On the morning of December 6, 2017, a Part Time Firefighter experienced a significant medical issue requiring transportation to the local hospital for evaluation. The incident occurred during standard and approved training involving fire evolutions at Crook County Fire and Rescue’s training annex building, which is located adjacent to CCFR’s main station in Prineville, Oregon. The training exercise involved multiple pieces of apparatus, simulating initial arrival and fire operations on a simulated single family dwelling. All participating members wore full firefighting PPE including SCBA and were breathing air. Smoke conditions in the building were simulated using an industrial smoke machine.
The training was led by the shift Captain, and was being supervised by a Battalion Chief. After the simulated operation had completed, and crews were ordered to exit the structure, firefighters noticed one member was having a significant issue moving and responding to commands. Crews immediately rendered aid, starting with removing the firefighters mask, SCBA and turnout jacket. It was clear he was having a medical issue of some kind, as he was described to be disoriented, confused and not acting appropriately.
He was assisted over to CCFR’s main station and seated in the back of a CCFR ambulance for a full ALS assessment, after which it was determined he should be transported to the hospital for evaluation. After several hours of tests in the emergency room, the firefighter was released with no significant findings.
Due to the firefighter’s presentation during the incident, immediate concern focused on his SCBA. The firefighter had been breathing air for approximately ten minutes leading up to the discovery. His bottle was immediately isolated and the shift Captain, along with a Battalion Chief, used an air monitoring device to initially check the contents of the SCBA bottle. The air monitoring device immediately alarmed “Low Oxygen” when the stream of air from the bottle passed the sensor. The bottle was then marked and placed in a locked office.
After consultation with Special Districts of Oregon, Oregon OSHA was contacted and a request was made to officially test the air inside the incident SCBA. The bottle and ensemble was sent to OR-OSHA’s lab in Portland, where test results showed the bottle did in fact have low oxygen levels, approximately 7.6% when compared to 20.9% of the ambient air.
During the initial internal investigation, it was noted the incident bottle had been sent to a third party company for its scheduled hydro-testing in late March of this year. No one in the department could remember using the bottle or ensemble since it had been returned from testing and filled at the CCFR’s SCBA fill station.
In conclusion, it is the opinion of the investigation the SCBA bottle the firefighter wore on the morning of December 6, 2017, had decreased levels of oxygen causing a hypoxic event leading to his “ashen” color, disorientation, and confusion. The decreased levels of oxygen in his bottle was a result of residual Nitrogen being left in the bottle after hydro-testing by the third party testing company. The bottle was then not purged by CCFR members upon return, but was filled using the departments SCBA fill station. While the bottle showed it was full, the residual Nitrogen in the bottle caused a “dilution” of oxygen when it was refilled and placed back into service. As this pack was assigned to medic 1274 (M1), CCFR’s fourth out ambulance, it had not been used since being placed back into service in March of 2017.
The department has taken several immediate steps to make sure an event such as this does not happen again. Immediately following the incident, all SCBA’s in the department were purged completely and refilled. As the department did not have a protocol for returning SCBA bottles to service after testing, one has been created with help from the third party company on best practices. Lastly the department has instituted a department wide training on appropriate steps when refilling SCBA bottles.
The most important lessoned learned from this incident is to continually improve on situational awareness. After the incident, the firefighter described knowing he was having an issue and should call a MAYDAY, but was unable to do so because of the hypoxic effects on his cognitive ability. Several members who participated in the training, described noticing the firefighter was not acting “himself,” either by being slow to react, forgetting steps in his assignment, or not responding to orders given during the exercise. The members who described these in their statements all assumed the firefighter was having an “off” day. It is a great reminder to always check your partners, and be aware of members who may not be acting appropriately or out of the norm.
This report finds the following contributing factors and key recommendations:
– Residual Nitrogen in SCBA bottle after testing.
– Department did not have a protocol for returning SCBA bottles to service after testing.
– Department wide inconsistency when filling SCBA bottles.
– Lack of situational awareness on the actions of members during training.
– Have a standing protocol for returning SCBA bottles to service that have returned from a third party vendor, regardless of what was being done to the bottle.
– Have yearly refresher training on safe operation of the SCBA bottle fill station.
– Train on and continue to improve on situational awareness and communication, not just during active incidents.