TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 1

PPE CASE

Personal Protective Equipment Conformity Assessment Studies and Evaluations

Evaluation of Three Self-Contained Breathing Apparatus Involved 

in a Fatality in the Fire Service

San Antonio County Fire Department Request for three Scott® Safety Air-Pak® 

Model AP50 4.5 units

The National Institute for Occupational Safety and Health (NIOSH) 

conducts a Fire Fighter Fatality Investigation and Prevention Program, 

which is executed by its Division of Safety Research. In support of this 

Program, NIOSH’s National Personal Protective Technology Laboratory

(NPPTL) inspects and evaluates the Self-Contained Breathing Apparatus 

(SCBA) that was being used by the fire fighter during a fatality.

This report provides a summary of NPPTL’s inspection and evaluation 

methods, and findings for the three SCBAs that were being used by the 

San Antonio Fire Department fire fighters during a fatal event. The 

SCBAs being used were the Scott® Safety Air-Pak® Model AP50 4.5, 45 

minute, 4500 psi unit. The San Antonio Fire Department was advised 

that NIOSH NPPTL would provide a written report of the investigation 

and any applicable test results.

What NIOSH Did to Protect the Worker

Upon receipt of the SCBAs, NPPTL managed the custody of evidence 

throughout the entire inspection and evaluation process at its 

Morgantown, West Virginia facility. NPPTL staff inspected all of the SCBA 

components and documented their findings with written and 

photographic evidence. NPPTL also tested two of the SCBAs to determine 

conformance to NPPTL’s approval requirements as outlined in Title 42, Code of Federal Regulations, Part 84 (42 

CFR 84). Further testing was conducted to provide an indication of the conformance of each SCBA to the 

National Fire Protection Association (NFPA) Air Flow Performance requirements of NFPA 1981, Standard on 

Open-Circuit Self-Contained Breathing Apparatus for the Fire Service, 1997 Edition. If the inspection or 

evaluation data suggested that the SCBA units may have contributed to the near miss, NPPTL would have 

NIOSH received three SCBAs 

used by three fire fighters 

involved in a fatality. Two of 

the SCBAs were not found to 

contribute to the fatality. 

The other respirator was 

damaged in the event and 

could not be tested.

A qualified service 

technician must inspect, 

repair, test, clean, and 

replace damaged 

components of any SCBA. 

involved in an incident 

before it may be returned to 

service.
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 2 

engaged in corrective action to ensure that no other users of the product would experience an incident. In this 

case, no such corrective action was necessary. NPPTL then managed the disposition of the SCBAs. 

Chain of Custody

The SCBA units were delivered via FedEx in a cardboard box to Lab H1513 in the NIOSH facility in Morgantown,

West Virginia on February 8, 2017. 

On June 13, 2017, NPPTL employees Jay Tarley and Jeremy Gouzd inspected the SCBA units. The SCBA units 

remained in Lab H1513 throughout the entire inspection and testing process. 

The SCBAs were identified as belonging to the San Antonio Fire Department and were visually examined,

component by component, in the condition received to determine the conformance of the units to the NIOSHapproved configuration. The units were both identified as the Scott® Safety Air-Pak® Model AP50 4.5, 45 

minute, 4500 psi unit, with NIOSH Approval Number TC-13F-0715CBRN. 
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 3 

SCBA Inspection

The inspection process was initiated by Jay Tarley and Jeremy Gouzd once the SCBA units were delivered via 

FedEx to Lab H1513. The SCBAs were identified as belonging to the San Antonio Fire Department and were 

visually examined, component by component, in the condition received to determine the conformance of the

units to the NIOSH-approved configuration. The units were both identified as the Scott® Safety Air-Pak® Model 

AP50 4.5, 45 minute, 4500 psi unit, NIOSH Approval Number TC-13F-0715CBRN. 

As Received (pictured below) SCBA Unit #1

• This unit received extensive fire damage and could not be inspected or tested

Figure 1: SCBA Unit #1 as received

Components and Observations for SCBA Unit #1 (Figure 1) (“right” or “left” are from the user’s 

perspective) (see Figures in Appendix) 

Unit #1 had extensive heat damage and could not be inspected or tested.

Overall condition (Figures 1 and 2) 
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 4 

 As Received (pictured below) SCBA Unit #2

• Corrosion residue found on metal components of unit

• Cylinder received full and closed

• Bypass was closed

• Donning switch off, regulator inactive

• Mask mounted regulator (MMR) was not connected to facepiece

Figure 2: SCBA Unit #2 and cylinder as received
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 5 

Components and Observations for SCBA Unit #2 (Figure 2) (“right” or “left” are from the user’s perspective) 

(see Figures in Appendix)

Facepiece (Figures 3 - 6) 

• Facepiece seal P/N: 31001740; Large; MFG date: 

05/2015

• Nosecup P/N: 201128 1; Size: Large; MFG date: 

4th Q 2015 

• Retaining ring MFG date: 04/2015; P/N: 31002810; 

Lot# 061715; FT 968

• Lens P/N: 805337-13/-33/-36; MFG date: 11/2014

• Overall condition good, very dirty, very smoky

• Lens was clouded, dirty, with scratches

• Lens had thermal insult 

• Hairnet was fair, but dirty

• Hairnet markings: 5655; 119950

• Hairnet straps good, straps moved freely held in 

place, held securely to facepiece

• Attachment points for straps were good

• The facepiece seal was in good condition

• Regulator interface area was in good condition 

Mask Mounted Regulator (MMR) (Figures 7 - 8) 

• Air-Pak® X3 with Vibralert and Heads Up Display 

(HUD) 

• Regulator assembly P/N: 200077-50; 

S/N:115S1528000122; MFG date: 07-06-15

• Other markings; A3Q15 stamped; 099X 

scribed/written

• Overall condition fair with signs of heat damage

• Outer case good and front label was also in good, 

but dirty condition

• Donning switch was in good condition

• Bypass found open, bypass knob in good shape

• Sealing area was dirty with no signs of fraying 

around the edge, but had minimal scratches

• Regulator could be attached and removed

• Locking assembly functioned, but sticky

• HUD fully intact

Low Pressure Regulator Hose (Figure 9) 

• P/N: SCOTT 31901446

• Overall condition was fair to poor; signs of heat 

damage and abrasion

• Attached from pack at Quick Disconnect

• Quick Disconnect was in good condition and 

functioned 

• Line ran through the shoulder strap to the reducer

Pressure Reducer Assembly (Figures 10, 11) 

• P/N: 201030-02 

• S/N 115S1525020969

• MFG date: 06-18-15 

• Overall condition was dirty with residual 

• All airline connections were secure with no sign of 

heat damage

High Pressure Hose and Cylinder Attachment (Figure 12) 

• Overall condition was good, but dirty and signs of 

corrosion

• Cylinder attachments threads dirty, corroded, 

threads on and off, “O” ring in place 

• RIC/UAC system connector markings: Eaton FD17-

1002-10-04

• RIC/UAC system connector cover in good 

condition, connection dirty

Buddy Breather (Figure 13)

• Auxiliary hose was in pouch and in good condition

 

PASS Console Assembly (Figures 14 and 15)

• Scott label; P/N: unreadable

• X3 Console assembly: unreadable

• MFG date: unreadable

• Overall condition was good

• Lines in good shape—pressure/electrical

• Gauge lens good and readable

• Protective casing good 

• SEI label present

Straps and Buckles (Figure 16) 

• Overall strap condition was fair with significant 

signs of corrosion and heat damage

• Both shoulder straps attached at the top of the 

backframe 

• Hose lines and wires passed through shoulder 

straps

• All adjustable buckles moved and held in place

• Waist area buckle latched and released

• Lumbar strap was in good condition; with heavy 

dye-sublimation

Compressed Air Cylinder and Cylinder Valve Assembly 

(Figures 17 - 20)

• Scott P/N 10009673

• DOT-E-10915-4500; IL 245112

• TC-SU-5134-310 

• Luxfer P/N: L65G-2; REE 118
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 6 

• Hydro date: 5/2006 45 Minute, 4500 PSI

• Overall condition was fair, with signs of heat damage 

• Gauge not easily readable; signs of heat damage

• Threads dirty with corrosion

• Rubber bumper had heavy signs of heat damage

• As received cylinder valve closed and empty

 

 
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 7 

As Received (pictured below) SCBA Unit #3

• SCBA Unit #3 was delivered by FedEx in a cardboard box to Lab H1513

• Corrosion residual found on threads on cylinder attachment 

• Cylinder was received empty and closed

• Donning switch was off with regulator intact 

• MMR was connected to waist belt

Figure 3: SCBA Unit #3 and cylinder as received
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 8

Components and Observations for SCBA Unit #3 (Figure 3) (“right” or “left” are from the user’s perspective) 

(see Figures in Appendix)

Facepiece (Figures 21 - 24)

• Facepiece seal P/N: 31001739 1; MFG date: 11/2013

• Nosecup P/N: 201127 1; Size: Medium; MFG date: 3rd Q 

2013 

• Retaining ring MFG date: 11/13; P/N: 31002809

• Lens P/N: 805337

• Overall condition was fair, but very dirty

• Lens was fair, but dirty, with scratches 

• Hairnet was fair, but very dirty 

• Hairnet straps good, straps moved freely, held in place, and 

held securely to facepiece

• Attachment points for straps were good

• The facepiece seal was in good condition

• Regulator interface area was dirty and smoky

Mask Mounted Regulator (MMR) (Figures 25 - 27)

• Air-Pak®AirPak® X3 with Vibralert and with Heads Up 

Display (HUD)

• Regulator assembly P/N: 200077-50; S/N: 115S1526023933; 

MFG date: 6-25-15

• Other markings; 11 HR; X865

• MMR was attached to waist belt

• Overall condition was fair with no sign of heat damage

• Outer case good and front label was also in good, but dirty 

condition

• Donning switch was in good condition 

• Bypass closed, bypass knob was in good shape

• Sealing area dirty with some signs of fraying around the 

edge and had minimal scratches

• Regulator could be attached and removed

• Locking assembly functioned

• HUD fully intact

Low Pressure Regulator Hose (Figures 28 and 29)

• P/N: unreadable

• Overall condition was good 

• Attached from pack at Quick Disconnect

• Quick Disconnect in good condition and functioned 

• Line runs through the shoulder strap to the reducer

Pressure Reducer Assembly (Figures 30)

• P/N: 201030-02;

• S/N 115S152600198

• MFG date: 6-22-15

• Overall condition was good, but dirty

• All airline connections were secure with no sign of heat 

damage

High Pressure Hose and Cylinder Attachment (Figures 31, 32)

• Overall condition was good, but dirty

• Cylinder attachments threads dirty, corroded, threads on 

and off, “O” ring in place

• RIC/UAC system connector markings: Eaton FD17-1002-10-

04

• RIC/UAC system connector cover in good condition, 

connection dirty

Buddy Breather (Figure 34)

• Auxiliary hose was in pouch, in good condition

PASS Console Assembly (Figures 35 and 36)

• Scott label; P/N: 20112-11

• X3 Console assembly SENS 4500 1/3

• MFG date: 6-21-15

• Overall condition was good

• Lines in good shape—pressure/electrical

• Gauge lens good and readable

• Protective casing good 

• SEI label present

PASS Control Module with PAK-Alert (Figure 37)

• Scott P/N: 201160-02

• Scott S/N: 115S1525026228

• MFG date: 6-20-15

• ID sticker: 00259155

• Other markings: X3305 

• Overall condition was good

• Held securely to backframe

• Wire connection connected to PASS device

• Wire held secure to backframe and ran to console assembly

Back frame Assembly (Figure 38)

• P/N: unreadable

• SEI label readable; NFPA 1981 2013 edition 

• NIOSH Approval Number TC-13F-0715CBRN

• Other marking: 11P-FF1 in yellow marking and sticker

• Other markings: Yellow marker-COSA 990541

• Overall condition good, no bends/cracks in wire frame, or 

plate

• Normal wear and tear

• Shoulder straps were attached to the frame

• Cylinder strap latch good condition and functional

Straps and Buckles (Figure 38)

• Overall strap condition was good 

• Both shoulder straps attached at the top of the backframe 

• Hose lines and wires passed through shoulder straps

• All adjustable buckles moved and held in place

• Waist area buckle latched and released

• Lumbar strap was in good condition; slight dye-sublimation
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 9

Compressed Air Cylinder and Cylinder Valve Assembly 

(Figures 39 - 42)

• Scott P/N 10009673

• DOT-E-10915-4500; IL 245130

• TC-SU-5134-310 

• Luxfer P/N: L65G-2; REE 118

• Hydro date: 5/2006 45 Minute, 4500 PSI

• Overall condition was good 

• Gauge readable 

• Threads dirty with corrosion

• Rubber bumper missing; metal attachment for bumper loose

• As received cylinder valve closed and was empty
 

 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 10

SCBA Testing

The SCBA unit was tested using the six NIOSH test methods and one NFPA test method as described in Table 1.

Table 1. Summary of results from testing SCBA Unit #2.

NIOSH Tests Description of Results PASS/

FAIL 

Positive Pressure Test -NIOSH Test Procedure No. 120 42 CFR Part 84 Reference: Subpart H, § 

84.70 (a)(2)(ii)

Requirement: 

The pressure inside the facepiece in relation to the immediate environment is positive during both 

inhalation and exhalation.

Procedure: 

A breathing machine with a 622 kg.-m./min. cam operating at 24 RPM with a 40-liter per minute 

flow rate (115 liters per minute peak flow) is connected to an anthropometric head for cycling. A 

pressure tap in the head is connected to a transducer which in turn is connected to a strip chart 

recorder for determining the pressure in the facepiece.

The unit met the test requirement. The 

inhalation breathing resistance did not 

become negative during the test. 

*The PASS unit functioned, the digital remote 

functioned and there was a HUD. 

*The corresponding cylinder was used 

Inhalation Breathing Resistance: (inches of 

water column) = 0.35

PASS 

Rated Service Time Test- NIOSH Test Procedure No. 121 42 CFR Part 84 Reference: Subpart F, § 

84.53 (a) and Subpart H, § 84.95 (a) and (b)

Requirement: 

Service time will be measured while the apparatus is operated by a breathing machine as described 

in § 84.88. The open-circuit apparatus will be classified according to the length of time it supplies air 

or oxygen to the breathing machine. Classifications are listed in § 84.53.

Procedure: 

A breathing machine with a 622 kg.-m./min. cam operating at 24 RPM with a 40 liters per minute 

flow rate is connected to an anthropometric head for cycling. A pressure tap in the head is 

connected to a transducer which in turn is connected to a strip chart recorder for determining the 

pressure in the facepiece. The breathing machine is run until the inhalation portion of the breathing 

curve falls below the minimum requirement.

The SCBA met the test requirement. The 

measured service time (adjusted to 

correspond with the recorded breathing 

cycles) was more than the rated service time 

of 45 minutes. The PASS unit functioned

during the test. The SCBA did not go negative 

on inhalation; therefore, maintained positive 

pressure in the facepiece. The measured 

service time (adjusted to correspond with the 

recorded breathing cycles) was more than the 

rated service time of 45 minutes. The PASS 

functioned.

Measured Service Time: 

50 Minutes 84 Seconds

PASS 
 

 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 11

Static Pressure Test- NIOSH Test Procedure No. 122 42 CFR Part 84 Reference: Subpart H, § 84.91 

(d)

Requirement:

The static pressure (at zero flow) in the facepiece shall not exceed 38 mm. (1.5 inches) water-column 

height.

Procedure: 

The facepiece is fitted to an anthropometric head for testing. A pressure tap in the head is 

connected to a calibrated manometer. Full cylinder pressure is applied to the unit at zero flow and 

a reading from the manometer is recorded.

The SCBA met the test requirement. 

Facepiece Static Pressure:(inches of water

column)= 1.17

PASS 

Gas Flow Test- NIOSH Test Procedure No. 123 42 CFR Part 84 Reference: Subpart H, § 84.93 (b) 

and (c)

Requirement: 

The flow from the apparatus shall be greater than 200 liters per minute when the pressure in the 

facepiece of demand apparatus is lowered by 51 mm. (2 inches) water column height when full 

container pressure is applied. Where pressure demand apparatus are tested, the flow will be 

measured at zero gage pressure in the facepiece.

Procedure: 

A pressure tap in the anthropometric head is connected to a manometer for determining when the 

pressure inside the facepiece is at zero. A mass flow meter is connected in line between the 

anthropometric head and an adjustable vacuum source to measure flow. The SCBA cylinder is 

replaced by a test stand which is adjusted initially to full cylinder pressure. The vacuum source is 

adjusted during the test to maintain the desired pressure inside the facepiece. Once the proper 

facepiece pressure has stabilized, a flow reading is recorded. The procedure is then repeated with 

the test stand adjusted to 500 psig.

The SCBA met the test requirement. 

Applied Pressure Air Flow (liters per min.)

4500 psig 484.2

500 psig 481.4

PASS 

PASS

Exhalation Resistance Test- NIOSH Test Procedure No. 122 42 CFR Part 84 Reference: Subpart H, 

§ 84.91 (c)

Requirement: 

The exhalation resistance of pressure-demand apparatus shall not exceed the static pressure in the 

facepiece by more than 51 mm. (2 inches) water-column height.

Procedure: 

The facepiece is mounted on an anthropometric head form. A probe in the head form is connected 

to a slant manometer for measuring exhalation breathing resistance. The air flow through the 

apparatus is adjusted to a rate of 85 liters per minute and the exhalation resistance is recorded.

The SCBA met the test requirement. 

Exhalation Breathing Resistance: (inches of

water column)= 2.09

Static Pressure: (inches of water

column)= 1.17

Difference: (inches of water column)= 0.92

PASS 
 

 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 12

Remaining Service Life Indicator Test- NIOSH Test Procedure No. 124 42 CFR Part 84 Reference: 

Subpart H, § 84.83 (f) and Subpart G, § 84.63 (c)

Requirement: 

Each remaining service life indicator or warning device shall give an alarm when the remaining 

service life of the apparatus is reduced within a range of 20 to 25 percent of its rated service time or 

pressure.

This requirement is modified under § 84.63(c) as follows: For apparatus which do not have a method 

of manually turning off remote gage in the event of a gage or gage line failure the remaining service 

life indicator is required to be set at 25% ± 2% of the rated service time or pressure.

Procedure: 

A calibrated gauge is connected in line between the air supply and the first-stage regulator. The unit 

is then allowed to gradually bleed down. When the low-air alarm is activated, the pressure on the 

gauge is recorded. This procedure is repeated six times. The average of the six readings is 

calculated and recorded.

As these SCBA models do not have a remote 

gauge shutoff, the test requirement is 33% +4 

-0%. 

Electric Vibralert

Run # Alarm Point (psi) Alarm Point (psi)

1 ---- 1580

2 ---- 1570

3 ---- 1570

4 ---- 1570

5 ---- 1570

6 ---- 1560

 Average ---- 1570

The electronics did not work = FAIL

Vibralert = PASS

FAIL

PASS

 

 National Fire Protection Association (NFPA) Test (in accordance with NFPA 1981, 1997 Edition):

NFPA Test Description of Results PASS/

FAIL 

NFPA Air Flow Performance Test—NFPA 1981 (1997 Edition) Reference: Chapter 5, Performance 

Requirements, Sec. 5-1.1

Requirement: 

SCBA shall be tested for air flow performance as specified in Section 6-1, Air Flow Performance Test, 

and the SCBA facepiece pressure shall not be less than 0.0 in. (0.0 mm) water column and nor 

greater than 31⁄2 in. (89 mm) water column above ambient pressure from the time the test begins 

until the time the test is concluded.

Procedure: 

The required equipment specified in the NFPA standards were used to conduct the tests on this 

unit. A pressure tap in the head is connected to a transducer which in turn is connected to a flatbed 

chart recorder for determining the pressure in the facepiece.

The SCBA passed this test. PASS, HUD, and 

alarm systems were functional.

Maximum Facepiece Pressure: (inches of 

water column)= 2.51

Minimum Facepiece Pressure: (inches of 

water column)= 0.60 

PASS

PASS
 

 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 13

Data Logger Information for SCBA Unit #2 tested and evaluated

TimeDateOff To SensingSensing To OffPreAlarm To AlarmManual Alar

m

Alarm ResetLow BatterySensing To PreAlarmClock Reset PendingClock ResetPower On ResetSEMS Link DownSEMS Link UPEVACEVAC ACKBluetooth ConnectBluetooth Disconnect

14:46:26 6/22/2017 - - - - - - - - X - - - - - - -

20:49:42 7/9/2126 - - - - - - - X - - - - - - - -

20:46:24 7/9/2126 - X - - - - - - - - - - - - - -

20:46:20 7/9/2126 - - - - - - - - - X - - - - - -

6:03:06 7/6/2126 - - - - - - X - - - - - - - - -

6:02:46 7/6/2126 - - - - - - X - - - - - - - - -

6:02:24 7/6/2126 - - - - - - X - - - - - - - - -

6:02:04 7/6/2126 - - - - - - X - - - - - - - - -

6:01:42 7/6/2126 - - - - - - X - - - - - - - - -

6:01:20 7/6/2126 - - - - - - X - - - - - - - - -

6:01:00 7/6/2126 - - - - - - X - - - - - - - - -

6:00:38 7/6/2126 - - - - - - X - - - - - - - - -

6:00:16 7/6/2126 - - - - - - X - - - - - - - - -

13:59:54 7/6/2126 - - - - - - X - - - - - - - - -

13:59:34 7/6/2126 - - - - - - X - - - - - - - - -

13:59:12 7/6/2126 - - - - - - X - - - - - - - - -

13:58:44 7/6/2126 - - - - - - - - - X - - - - - -
 

 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 14

13:33:04 7/6/2126 - - - - - - X - - - - - - - - -

13:32:46 7/6/2126 - - - - - X - - - - - - - - - -

13:32:42 7/6/2126 - - - - - - X - - - - - - - - -

13:32:22 7/6/2126 - - - - - - - - - X - - - - - -

12:53:56 7/6/2126 - - - - - - X - - - - - - - - -

12:53:36 7/6/2126 - - - - - - - - - X - - - - - -

12:51:02 7/6/2126 - - - - - - X - - - - - - - - -

12:49:50 7/6/2126 - - - - - - X - - - - - - - - -

12:49:28 7/6/2126 - - - - - - X - - - - - - - - -

12:49:06 7/6/2126 - - - - - - X - - - - - - - - -

12:48:42 7/6/2126 - - - - - - X - - - - - - - - -

12:48:16 7/6/2126 - - - - - - - - - X - - - - - -

12:44:40 7/6/2126 - - - - - - X - - - - - - - - -

12:44:18 7/6/2126 - - - - - - X - - - - - - - - -

12:43:54 7/6/2126 - - - - - - X - - - - - - - - -

12:43:32 7/6/2126 - - - - - - - - - X - - - - - -

13:21:00 7/6/2126 - - - - - - X - - - - - - - - -

13:21:20 7/6/2126 - - - - - - - - - X - - - - - -

21:50:58 5/18/2017 - - - - - - X - - - - - - - - -

21:47:10 5/18/2017 X - - - - - - - - - - - - - - -

10:05:42 5/15/2017 - X - - - - - - - - - - - - - -

10:03:46 5/15/2017 - - - - - - X - - - - - - - - -
 

 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 15

10:01:32 5/15/2017 - - - - - - X - - - - - - - - -

9:58:08 5/15/2017 - - - - - - X - - - - - - - - -

9:57:44 5/15/2017 - - - - - - X - - - - - - - - -

9:56:54 5/15/2017 - - - - - - X - - - - - - - - -

9:56:16 5/15/2017 - - - - - - X - - - - - - - - -

9:54:26 5/15/2017 X - - - - - - - - - - - - - - -

9:48:26 5/15/2017 - X - - - - - - - - - - - - - -

9:46:54 5/15/2017 - - - - - - X - - - - - - - - -

9:45:54 5/15/2017 - - - - - - X - - - - - - - - -

9:44:10 5/15/2017 - - - - - - X - - - - - - - - -

9:35:08 5/15/2017 - - - - - - X - - - - - - - - -

9:27:38 5/15/2017 - - - - - - X - - - - - - - - -

9:24:54 5/15/2017 - - - - - - X - - - - - - - - -

9:24:18 5/15/2017 - - - - - - X - - - - - - - - -

9:23:30 5/15/2017 - - - - - - X - - - - - - - - -

9:23:08 5/15/2017 - - - - - - X - - - - - - - - -

9:22:30 5/15/2017 - - - - - - X - - - - - - - - -

9:22:02 5/15/2017 X - - - - - - - - - - - - - - -
 

 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 16

SCBA Testing 

 The SCBA unit was tested using the six NIOSH test methods and one NFPA test method as described in Table 2. 

 Table 2. Summary of results from testing SCBA Unit #3. 

NIOSH Tests Description of Results PASS/

FAIL 

Positive Pressure Test -NIOSH Test Procedure No. 120 42 CFR Part 84 Reference: Subpart H, § 84.70 

(a)(2)(ii)

Requirement: 

The pressure inside the facepiece in relation to the immediate environment is positive during 

both inhalation and exhalation.

Procedure: 

A breathing machine with a 622 kg.-m./min. cam operating at 24 RPM with a 40-liter per minute flow 

rate (115 liters per minute peak flow) is connected to an anthropometric head for cycling. A pressure 

tap in the head is connected to a transducer which in turn is connected to a strip chart recorder for 

determining the pressure in the facepiece.

The unit met the test requirement. The 

inhalation breathing resistance did not 

become negative during the test. 

*The PASS unit functioned, the digital remote 

functioned and there was a HUD. 

*The corresponding cylinder was used 

Inhalation Breathing Resistance: (inches of 

water column) = 0.30

PASS 

Rated Service Time Test- NIOSH Test Procedure No. 121 42 CFR Part 84 Reference: Subpart F, § 84.53 

(a) and Subpart H, § 84.95 (a) and (b)

Requirement: 

Service time will be measured while the apparatus is operated by a breathing machine as described in § 

84.88. The open-circuit apparatus will be classified according to the length of time it supplies air or 

oxygen to the breathing machine. Classifications are listed in

§ 84.53.

Procedure: 

A breathing machine with a 622 kg.-m./min. cam operating at 24 RPM with a 40 liters per minute flow 

rate is connected to an anthropometric head for cycling. A pressure tap in the head is connected to a 

transducer which in turn is connected to a strip chart recorder for determining the pressure in the 

facepiece. The breathing machine is run until the inhalation portion of the breathing curve falls below 

the minimum requirement.

The SCBA met the test requirement. The 

measured service time (adjusted to 

correspond with the recorded breathing 

cycles) was more than the rated service time 

of 45 minutes. The PASS unit functioned

during the test. The SCBA did not go negative 

on inhalation; therefore, maintained positive 

pressure in the facepiece. The measured 

service time (adjusted to correspond with the 

recorded breathing cycles) was more than the 

rated service time of 45 minutes. The PASS 

functioned. 

Measured Service Time: 

49 Minutes 72 Seconds

PASS 
 

 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 17

Static Pressure Test- NIOSH Test Procedure No. 122 42 CFR Part 84 Reference: Subpart H, § 84.91 (d)

Requirement:

The static pressure (at zero flow) in the facepiece shall not exceed 38 mm. (1.5 inches) water-column 

height.

Procedure: 

The facepiece is fitted to an anthropometric head for testing. A pressure tap in the head is connected 

to a calibrated manometer. Full cylinder pressure is applied to the unit at zero flow and a reading from 

the manometer is recorded.

The SCBA met the test requirement. 

Facepiece Static Pressure:(inches of water

column)= 1.02

PASS 

Gas Flow Test- NIOSH Test Procedure No. 123 42 CFR Part 84 Reference: Subpart H, § 84.93 (b) and 

(c)

Requirement: 

The flow from the apparatus shall be greater than 200 liters per minute when the pressure in the 

facepiece of demand apparatus is lowered by 51 mm. (2 inches) water column height when full 

container pressure is applied. Where pressure demand apparatus are tested, the flow will be measured 

at zero gage pressure in the facepiece.

Procedure: 

A pressure tap in the anthropometric head is connected to a manometer for determining when the 

pressure inside the facepiece is at zero. A mass flow meter is connected in line between the 

anthropometric head and an adjustable vacuum source to measure flow. The SCBA cylinder is replaced 

by a test stand which is adjusted initially to full cylinder pressure. The vacuum source is adjusted 

during the test to maintain the desired pressure inside the facepiece. Once the proper facepiece 

pressure has stabilized, a flow reading is recorded. The procedure is then repeated with the test stand 

adjusted to 500 psig.

The SCBA met the test requirement. 

Applied Pressure Air Flow (liters per min.)

4500 psig 481.39

500 psig 526.7

PASS 

PASS

Exhalation Resistance Test- NIOSH Test Procedure No. 122 42 CFR Part 84 Reference: Subpart H, § 

84.91 (c)

Requirement: 

The exhalation resistance of pressure-demand apparatus shall not exceed the static pressure in the 

facepiece by more than 51 mm. (2 inches) water-column height.

Procedure: 

The facepiece is mounted on an anthropometric head form. A probe in the head form is connected to a 

slant manometer for measuring exhalation breathing resistance. The air flow through the apparatus is 

adjusted to a rate of 85 liters per minute and the exhalation resistance is recorded.

The SCBA met the test requirement. 

Exhalation Breathing Resistance: (inches of 

water column)= 2.06

Static Pressure: (inches of water

column)= 1.02

Difference: (inches of water column)= 1.04

PASS 
 

 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 18

Remaining Service Life Indicator Test- NIOSH Test Procedure No. 124 42 CFR Part 84 Reference: 

Subpart H, § 84.83 (f) and Subpart G, § 84.63 (c)

Requirement: 

Each remaining service life indicator or warning device shall give an alarm when the remaining service 

life of the apparatus is reduced within a range of 20 to 25 percent of its rated service time or pressure.

This requirement is modified under § 84.63(c) as follows: For apparatus which do not have a method of 

manually turning off remote gage in the event of a gage or gage line failure the remaining service life 

indicator is required to be set at 25% ± 2% of the rated service time or pressure.

Procedure: 

A calibrated gauge is connected in line between the air supply and the first-stage regulator. The unit is 

then allowed to gradually bleed down. When the low-air alarm is activated, the pressure on the gauge 

is recorded. This procedure is repeated six times. The average of the six readings is calculated and 

recorded.

As these SCBA models do not have a remote 

gauge shutoff, the test requirement is 33% +4 

-0%. 

Electric Vibralert

Run # Alarm Point (psi) Alarm Point (psi)

1 1530 1580

2 1530 1570

3 1535 1580

4 1540 1570

5 1530 1570

6 1535 1560

 Average 1533.33 1576.66

PASS

PASS 

National Fire Protection Association (NFPA) Test (in accordance with NFPA 1981, 1997 Edition):

NFPA Test Description of Results PASS/

FAIL 

NFPA Air Flow Performance Test—NFPA 1981 (1997 Edition) Reference: Chapter 5, Performance 

Requirements, Sec. 5-1.1

Requirement: 

SCBA shall be tested for air flow performance as specified in Section 6-1, Air Flow Performance Test, 

and the SCBA facepiece pressure shall not be less than 0.0 in. (0.0 mm) water column and nor greater 

than 31⁄2 in. (89 mm) water column above ambient pressure from the time the test begins until the time 

the test is concluded.

Procedure: 

The required equipment specified in the NFPA standards were used to conduct the tests on this unit. A 

pressure tap in the head is connected to a transducer which in turn is connected to a flatbed chart 

recorder for determining the pressure in the facepiece.

The SCBA passed this test. PASS, HUD, and 

alarm systems were functional.

Maximum Facepiece Pressure: (inches of 

water column)= 2.6

Minimum Facepiece Pressure: (inches of 

water column)= 0.55 

PASS

PASS
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 19

Data Logger Information for SCBA Unit #3 tested and evaluated

Time

Date

Off To 

Sensing

Sensing To 

Off

PreAlarm To 

Alarm

Manual 

Alarm Reset

Low Battery

Sensing To 

PreAlarm

Clock Reset 

Pending

Clock Reset

Power On 

Reset

SEMS Link 

Down

SEMS Link UP

EVAC

EVAC ACKBluetooth 

Connect

Bluetooth 

Disconnect

14:25:36 6/19/2017 - - - - - - - - X - - - - - - -

13:43:26 6/19/2017 - - - - - - - X - - - - - - - -

13:42:30 6/19/2017 - X - - - - - - - - - - - - - -

13:42:26 6/19/2017 - - - - X - - - - - - - - - - -

13:42:24 6/19/2017 - - - X - - - - - - - - - - - -

13:42:20 6/19/2017 - X - - - - - - - - - - - - - -

13:42:18 6/19/2017 - - - - X - - - - - - - - - - -

13:42:14 6/19/2017 - - - X - - - - - - - - - - - -

13:42:08 6/19/2017 - X - - - - - - - - - - - - - -

13:42:04 6/19/2017 - - - - X - - - - - - - - - - -

13:42:02 6/19/2017 - - - X - - - - - - - - - - - -

13:41:58 6/19/2017 - X - - - - - - - - - - - - - -

13:41:54 6/19/2017 - - - - X - - - - - - - - - - -

13:41:50 6/19/2017 - - - - - - - - - X - - - - - -

13:41:22 6/19/2017 - - - X - - - - - - - - - - - -

13:40:18 6/19/2017 - - - - - - - - - X - - - - - -

9:05:50 6/8/2017 - X - - - - - - - - - - - - - -

9:05:40 6/8/2017 - - - - X - - - - - - - - - - -

1:37:36 6/8/2017 - - - X - - - - - - - - - - - -

22:27:48 5/18/2017 - X - - - - - - - - - - - - - -

22:27:44 5/18/2017 - - - - X - - - - - - - - - - -

22:27:40 5/18/2017 - - X - - - - - - - - - - - - -

22:27:28 5/18/2017 - - - - - - X - - - - - - - - -

22:27:06 5/18/2017 - - - - X - - - - - - - - - - -

22:22:30 5/18/2017 - - X - - - - - - - - - - - - -

22:22:18 5/18/2017 - - - - - - X - - - - - - - - -

22:21:18 5/18/2017 - - - - - - X - - - - - - - - -

22:19:30 5/18/2017 - - - - X - - - - - - - - - - -

22:17:22 5/18/2017 - - - - - - - - - - - X - - - -

22:17:14 5/18/2017 - - - - - - - - - - X - - - - -

22:16:36 5/18/2017 - - X - - - - - - - - - - - - -

22:16:24 5/18/2017 - - - - - - X - - - - - - - - -

22:15:42 5/18/2017 - - - - - - X - - - - - - - - -

22:10:14 5/18/2017 - - - - - - X - - - - - - - - -

22:06:52 5/18/2017 - - - - - - - - - - - X - - - -

21:56:16 5/18/2017 - - - - - - X - - - - - - - - -

21:51:50 5/18/2017 - - - - - - X - - - - - - - - -

21:51:20 5/18/2017 X - - - - - - - - - - - - - - -
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 20

20:56:20 5/15/2017 - X - - - - - - - - - - - - - -

20:56:14 5/15/2017 - - - - - - X - - - - - - - - -

20:53:32 5/15/2017 - - - - - - X - - - - - - - - -

20:49:44 5/15/2017 - - - - - - X - - - - - - - - -

20:39:40 5/15/2017 - - - - - - X - - - - - - - - -

20:32:54 5/15/2017 - - - - - - X - - - - - - - - -

20:29:00 5/15/2017 - - - - - - X - - - - - - - - -

20:28:28 5/15/2017 X - - - - - - - - - - - - - - -
 

 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 21

Disposition of SCBA

Following testing on June 19, 2017, both SCBA units were returned to secure storage in Lab H1513 at the 

NIOSH facility in Morgantown, West Virginia. 

Synopsis of Findings

The SCBA units inspected and evaluated by NPPTL were Scott® Safety Air-Pak® Model AP50 4.5, 45 minute, 

4500 psi unit with NIOSH Approval Number TC-13F-0715CBRN. A corresponding facepiece was provided for 

the units. Unit #1 had excessive heat damage, and could not be inspected or tested. The cylinders in Units #2 

and #3 were delivered empty and closed. The mask mounted regulator on Unit #2 was loose while the MMR 

on Unit #3 was attached to the waist belt. Overall, the units were in good condition. The NFPA approval

labels were present and readable. The PASS, HUD, and alarm systems functioned on both units 2 and 3.

Both SCBA units met the requirements of the NIOSH Positive Pressure Test, as the units maintained a positive

pressure for the 45 minute minimum duration of the test. The units passed all of the other NIOSH tests. 

In light of the information obtained during this investigation, NIOSH NPPTL has proposed no further action on 

its part at this time. The SCBA units were returned to the SCBA bags to be transported back to the San 

Antonio Fire Department. 

CASE Conclusion

No evidence was identified to suggest that the SCBA units inspected and evaluated contributed to the fatality. 

NIOSH determined that there was no need for corrective action with regards to the approval holder or users 

of the SCBAs manufactured under the approval number granted to this product.
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 22

Actions to be Taken by the Fire Departments with SCBAs Involved 

in an Incident

• Any SCBA unit involved in an incident may not be placed back in service until the SCBA has been

repaired, tested, cleaned, and any damaged components replaced and inspected by a qualified

service technician, including such testing and other maintenance activities as prescribed by the 

schedule from the SCBA manufacturer. 

• All SCBA units, even those not involved in an incident, must undergo a flow test on at least an annual

basis.

Actions the PPE Users, Selectors, and Purchasers May Take to 

Further Protect Themselves and Others from Hazards

• Sign up for NPPTL’s Listserv at https://www.cdc.gov/niosh/npptl/sub-NPPTL.html to receive email 

notifications relevant to PPE.

To request additional information about this report, contact NPPTL at ppeconcerns@cdc.gov, and reference 

NIOSH Task Number 21618 in your request. 

For more information related to personal protective equipment, visit the NIOSH NPPTL website

https://www.cdc.gov/niosh/npptl/

To receive documents or other information about occupational safety and health topics, contact NIOSH:

Telephone: 1–800–CDC–INFO (1–800–232–4636) 

TTY: 1–888–232–6348

CDC INFO: www.cdc.gov/info

Or visit the NIOSH website at https://www.cdc.gov/niosh/

For a monthly update on news at NIOSH, subscribe to NIOSH eNews by visiting 

https://www.cdc.gov/niosh/eNews/
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 23

Appendix Photographs to Support Inspection Findings for SCBA 

Units #1, #2, and #3.

List of Figures

Figure 1: Overall condition of Unit #1 ..................................................................................................................... 25

Figure 2: Facepiece remains Unit #1 ....................................................................................................................... 25

Figure 3: Unit #2 overall condition.......................................................................................................................... 26

Figure 4: Top view of facepiece............................................................................................................................... 26

Figure 5: Side view of facepiece .............................................................................................................................. 27

Figure 6: Inside view of facepiece ........................................................................................................................... 27

Figure 7: MMR with identifying markings............................................................................................................... 28

Figure 8: Inside flange of MMR ............................................................................................................................... 28

Figure 9: Low pressure hose and quick disconnect................................................................................................. 29

Figure 10: Pressure reducer assembly..................................................................................................................... 29

Figure 11: RIC UAC system connector..................................................................................................................... 30

Figure 12: High pressure hose and cylinder attachment ........................................................................................ 30

Figure 13: Buddy breather....................................................................................................................................... 31

Figure 14: PASS console........................................................................................................................................... 31

Figure 15: Back view of PASS console, SEI label...................................................................................................... 32

Figure 16: Straps and buckles.................................................................................................................................. 32

Figure 17: Overall condition of cylinder.................................................................................................................. 33

Figure 18: Cylinder label.......................................................................................................................................... 33

Figure 19: Cylinder gauge heat damage.................................................................................................................. 34

Figure 20: All components of Unit #3 to be examined............................................................................................ 34

Figure 21: Top view of facepiece............................................................................................................................. 35

Figure 22: Inside view of facepiece ......................................................................................................................... 35

Figure 23: Smoke stains inside of facepiece............................................................................................................ 36

Figure 24: Smoke stains visible on inside of facepiece lens.................................................................................... 36

Figure 25: MMR with identifying markings............................................................................................................. 37

Figure 26: Sticker on MMR with identifying markings............................................................................................ 37

Figure 27: Inside flange of MMR ............................................................................................................................. 38

Figure 28: Low pressure hose and Quick Disconnect.............................................................................................. 38

Figure 29: Quick Disconnect.................................................................................................................................... 39

Figure 30: Pressure reducer assembly..................................................................................................................... 39

Figure 31: High pressure hose and cylinder attachment........................................................................................ 40

Figure 32: RIC UAC system connector with cap on ................................................................................................. 40

Figure 33: RIC UAC system connector with cap off................................................................................................. 41

Figure 34: Buddy breather....................................................................................................................................... 41

Figure 35: PASS console........................................................................................................................................... 42

Figure 36: Back view of PASS console, SEI label...................................................................................................... 42

Figure 37: PASS control module .............................................................................................................................. 43

Figure 38: Straps and buckles.................................................................................................................................. 43
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 24

Figure 39: Overall condition of cylinder.................................................................................................................. 44

Figure 40: Cylinder label.......................................................................................................................................... 44

Figure 41: Cylinder gauge........................................................................................................................................ 45

Figure 42: View of cylinder threads......................................................................................................................... 45
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 25

Figure 1: Overall condition of Unit #1

Figure 2: Facepiece remains of Unit #1
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 26

Figure 3: Unit #2 overall condition

Figure 4: Top view of facepiece
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 27

Figure 5: Side view of facepiece

Figure 6: Inside view of facepiece
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 28

Figure 7: MMR with identifying markings

Figure 8: Inside flange of MMR
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 29

Figure 9: Low pressure hose and Quick Disconnect

Figure 10: Pressure reducer assembly
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 30

Figure 11: RIC UAC system connector

Figure 12: High pressure hose and cylinder attachment
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 31

Figure 13: Buddy breather

Figure 14: PASS console
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 32

Figure 15: Back view of PASS console, SEI label

Figure 16: Straps and buckles
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 33

Figure 17: Overall condition of cylinder

Figure 18: Cylinder label
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 34

Figure 19: Cylinder gauge heat damage

Figure 20: All components of Unit #3 to be examined
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 35

Figure 21: Top view of facepiece

Figure 22: Inside view of facepiece
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 36

Figure 23: Smoke stains inside of facepiece

Figure 24: Smoke stains visible on inside of facepiece lens
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 37

Figure 25: MMR with identifying markings

Figure 26: Sticker on MMR with identifying markings
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 38

Figure 27: Inside flange of MMR

Figure 28: Low pressure hose and Quick Disconnect
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 39

Figure 29: Quick Disconnect

Figure 30: Pressure reducer assembly
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 40

Figure 31: RIC UAC system connector with cap on

Figure 32: High pressure hose and cylinder attachment
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 41

Figure 33: RIC UAC system connector with cap off

Figure 34: Buddy breather
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 42

Figure 35: PASS console

Figure 36: Back view of PASS console, SEI label
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 43

Figure 37: PASS control module

Figure 38: Straps and buckles
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 44

Figure 39: Overall condition of cylinder

Figure 40: Cylinder label
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 45

Figure 41: Cylinder gauge

Figure 42: View of cylinder threads
 TN-21618 San Antonio, Texas Fire Department – Status Investigation Report 46

Disclaimer 

The purpose of this effort was to determine the conformance of a respirator to the NIOSH approval

requirements found in Title 42, Code of Federal Regulations, Part 84. A number of performance tests are

selected from the complete list of Part 84 requirements and each respirator is tested in its “as received”

condition to determine its conformance to those performance requirements. Each respirator is also

inspected to determine its conformance to the quality assurance documentation on file at NIOSH.

In order to gain additional information about its overall performance, each respirator may also be subjected

to other recognized test parameters, such as National Fire Protection Association (NFPA) consensus

standards. While the test results give an indication of the respirator’s conformance to the NFPA

approval requirements, NIOSH does not actively correlate the test results from its NFPA test equipment

with those of certification organizations which list NFPA-compliant products. Thus, the NFPA test results

are provided for information purposes only.

Selected tests are conducted only after it has been determined that each respirator is in a condition that

is safe to be pressurized, handled, and tested. Respirators whose condition has deteriorated to the point

where the health and safety of NIOSH personnel and/or property is at risk will not be tested.