CO.

16. ATSDR [1994]. Phosgene. In: Managing

hazardous materials incidents. Vol. III, Medical

management guidelines for acute chemical

exposures. Agency for Toxic Substances and

Disease Registry. Washington DC: U.S. Government Printing Office.

17. Proctor NH, Hughs JP, Fishman ML [1996].

Phosgene. In: Chemical hazards of the workplace.

4th ed. New York, NY: Van Nostrand Reinhold.

18. Poisindex® [1999]. Toxicological Management: Phosgene. Micromedex Inc. Englewood,

CO.

19. Kroschswitz MH, ed. [1993]. Chloramines

and Bromines. In: Encyclopedia of chemical

technology. 4th ed. Vol. 5. New York, NY: John

Wiley and Sons.

20. Barbee SJ, Thackara JW, Rinehart WE

[1983]. Acute inhalation toxicology of nitrogen

trichloride. Am Ind Hyg Assoc 44(2):145-6.

21. Massin N, Bohadana AB, Wild P, Hery M,

et al. [1998]. Respiratory symptoms and bronchial

responsiveness in lifeguards exposed to nitrogen

trichloride in indoor swimming pools. Occup

Environ Med 55:258-63.

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developing fire protection services for the public.

Boston, MA: National Fire Protection

Association, NFPA 1201–1989.

23. NFA [1987]. The incident command system.

Emmitsburg, MD: U.S. Federal Emergency Management Administration, U.S. Fire Administration,

National Fire Academy, NFA–ICS–SM.

24. NFPA [1992]. Hazardous materials response

handbook. Quincy, MA: National Fire Protection

Association, p. 711. 

25. NFPA [1990]. Standard on fire department

incident management system. Quincy, MA:

National Fire Protection Association, NFPA 1561–

1990.

26. IFSTA [1998]. Essentials of fire fighting. 4th

ed. Oklahoma State University: International Fire

Service Training Association, p. 14. 

27. NFPA [1987]. Standard on fire department

occupational safety and health. Quincy, MA:

National Fire Protection Association, NFPA 1500–

1987.

28. NFS [1996]. Model procedures guide for

high–rise fire fighting. 1st ed. Stillwater, OK:

Fire Protection Publications, Oklahoma State University, National Fire Service Incident

Management Consortium.

29. NFPA [1987]. Fire command. Boston, MA:

National Fire Protection Association.

30. Oklahoma State University [1983]. Incident

command system. Stillwater, OK: Oklahoma

State University.

31. CFR [1998]. OSHA 29 CFR 1910.134.

Respiratory protection. Code of Federal Regulations. Washington, DC: U.S. Government

Printing Office, Office of the Federal Register.

32. CFR [1999]. OSHA 29 CFR 1910.120.

Hazardous Waste Operations and Emergency

Response. Code of Federal Regulations.

Washington, DC: U.S. Government Printing

Office, Office of the Federal Register.

33. Terrill JB, Montgomery RR, Reinhardt CF

[1978]. Toxic gases from fires. Science 200:

1343-9.

34. Hung OL, Shih RD [1997]. Firefighters. In:

Greenberg MI, Hamilton RJ, Phillips SD, eds.

Occupational, Industrial, and Environmental Toxicology. St. Loius, MO: Mosby.
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35. Jankovic J, Jones W, Burkhart, Noonan

[1991]. Environmental study of firefighters. Ann

Occup Hyg 35:581-602.

36. NIOSH [1998]. Health hazard evaluation

report: International Association of Fire Fighters

(IAFF), Indianapolis, IN. HETA 97-0034-2683.

Cincinnati, OH: US DHHS, CDC, NIOSH.

37. Teixidor HS, Rubin E, Novick GS, Alonzo

DR [1983]. Smoke inhalation: radiographic

manifestations. Radiol 149:383-7.

38. Lee MJ, O’Connell DJ [1988]. The plain

chest radiograph after acute smoke inhalation.

Clin Radiol 39(1):33-7.

39. Gochfeld M, Szenics J, Boesch R, Fontus H

[1992]. Guidelines for the emergency

management of firefighters. Division of

Occupational Health, UMDNJ- Robert Wood

Johnson Medical School, Piscataway, NJ.

Glossary of Medical Terminology

Airways. Any part of the respiratory tract (e.g., lungs and windpipe) through which air passes during

breathing.

Alveoli. Microscopic air sacs in the lungs in which gas travels between the blood and the lung.

Arterial blood gas. A procedure that measures the oxygen content, carbon dioxide content, and the pH in

arterial blood.

Asphyxiant. An agent, especially a gas, that will cause the insufficient intake or utilization of oxygen.

Asthma. A chronic health condition in which constriction of the bronchial tubes occurs in response to

irritation, allergy, or other stimuli.

Atelectasis. Partial collapse of the lung.

Bronchiectasis. Chronic dilation of a bronchus or bronchi, with a secondary infection that usually involves

the lower portion of the lung.
Health Hazard Evaluation Report No. 99-0062-2804 Page 19

Bronchus ( bronchi). Large division of the windpipe that carries air to and from the lungs.

Bronchiole. A small diameter airway branching from a bronchus.

Bronchitis. Inflammation of the mucous membrane of the bronchial tubes, usually associated with persistent

cough and sputum production.

Bronchospasm. Contraction of the smooth muscle of the bronchi, causing narrowing of the bronchi. This

narrowing increases the resistance of air flow into the lungs and may cause a shortness of breath and

wheezing.

Bronchotracheitis. Inflammation of the membrane lining of the bronchi and trachea.

Carboxyhemoglobin. Compound formed in the blood from hemoglobin upon exposure to carbon monoxide.

Complete blood count. Enumeration of the components of the whole blood, such are red blood cells and

white blood cells.

Conjunctiva. The delicate mucous membrane that covers the exposed surface of the eyeball and lines the

eyes.

Conjunctivitis. Inflamation of the conjunctiva; can result in redness, irritation, and tearing of the eye.

Co-oximeter. A device that is used to measure oxygen saturation in samples of arterial blood. It uses at least

four wavelengths of light and is capable of distinguishing oxyhemoglobin, deoxygenated hemoglobin,

carboxyhemoglobin, and methemoglobin.

Cornea. Transparent membrane that covers the anterior part of the eye.

Corrosive. A substance with the ability to destroy the texture or substance of a tissue.

Decontamination. The process of removing hazardous material from exposed persons and equipment.

Dermal. Relating to the skin.

Dermatitis. Inflammation of the skin.

Dyspnea. Shortness of breath; difficult or labored breathing.

Edema. Accumulation of fluid in the body cells or tissues; usually identified as swelling.

Electrocardiogram (EKG). A record of the electrical activity of the heart.

Electrolytes. Ionized salts in the blood. Commonly measured electrolytes include sodium, potassium,

chloride, and bicarbonate.
Page 20 Health Hazard Evaluation Report No. 99-0062-2804

Emphysema. A chronic lung disease characterized by increase in size of air spaces beyond the terminal

bronchiole with destructive changes in their walls.

Hemoglobin. The iron-containing pigment of red blood cells. Its function is to carry oxygen from the lungs

to the tissues.

Hypoxia. Condition in which below normal levels of oxygen are present in the air, blood, or body tissues.

Inadequate warning property. Characteristic (e.g., odor, irritation) of a substance that is not sufficient to

cause a person to notice exposure.

Irritant. An agent which produces an inflammatory reaction upon contact.

Lacrimation. Secretion of tears, especially in excess.

Larynx. The enlarged upper end of the trachea below the root of the tongue.

Methemoglobin. A transformation product of hemoglobin in which normal iron is oxidized. Methemoglobin

contains oxygen that if firmly bound to the oxidized iron, which prevents release of oxygen to the tissues.

Necrosis. Death of one or more cells or a portion of a tissue or organ.

Obstructive lung disease. Increased resistance to the passage of air in and out of the lung due to narrowing

of the bronchial tree.

Ocular. Pertaining to the eye.

Olfactory fatigue. Temporary loss of the sense of smell due to repeated or continued stimulation.

Oxidation. To increase the positive valence (usually by adding oxygen), or to decrease the negative valence

(usually by the loss of electrons).

Photophobia. Unusual intolerance of light, usually painful.

Pneumonitis. Inflammation of the lungs.

Pulmonary. Concerning or involving the lung.

Pulmonary edema. Accumulation of excess fluid in the lungs that impairs gas exchange; usually due to

either increased pulmonary artery pressure or leaky pulmonary capillaries.

Pulmonary function test. A procedure that measures the flow of air through the lungs.

Pulse oximeter. Photoelectric device for determining the amount of oxygen in the blood. Usually done by

measuring the amount of light transmitted through a translucent part of the skin.
Health Hazard Evaluation Report No. 99-0062-2804 Page 21

Reactive airways dysfunction syndrome. Increased or excessive constriction of the bronchial tubes in

response to chemical exposure.

Respiratory. Pertaining to breathing. 

Rhinitis. Inflammation of the mucous membranes of the nose.

Routes of exposure. The manner in which a chemical contaminant enters the body (e.g., through the lungs

or gastrointestinal tract).

Secondary contamination. Transfer of a harmful substance from one body (primary body) to another

(secondary body), potentially permitting adverse effects to the secondary body.

Stridor. A harsh, high-pitched respiratory sound often heard in acute respiratory obstruction.

Toxic. Having the ability to harm the body especially by chemical means.

Trachea. The tube that runs from the larynx to the bronchial tubes. Also called the windpipe.

Wheezing. A whistling or sighing sound resulting from narrowing of the respiratory passages.

For Information on Other

Occupational Safety and Health Concerns

Call NIOSH at:

1–800–35–NIOSH (356–4674)

or visit the NIOSH Web site at:

www.cdc.gov/niosh

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