TN-23126 Christopher, Illinois Fire Department – Status Investigation Report 1

PPE CASE

Personal Protective Equipment Conformity Assessment Studies and Evaluations

Evaluation of a Self-Contained Breathing Apparatus for Potential 

Contribution to a Fatal Event in the Fire Service

Christopher, Illinois Fire Department Request for an 

MSA Model Firehawk® M7 

The National Institute for Occupational Safety and Health (NIOSH) 

conducts a Fire Fighter Fatality Investigation and Prevention Program

(FFFIPP) 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 personal protective 

equipment (PPE) used by firefighters during fatal events. 

This report provides a summary of NPPTL’s inspection and 

evaluation methods and findings for the self-contained 

breathing apparatus (SCBA) used by the Christopher Fire

Department firefighter during a fatal event. The SCBA being 

used was an MSA Model Firehawk® M7, 4500 psi, 30-minute 

unit. The Christopher 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 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-23126 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. 

NIOSH evaluated an SCBA 

used by a firefighter 

involved in a fatal event. 

The SCBA was 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.
 TN-23126 Christopher, Illinois Fire Department – Status Investigation Report 2

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.

Chain of Custody

The SCBA unit was delivered to NIOSH investigators, from DSR, who were assigned to investigate the 

Christopher Fire Department’s fatal event. They delivered the unit to Lab H1513 for secure storage at the 

NIOSH facility in Morgantown, West Virginia on June 10, 2019. 

On July 1, 2019, NPPTL employees Jay Tarley and Matt Duling inspected the SCBA unit. The unit was tested by 

the same employees on July 2, 2019. The SCBA unit remained in secure storage in Lab H1513 throughout the 

entire inspection and testing process. 
 TN-23126 Christopher, Illinois Fire Department – Status Investigation Report 3

SCBA Inspection

The inspection process was initiated by employees Jay Tarley and Matt Duling once the SCBA unit was delivered 

by NIOSH DSR investigators appointed to investigate the Christopher Fire Department’s fatal event. They 

delivered the unit to Lab H1513 in the NIOSH facility in Morgantown, West Virginia on June 10, 2019. The SCBA

was identified as belonging to the Christopher Fire Department and was visually examined, component by

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

configuration. The unit was identified as an MSA Model Firehawk® M7, 4500 psi, 30-minute unit with NIOSH

Approval Number TC-13F-302.

SCBA unit as received (pictured below)

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

• Cylinder was received empty and closed, not attached to CGA fitting

• Bypass was closed

• Mask-mounted regulator (MMR) was not connected to facepiece, a separate facepiece was sent to 

complete testing

Figure 1: SCBA unit and cylinder as received
 TN-23126 Christopher, Illinois Fire Department – Status Investigation Report 4

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

perspective) (see Figures in Appendix)

Mask-Mounted Regulator (MMR) (Figure 3)

• MMR label on front: MSA; M/N: 10023684; numbers on 

inside flange: MX090149 and 10025003

• Overall condition was dirty and scuffed

• MMR was secured to low pressure line

• Bypass closed

• Inside flange dirty with markings

• Sealing area was dirty with substance on seal, possible bodily 

fluids 

• Regulator could be attached and removed

• Locking assembly functioned

Low Pressure Regulator Hose (Figure 4)

• Secured at all attachment points

• Line was in good condition 

• Line passed through the shoulder strap to the reducer

• Markings on line: Superflex AUER/MSA 04/03

Pressure Reducer Assembly (Figures 5, 6) 

• Overall condition was good

• All airline connections were secure

• Number 10026233 KJH EX091430

PASS Control Console MSA Control Module (Figures 7-9)

• Lines to control module looked good

• Gauge lens was readable

• Protective casing was good and in place

• Manufacturer label present but damaged

• MSA NightfighterTM HUD unit attached in line with console 

M/N: 7-1219-1, ASSY# 10036995

High Pressure Hose and Cylinder Attachment (Figures 11-12)

• High pressure S/N: 10037490

• High pressure line was in good condition, but soot covered

• Cylinder quick connect attachments were in good condition, 

EATON FD17-1002-10-04. Covering PN: 10038031

• Pressure relief valve in good condition, markings 0904

• Warning label present, number 10036292

Backframe Assembly (Figure 13, 14)

• S/N: 10024153

• SEI label not present

• NIOSH Approval Number label: TC-13F-302

• Additional Labels: Sentinel Emergency Solutions: Test to 

factory specs 8/8/16; CFD

• Overall condition was good

• No cracks or melting found

• Some soot present

• Shoulder straps were attached to the frame

Straps and Buckles (Figure 15)

• Overall condition of straps was good, but dirty

• Hose lines passed through shoulder straps 

• All adjustable buckles moved and held in place

• Waist area buckle latched

• MMR holder on waist strap was broken
 

 TN-23126 Christopher, Illinois Fire Department – Status Investigation Report 5

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 the SCBA against established NIOSH SCBA certification tests.

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 did not meet the test requirement. 

The unit went negative three times during the 

test. Twice at the 15 min mark and also at the 

19 min mark.

*A different facepiece was supplied by the 

Christopher FD.

* A different cylinder was supplied by the 

Christopher FD.

Inhalation Breathing Resistance: (inches of 

water column) = -0.1

FAIL

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 SCBA did not meet the test requirement. 

The measured service time (adjusted to 

correspond with the recorded breathing 

cycles) was more than the rated service time 

of 30 minutes; however, the unit went 

negative on inhalation and did not maintain 

positive pressure in the facepiece. The PASS 

unit did sound but was hard to reset with 

movement. 

Measured Service Time: 

31 Minutes 56 Seconds

FAIL
 

 TN-23126 Christopher, Illinois Fire Department – Status Investigation Report 6

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. 

* A different facepiece was supplied by the 

Christopher FD.

Facepiece Static Pressure:(inches of water

column) = 1.4

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. 

* A different facepiece was supplied by the 

Christopher FD.

Applied Pressure Airflow (liters per minute)

4500 psig 237.86

500 psig 240.69

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 head form. A probe in the head form 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. 

* A different facepiece was supplied by the 

Christopher FD.

Exhalation Breathing Resistance: (inches of 

water column) = 1.75

Static Pressure: (inches of water

column) = 1.4

Difference: (inches of water column) = 0.35

PASS 
 

 TN-23126 Christopher, Illinois Fire Department – Status Investigation Report 7

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.

As these SCBA models do not have a remote 

gauge shutoff, the test requirement is 25% +/-

4%.

Electric Bell

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

1 1175 1010

2 1210 1175

3 1175 NA

4 1180 NA

5 1180 NA

6 1180 NA

 Average 1183 NA

Electric 

AlarmPASS

Bell 

AlarmFAIL 
 

 TN-23126 Christopher, Illinois Fire Department – Status Investigation Report 8

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 5, Performance 

Requirements, Sec. 5-1.1

Requirement: 

SCBA shall be tested for airflow performance as specified in Section 6-1, 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 unit failed this test due to the resistance 

of the first breath activation being too great 

for the machine to start.

Maximum Facepiece Pressure: (inches of 

water column) = N/A

Minimum Facepiece Pressure: (inches of 

water column) = N/A

FAIL

FAIL
 

TN-23126, Christopher, Illinois Fire Department – Status Investigation Report 9

Disposition of SCBA

Following testing at the NIOSH facility, the SCBA was returned to secure storage in Lab H1513 at the NIOSH 

facility in Morgantown, West Virginia. The unit was then transported to MSA headquarters in Cranberry

Township, Pennsylvania on Tuesday August 6, 2019 so that the manufacturer could inspect the mask mounted 

regulator.

Synopsis of Findings

The SCBA unit inspected and evaluated by NPPTL was identified as an MSA Model Firehawk® M7, 4500 psi, 30-

minute unit with NIOSH Approval Number TC-13F-302. The unit was hand delivered by DSR investigators with a 

replacement facepiece that was supplied by the Christopher Fire Department. During the inspection process by 

the NPPTL investigators, it was determined that a replacement cylinder was needed because the investigators 

were not able to verify that the hydrostatic test was in compliance. As received, the cylinder was empty with the 

valve closed and not attached to the GCA fitting. The MMR bypass was found in the closed position. Overall 

condition of this unit was fair with normal wear and tear. This unit did not meet the requirements of the NIOSH 

Positive Pressure Test (Standard Test Procedure Number 120, 42 CFR Part 84 Reference: Subpart H, 84.70 

(a)(2)(ii)), which caused a failure of the Rated Service Time Test (Standard Test Procedure Number 121, 42 CFR 

Part 84 Reference: Subpart F, § 84.53 (a) and Subpart H, § 84.95 (a) and (b)), even though the unit lasted for 

31.56 minutes. The unit passed all the other NIOSH tests except the Remaining Service Life Indicator Test 

(Standard Test Procedure Number 124, 42 CFR Part 84 Reference: Subpart H, § 84.83 (f) and Subpart G, § 84.63 

(c)). The mechanical alarm portion (bell) of this unit only sounded the first two times during this test and failed. 

The electronic portion of this test passed. The unit did not pass the NFPA Airflow Performance Test - NFPA 1981 

(2013 Edition) Reference: Chapter 5, Performance Requirements, Sec. 5-1.1. The testing apparatus was not able 

to overcome the pressure for the first breath activation to initiate the test. 

It was suspected that the bodily fluids observed by the NPPTL investigators during the inspecting and testing 

process contributed to the pressure failures. The NIOSH investigators transported the unit to MSA headquarters in 

Cranberry Township, Pennsylvania on Tuesday August 6, 2019 so that the manufacturer could inspect the mask 

mounted regulator. MSA verified that the MMR had bodily fluids inside the diaphragm and all around the seal. It 

was also verified that the MMR was out of adjustment. The manufacturer determined that these factors 

contributed to the unit failing the tests, but they did not have a contributing factor to the fatality.

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 users 

of SCBAs manufactured under the approval number granted to this product.
 

TN-23126, Christopher, Illinois Fire Department – Status Investigation Report 10

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 23126 in your request. 

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

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 www.cdc.gov/niosh.

For a monthly update on news at NIOSH, subscribe to NIOSH eNews by visiting www.cdc.gov/niosh/eNews
TN-23126, Christopher, Illinois Fire Department – Status Investigation Report 11

Appendix Photographs to Support Inspection Findings for SCBA 

List of Figures

Figure 1: SCBA unit and cylinder as received .......................................................................................................... 12

Figure 2: Overall of SCBA unit.................................................................................................................................. 12 

Figure 3: MMR with identifying markings............................................................................................................... 12 

Figure 4: MMR and low pressure line ..................................................................................................................... 13 

Figure 5: Pressure reducer, outside view................................................................................................................ 13 

Figure 6: Pressure reducer, inside view................................................................................................................... 14 

Figure 7: Front of PASS control console ..................................................................................................................14 

Figure 8: Back of PASS control held console, 1998 edition..................................................................................... 15 

Figure 9: Top view NightfighterTM heads-up display................................................................................................ 15 

Figure 10: Side view of NightfighterTM..................................................................................................................... 16 

Figure 11: Cylinder attachment and RIC UAC connector ........................................................................................ 16 

Figure 12: Cylinder attachment and RIC UAC connector with dust cover off......................................................... 17 

Figure 13: Backframe............................................................................................................................................... 17 

Figure 14: Backframe showing cylinder attachment............................................................................................... 18 

Figure 15: Backframe straps and buckles................................................................................................................ 18 
 

TN-23126, Christopher, Illinois Fire Department – Status Investigation Report 12

Figure 2: Overall of SCBA unit

Figure 3: MMR with identifying markings

Figure 1: All components of SCBA unit #12 to be examined
 

TN-23126, Christopher, Illinois Fire Department – Status Investigation Report 13

Figure 4: MMR and low pressure line

Figure 5: Pressure reducer, outside view
 

TN-23126, Christopher, Illinois Fire Department – Status Investigation Report 14

Figure 6: Pressure reducer, inside view

Figure 7: Front of PASS control console
 

TN-23126, Christopher, Illinois Fire Department – Status Investigation Report 15

Figure 8: Back of PASS control held console, 1998 edition

Figure 9: Top view NightfighterTM heads-up display
 

TN-23126, Christopher, Illinois Fire Department – Status Investigation Report 16

Figure 10: Side view of NightfighterTM

Figure 11: Cylinder attachment and RIC UAC connector
 

TN-23126, Christopher, Illinois Fire Department – Status Investigation Report 17

Figure 12: Cylinder attachment and RIC UAC connector with dust cover off

Figure 13: Backframe
 

TN-23126, Christopher, Illinois Fire Department – Status Investigation Report 18

Figure 14: Backframe showing cylinder attachment

Figure 15: Backframe straps and buckles
 

TN-23126, Christopher, Illinois Fire Department – Status Investigation Report 19

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.