TN-24882 Watertown Fire Department – Status Investigation Report 1

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PPE CASE

Personal Protective Equipment Conformity Assessment Studies and Evaluations

Evaluation of a Self-Contained Breathing Apparatus Involved in a 

Fatality While Operating at a Structure Fire

Watertown Fire Department Request for a MSA Model G1, 45 minute, 4500 psi unit

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 (DSR). In support of 

this Program, NIOSH’s National Personal Protective Technology 

Laboratory (NPPTL) inspects and evaluates the self-contained breathing 

apparatus (SCBA) used by the fire fighter during a fatality. 

This report provides a summary of NPPTL’s inspection and 

evaluation methods as well as findings for testing related to an 

SCBA that was being used by the Watertown Fire Department 

fire fighter during a fatal event. The SCBA used was an MSA 

Model G1, 45 minute, 4500 psi unit. NIOSH DSR and the 

Watertown Fire Department were 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 SCBA, NPPTL managed the custody of evidence 

throughout the entire inspection and evaluation process at its 

Morgantown, West Virginia, facility. NPPTL staff inspected all SCBA components and documented their findings 

with written and photographic evidence. NIOSH assigned Task Number TN-24882 to identify the unit. NPPTL also 

tested the SCBA 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 the SCBA to the National Fire Protection Association (NFPA) Airflow Performance requirements 

of NFPA 1981, Standard on Open-Circuit Self-Contained Breathing Apparatus for the Fire Service, 2013 Edition. If 

the inspection or evaluation data suggested that the SCBA unit may have contributed to the fatal event, NPPTL 

would have engaged in corrective action to ensure that no other users of the product would experience a fatal 

event. In this case, no such corrective action was necessary. NPPTL then managed the disposition of the SCBA.

NIOSH received an SCBA 

used by a fire fighter 

involved in a fatality. The 

tested components of the 

SCBA were not found to 

contribute to the fatality. 

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.
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Chain of Custody

The SCBA unit was delivered by the NIOSH DSR investigators assigned to investigate the Watertown Fire 

Department fatal event. They delivered the unit to Lab H1513 for secure storage at the NIOSH facility in

Morgantown, West Virginia, on April 21, 2021. The SCBA unit remained in secure storage in Lab H1513 

throughout the inspection and testing process.

SCBA Inspection

On May 26, 2021, NPPTL employees Jay Tarley and Angela Andrews inspected the SCBA unit. These employees 

identified the SCBA as a Watertown Fire Department SCBA and visually examined the device, component by

component, in the condition received to determine the conformance of the unit to the NIOSH-approved

configuration. The unit was an MSA Model G1, 45 minute, 4500 psi with NIOSH Approval Numbers TC-13F0787CBRN.

As-received (pictured below) SCBA unit

• SCBA unit was hand delivered to Lab H1513 by NIOSH DSR investigators

• Cylinder was received with less than 1000 psi and was closed

• Bypass was closed

• Mask-mounted regulator (MMR) was securely connected to the low-pressure line

• Facepiece was included with blackout cover

Figure 1: SCBA as received
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Components and Observations for SCBA (“right” or “left” are from the user’s perspective; “good” means 

functional and may show signs of dirt/soot; “fair” means functional, but signs of some damage; “bad” means not 

functional, needs to be inspected by technician to possibly replace part(s)) (see Figures in Appendix)

Facepiece (Figures 2-5)

• Facepiece seal P/N: 10161810; M/N: 7-2771-1

• Nosecup MFG date: 10/2016 

• Overall condition was good condition 

• Lens was in good condition

• Upper lens ring was in good condition

• Lens retaining ring was intact

• MMR housing was clean and in good condition; M/N 7-

2774-1; 10144213

• HUD was present and intact

• Hairnet was in good condition with dirt present

• All straps and buckles functioned properly

• Blackout cover for facepiece was present

Mask-Mounted Regulator (MMR) (Figures 6-8)

• MMR label on front: MSA; M/N: 7-2779-1

• Overall condition was good with signs of dirt

• MMR was secured to low-pressure line

• Bypass closed

• Inside flange had normal wear and in good condition

• Sealing area was good and slightly dirty

• Regulator could be attached and removed

• Outer rubber in good condition

• RFID stamp

Low-Pressure Regulator Hose (Figures 8-9)

• Secured at all attachment points

• Line was in good condition 

• Line passed through the shoulder strap to the reducer

Pressure Reducer Assembly (Figure 10-11) 

• Overall condition was good

• All airline connections were secure

• All lines going to the pressure reducer were in good 

condition

• 4500 psi; 0817750

PASS Control Module (Figures 12-14)

• Lines to control module looked good

• Gauge lens was readable

• Protective casing was good and in place

• M/N 7-2816-1

High-Pressure Hose and Cylinder Attachment (Figures 15-18)

• High-pressure M/N: 7-2844-1 (cylinder attachment #)

10149679 hose

• High-pressure line good condition with some signs of wear;

M/N 7-2844-1

• Cylinder quick connect attachments WO 11082108, 

02/17-U 4500/5500 psi, 10149700 were in good condition 

Quick-Fill line (18)

• Protective cover and sleeve in good condition

PASS Power Module (Figures 19-21)

• SEI label:02-2017; 10148687 4500 psi; RFID

• PASS met requirements of NFPA 1982: Standard on 

Personal Alert Safety Systems (PASS) 2013 edition 

• FCC ID P9R 10154953, RPN 10069330

• Overall condition was good

• Li-ion Rechargeable Battery Pack 7-2814-1

• Held securely to backframe

• Power module battery was attached

Backframe Assembly (Figures 22-25)

• SEI label 1981-2013 edition

• NIOSH Approval Number label: TC-13F-0787CBRN

• FD label with 470262

• Overall condition was good

• Shoulder straps were attached to the frame

Straps and Buckles (Figures 23-24)

• Overall condition of straps was good

• Hose lines passed through shoulder straps 

• All adjustable buckles moved and held in place

• Waist area buckle latched

Compressed Air Cylinder and Cylinder Valve Assembly (Figures 

26-32)

• DOT-SP 10915-4500; TC-3CCM -310

• Luxfer R388; ACU258211; REE: 126 

• MSA M/N 7-1348-1

• Hydrostatic date: 3/2017; 45-minute, 4500 PSI

• Received with less than 1000 psi

• Overall condition was good

• Gauge was readable 

• Threads were good

• O-ring was present and in good condition 

• Rubber bumper at base of cylinder valve was in good 

condition

• FD labels 7-3 and City Watertown 17-012
 

 

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SCBA Testing

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

Table 1. Summary of results from testing SCBA unit.

NIOSH Tests Description of Results PASS/

FAIL 

Positive Pressure Test - NIOSH Standard Test Procedure Number 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 liters 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. 

Inhalation Breathing Resistance: (inches of 

water column) = 0.36

PASS 

Rated Service Time Test - NIOSH Standard Test Procedure Number 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 unit met the test requirements. The 

measured service time (adjusted to correspond 

with the recorded breathing cycles) was more 

than the rated service time of 45 minutes. The 

SCBA did not go negative on inhalation;

therefore, maintained positive pressure was 

maintained in the facepiece

Measured Service Time: 

51 Minutes 20 Seconds

PASS 
 

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Static Pressure Test - NIOSH Standard Test Procedure Number 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) = 1.12

PASS

Gas Flow Test - NIOSH Standard Test Procedure Number 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 gauge 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 Airflow (liters per minute)

4500 psig 331.3

500 psig 325.6

PASS 

PASS

Exhalation Resistance Test - NIOSH Standard Test Procedure Number 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 headform. A probe in the headform is connected to 

a slant manometer for measuring exhalation breathing resistance. The airflow 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) = 2.20

Static Pressure: (inches of water

column) = 1.12

Difference: (inches of water column) = 1.08

PASS
 

 TN-24882 Watertown Fire Department – Status Investigation Report 6

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Remaining Service Life Indicator Test - NIOSH Standard Test Procedure Number 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 33 to 37 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 gauge in the event of a gauge or gauge line failure the remaining 

service life indicator is required to be set at 33% + 4% 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.

The test requirement was identified on the label

as 33% - 37% of its remaining rated service time.

 Electrical Bell 

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

1 1570 1570

2 1565 1560

3 1580 1570

4 1570 1560

5 1570 1580

6 1590 1580

 Average: 1574 1570

PASS

PASS

National Fire Protection Association (NFPA) Test (in accordance with NFPA 1981, 2013 Edition):

NFPA Test Description of Results PASS/

FAIL 

NFPA Airflow Performance Test - NFPA 1981 (2013 Edition) Reference: Chapter 8, Performance 

Requirements, Sec. 8-1.1

Requirement: 

SCBA shall be tested for airflow performance as specified in Section 8.1, Airflow Performance Test, 

and the SCBA facepiece pressure shall not be less than 0.0 in (0.0 mm) water column and not 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. 

*During initializing the PosiChek, a message 

popped up stating exhalation valve could be 

sticky

Maximum Facepiece Pressure: (inches of water 

column) = 2.35

Minimum Facepiece Pressure: (inches of water 

column) = 0.15

PASS

PASS
 

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Disposition of SCBA

Following testing on May 26, June 7, and June 8, 2021, the SCBA unit was returned to secure storage in Lab 

H1513 at the NIOSH facility in Morgantown, West Virginia.

Synopsis of Findings

The SCBA unit inspected and evaluated by NPPTL was identified as an MSA Model G1, 45 minute, 4500 psi 

unit with NIOSH Approval Numbers TC-13F-0787CBRN. The fire fighter was wearing the unit when the event 

occurred. The corresponding facepiece and cylinder were provided with the unit. The testing team determined 

a replacement facepiece was needed because they were unable to achieve a passing static pressure test with 

the facepiece provided after the Gas Flow Test. Therefore, the remainder of the testing was conducted 

utilizing an NPPTL facepiece. Overall, the SCBA was in good condition. The NFPA approval label was present 

and readable. The PASS, HUD, and alarm systems functioned as designed during the inspection and during the 

remaining service life indicator testing completed on 5/26/2021. However, it seems as though the battery is 

no longer charged. The unit passed all the NIOSH tests as well as meeting the requirements for the NFPA 

“Airflow Performance” test.

The information obtained during this investigation does not suggest that the components tested contributed to 

the fatality. The SCBA was returned to the shipping container to be shipped back to the Watertown Fire 

Department.

CASE Conclusion

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

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

user of SCBA manufactured under the approval numbers granted to this product.

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.
 

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

Protect Themselves and Others from Hazards

• Sign up for NPPTL’s Listserv 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 24882 in your request. 

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

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Appendix Photographs to Support Inspection Findings for SCBA 

List of Figures

Figure 1: SCBA as received .........................................................................................................................................2

Figure 2: Front of facepiece..................................................................................................................................... 10

Figure 3: Inside facepiece and HUD......................................................................................................................... 10

Figure 4: Facepiece hairnet and straps.................................................................................................................... 11

Figure 5: Blackout cover for facepiece .................................................................................................................... 11

Figure 6: Mask-mounted regulator ......................................................................................................................... 12

Figure 7: Inside of mask-mounted regulator........................................................................................................... 12

Figure 8: Mask-mounted regulator and low-pressure line connected to SCBA...................................................... 13

Figure 9: Low-pressure line in protective sleeve..................................................................................................... 13

Figure 10: Pressure reducer, RIC UAC with primary low-pressure warning device (bell)....................................... 14

Figure 11: Bottom view of pressure reducer assembly........................................................................................... 14

Figure 12: Front of PASS control module ................................................................................................................ 15

Figure 13: Back of PASS control module ................................................................................................................. 15

Figure 14: Labeling on PASS control module........................................................................................................... 16

Figure 15: High-pressure hose and cylinder attachment........................................................................................ 16

Figure 16: Top view of high-pressure hose ............................................................................................................. 17

Figure 17: Quick Connect adapter cover................................................................................................................. 17

Figure 18: Quick Connect adapter........................................................................................................................... 18

Figure 19: PASS power module SEI label................................................................................................................. 18

Figure 20: Power module ........................................................................................................................................ 19

Figure 21: Power module MSA label ....................................................................................................................... 19

Figure 22: Back of backframe with labels................................................................................................................ 20

Figure 23: Overview of backframe, waist belt, straps, and buckles........................................................................ 20

Figure 24: Overview of waist belt, straps, and buckles........................................................................................... 21

Figure 25: Backframe with cylinder holder ............................................................................................................. 21

Figure 26: Top view of cylinder with labeling.......................................................................................................... 22

Figure 27: Top view of cylinder with labeling.......................................................................................................... 22

Figure 28: Top view of cylinder with labeling.......................................................................................................... 23

Figure 29: Cylinder gauge........................................................................................................................................ 23

Figure 30: Cylinder valve and rubber bumper......................................................................................................... 24

Figure 31: Threaded CGA connector attached to cylinder...................................................................................... 24

Figure 32: Threaded CGA connector removed to show cylinder threads............................................................... 25
 

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Figure 3: Inside facepiece and HUD

Figure 2: Front of facepiece
 

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Figure 4: Facepiece hairnet and straps

Figure 5: Blackout cover for facepiece
 

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Figure 6: Mask-mounted regulator 

Figure 7: Inside of mask-mounted regulator
 

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Figure 8: Mask-mounted regulator and low-pressure line connected to SCBA

Figure 9: Low-pressure line in protective sleeve
 

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Figure 10: Pressure reducer, RIC UAC with primary low-pressure warning device (bell)

Figure 11: Bottom view of pressure reducer assembly
 

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Figure 12: Front of PASS control module

Figure 13: Back of PASS control module
 

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Figure 14: Labeling on PASS control module

Figure 15: High-pressure hose and cylinder attachment
 

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Figure 16: Top view of high-pressure hose

Figure 17: Quick Connect adapter cover
 

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Figure 18: Quick Connect adapter

Figure 19: PASS power module SEI label
 

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Figure 20: Power module 

Figure 21: Power module MSA label
 

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Figure 22: Back of backframe with labels

Figure 23: Overview of backframe, waist belt, straps, and buckles
 

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Figure 24: Overview of waist belt, straps, and buckles

Figure 25: Backframe with cylinder holder
 

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Figure 26: Top view of cylinder with labeling

Figure 27: Top view of cylinder with labeling
 

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Figure 28: Top view of cylinder with labeling

Figure 29: Cylinder gauge
 

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Figure 30: Cylinder valve and rubber bumper

Figure 31: Top view of cylinder with labeling

Figure 31: Threaded CGA connector attached to cylinder
 

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Figure 32: Threaded CGA connector removed to show cylinder threads
 

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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.