HETA 94-0244-2431 NIOSH INVESTIGATORS: MEMPHIS FIRE .
ThisThis HealthHealth HazardHazard EvaluationEvaluation (HHE)(HHE) reportreport andand anyany recommendationsrecommendations mademade hereinherein areare forfor thethe specificspecific facilityfacility evaluatedevaluated andand maymay notnot bebe universallyuniversallyapplicable. /www.cdc.gov/niosh/hhe/reportsThis Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universallyapplicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reportsHETA 94-0244-2431JUNE 1994MEMPHIS FIRE DEPARTMENTMEMPHIS, TENNESSEEI.NIOSH INVESTIGATORS:Ted A. Pettit, M.S.Tim R. Merinar, M.S.SUMMARYOn April 15, 1994, the Division of Safety Research (DSR)received a request from the International Association ofFire Fighters (IAFF) for technical assistance in investigating the circumstances of the deaths of two fire fighters inMemphis, Tennessee, on April 11, 1994. The IAFF requestedtechnical assistance in determining if the self-containedbreathing apparatus (SCBA) failed or contributed to the firefighters' deaths, assessing the accountability of personnelutilizing SCBA in the hazard area, and evaluating thetraining of command and suppression personnel. This requestwas handled as a National Institute for Occupational Safetyand Health (NIOSH) Health Hazard Evaluation.From April 19 to 23, 1994, NIOSH investigators from theDivision of Safety Research travelled to Memphis, Tennessee,to conduct an investigation of this incident. Theinvestigation was coordinated through the Memphis FireDepartment, and consisted of four phases: (1) the interviewof several fire fighters, fire chiefs, union representatives, safety personnel, fire investigators, and thedirector of fire services; (2) a site visit to the elevenstory high rise apartment building involved in the fire;(3) the review of respirator maintenance records of the firedepartment; (4) and the evaluation of breathing apparatus(4 units) worn by the first respondents to the fire. Basedon the results of this investigation, NIOSH investigatorsidentified several contributing factors to this incident:(1) adherence to established departmental policies andprocedures at the fire scene; (2) imple-mentation of anadequate respirator maintenance program; (3) fire fighteraccountability at the fire scene; and (4) use of PersonalAlert Safety System (PASS) devices at the fire scene.On the basis of the information obtained during thisinvestigation, the NIOSH investigators concluded thatthere were four contributing factors to this incident:(1) Adherence to established departmental policies andprocedures at the fire scene; (2) implementation of anadequate respirator maintenance program; (3) firefighter accountability at the fire scene; and (4) theuse of Personal Alert Safety System (PASS) devices atthe fire scene. Recommendations for command and safetyKEY WORDS:SIC 9224 (Fire Departments), fire fighters,
Page 2 - Health Hazard Evaluation Report No. 94-0244-2431death, self-contained breathing apparatus, SCBA.
Page 3 - Health Hazard Evaluation Report No. 94-0244-2431II. INTRODUCTIONOn April 15, 1994, the Division of Safety Research (DSR)received a request from the International Association ofFire Fighters (IAFF) for technical assistance ininvestigating the circumstances of the deaths of two firefighters in Memphis, Tennessee, on April 11, 1994. The IAFFrequested technical assistance in determining if the selfcontained breathing apparatus (SCBA) failed or contributedto the fire fighters' deaths, assessing the accountabilityof personnel utilizing SCBA in the hazard area, andevaluating the training of command and suppressionpersonnel. This request was handled as a NIOSH HealthHazard Evaluation.From April 19 to 23, 1994, NIOSH investigators from theDivision of Safety Research travelled to Memphis, Tennessee,to conduct an investigation of this incident. Theinvestigation was coordinated through the Memphis FireDepartment, and consisted of four phases: (1) the interviewof several fire fighters, fire chiefs, union representatives, safety personnel, fire investigators, and thedirector of fire services; (2) a site visit to the elevenstory high rise apartment building involved in the fire;(3) the review of respirator maintenance records of the firedepartment; (4) and the evaluation of breathing apparatus(4 units) worn by the first respondents to the fire. A copyof the Memphis Fire Department procedures for high risefires was obtained during the investigation. A copy ofrespirator maintenance calibration records and proceduresfor respirator maintenance was not available during theinvestigation. These procedures and records were requestedfrom the Memphis Fire Department in a letter dated April 28,1994, to the Director of Fire Services. On May 11, 1994,NIOSH received a letter from the Memphis Fire Departmentdated May 6, 1994, along with several documents. Theseincluded copies of the Memphis Fire Department TrainingManual, Fire Station No. 5/9, Book No. 13; two trainingbulletins; a one page document titled Airmask Policy rev10/88; an Air Mask Repair and Maintenance Form; an MSARegulator Repair Personnel certificate; an Inspection &Maintenance Check List for SCBA; and a copy of the MSAInspection and Maintenance Procedures for the Ultralite IIand Custom 4500 Pressure Demand Air Masks . The cover letterstated that the criteria for recycling regulators is onceevery six months.
Page 4 - Health Hazard Evaluation Report No. 94-0244-2431III.BACKGROUNDOn April 11, 1994, at 0205 hours, a call was placed to theMemphis Fire Department from the security service for a highrise apartment building in Memphis, reporting a possiblefire on the ninth floor.Engine Company 7 and Snorkel 13 were the first respondentsand arrived at the apartment high rise at 0208 hours.Engine Company 7, being the first on the scene, assumedcommand. Fire Fighter No. 1 (victim No. 1), Fire FighterNo. 2 (victim No. 2), and Fire Fighter No. 3 of EngineCompany 7, and Fire Fighter No. 4 and No. 5 of Snorkel 13entered the building through the main lobby; they were awarethat the annunciator board was showing possible fires on theninth and tenth floors. All five fire fighters used thelobby elevator and proceeded to the ninth floor (lobbycommand radioed Fire Fighter No. 1 that smoke was showingfrom a ninth floor window). When the doors of the elevatoropened on the ninth floor, the hall was filled with thickblack smoke. Fire Fighters No. 1, No. 2, No. 4, and No. 5stepped off the elevator. Fire Fighter No. 3, who wascarrying the hotel pack (two 50-foot lengths of hose) wasstill on the elevator, holding the door open with his foot,as he struggled to don his self-contained breathingapparatus (SCBA). Fire Fighter No. 3's foot slipped off theelevator door, allowing the door to close and the elevatorto return to the ground floor, with Fire Fighter No. 3 stillinside. Note: This elevator was not equipped with firefighter control.Fire Fighters No. 1, No. 2, No. 4 and No. 5 entered thesmall ninth floor lobby (see Figure) directly in front ofthe elevator. Fire Fighter No. 2 was experiencing problemswith his SCBA. Fire Fighter No. 4 stated that he heard airleaking from the back of Fire Fighter No. 2's SCBA and heardFire Fighter No. 2 cough. Fire Fighter No. 2 radioed thathe was having difficulties and asked for the location of thestairwell. Fire Fighter No. 1 was heard on the radio to say"I've got him." At this point, Fire Fighter No. 1 and FireFighter No. 2 proceeded into the hallway, turning right. Itis not known if Fire Fighter No. 1 was aware that FireFighter No. 3 was not on the ninth floor at this time.Fire Fighter No. 4 and Fire Fighter No. 5 entered thehallway and turned left, reporting zero visibility (due tothick black smoke). Excessive heat forced them to retreatafter they had gone some 15 to 20 feet down the hall. Theyproceeded back down the hall, past the elevator lobby, andencountered a male resident, who attacked Fire Fighter
Page 5 - Health Hazard Evaluation Report No. 94-0244-2431No. 5, knocking him to the floor, and forcibly removed hisfacepiece. Fire Fighter No. 4 heard the commotion, and wentto assist Fire Fighter No. 5. The two fire fighters and theresident moved through the doorway of the apartment, wherethe fire fighters were able to subdue the resident. At thispoint the low air alarm on Fire Fighter No 5's SCBA wassounding. Fire Fighter No. 5 then broke out a window toprovide fresh air to the resident, in an effort to calm him.Fire Fighter No. 4 attempted to close the door to thehallway; however, the excessive heat from the hallwayprevented him from closing the door. Both fire fighters andthe resident had to be rescued from the ninth floorapartment window by a ladder truck. NOTE: It was not knownat the time that a 31-year-old female victim (victim No. 3)was in the same apartment. Her body was found when the firewas under control and a search was conducted of the ninthfloor.Fire Fighters No. 6, No. 7, and No. 8 from Engine Company 1arrived on the scene at 0209 hours (upon arrival, theyobserved a window on the ninth floor blow out) and proceededup the West End stairwell to the ninth floor, carrying ahotel pack and extra air tanks. Fire Fighter No. 6 and FireFighter No. 8 entered the ninth floor with a charged firehose, and crawled down the smoke-filled hall, forapproximately 60 feet (the hallway was 104 feet long) beforeextreme heat forced them to retreat. Neither fire fightercould see anything in the dense smoke and became disoriented(they were within 6 feet of the exit door and could not seeit). As they retreated, they crawled over something theythought may have been a piece of furniture, although theydid not remember any furniture being there when they enteredthe hallway.Fire Fighter No. 3 from Engine Company 7, after riding theelevator to the ground floor lobby, obtained a replacementSCBA, and climbed the stairs at the west end of the buildingto the ninth floor. Fire Fighter No. 3 opened the ninthfloor exit door and saw Fire Fighter No. 6 and Fire FighterNo. 8 in trouble. He grabbed Fire Fighter No. 6 and pulledhim through the doorway into the stairwell. He thenreopened the door and pulled Fire Fighter No. 8 into thestairwell.At 0224 hours, Rescue Squad 2 arrived at the scene andproceeded up the west end stairwell to the ninth floor.They asked, "Where are the 7's?" (referring to the firefighters on Engine Company 7). The response was, "We don'tknow the location of the 7's." Fire Fighter No. 9 and FireFighter No. 10 of Rescue Squad 2 opened the ninth floor exit
Page 6 - Health Hazard Evaluation Report No. 94-0244-2431door, and as they entered, spotted a downed firemanapproximately 9 feet from the door, tangled in wire cables.After the fire these were determined to be television cablesthat had been attached to the hallway ceiling in plastictubing - the extreme heat caused the plastic to melt,allowing the cables to fall to the floor. The downedfireman was Fire Fighter No. 2 of Engine Company 7 (his bodymay have been what Fire Fighters No. 6 and No. 8 encounteredin the hallway). Fire Fighter No. 2 was unresponsive andwas still wearing his SCBA. He was removed from the ninthfloor and carried down the stairs to the eighth floor, whereadvanced life support was started immediately. The firefighters of Rescue Squad 2 then entered the first apartmentto the left of the exit door and found Fire Fighter No. 1 inthe corner of the apartment. He was in a kneeling position- his head facing into the corner, holding his mask to hisface and was unresponsive. Fire Fighter No. 1 was removedfrom the ninth floor and carried down the stairs to theeighth floor where advanced life support was started. Bothfire fighters were removed within minutes and taken to alocal hospital, where advanced life support was continued;however, neither responded to life-saving measures and theywere both pronounced dead by the attending physician. FireFighter No. 1 was found in the same apartment where a secondcivilian victim (a 19-year-old female) was found.The PASS (personal alert safety system) devices worn by bothfire fighters (victims) were not activated, therefore, noaudible alarm was given when the fire fighters went down.Several other fire fighters and fire companies from theMemphis Fire Department responded to this fire, however,only those directly involved on the ninth floor are cited inthis report. As part of the NIOSH investigation, the SCBAsworn by Fire Fighters No. 1, No. 2, No. 4, and No. 5 weresent to the NIOSH Laboratories in Morgantown, West Virginia,for evaluation and testing (see Appendix for a completereport on the NIOSH evaluation of these respirators).IV.INVESTIGATIONThe City of Memphis has a population of approximately onemillion people. The Memphis Fire Department is comprised ofapproximately 1400 workers, of which 900 are fire fighters.On April 11, 1994, a fire broke out in a high-rise apartmentbuilding in Memphis that resulted in four fatalities—twofire fighters and two civilians. The IAFF contacted NIOSHand requested an investigation be conducted into thecircumstances of this fire.
Page 7 - Health Hazard Evaluation Report No. 94-0244-2431The NIOSH investigative team leader contacted the MemphisFire Department on April 15, 1994, to inform the firedepartment investigation liaison official of the requestreceived from the IAFF. During this telephone conversation,a request was made by NIOSH to the Memphis Fire Departmentfor their assistance and cooperation in conducting an onsite investigation. Permission for the investigation wasgiven by the Memphis Fire Department, and the NIOSHinvestigators travelled to Memphis during the week ofApril 19 to 23, 1994, to conduct the investigation.The NIOSH investigators met with the Memphis Fire Departmentliaison investigator on April 19, 1994, to discuss thepurpose of the NIOSH investigation, and review the detailsof the incident. On April 20, 1994, the NIOSH investigatorsmet with the director and assistant director of fireservices, and the department liaison investigator to conductan opening conference. After the opening conference, theNIOSH investigative team met with the five-member firedepartment investigative team appointed by the fire directorto investigate this incident. The NIOSH team was briefed onthe incident and viewed video tapes taken the night of thefire (taken from the outside of the building).On the afternoon of April 20, the NIOSH team and threemembers of the fire department investigative team toured theninth-floor fire scene. A walk through of the ninth floorwas conducted; starting with the elevator lobby area, thenproceeding to the point of origin of the fire, thenfollowing the path of the fire. Next, the suspected path ofthe fire fighters the night of the incident, was followed tothe locations where the victims (two fire fighters and twocivilians) were found.After leaving the fire scene, the NIOSH investigators andthe complete fire department investigative team convened atthe fire department training center to inspect the firefighters' protective equipment and clothing used the nightof the fire. This equipment had been secured as evidencethe night of the fire, and had been locked in a storage areaat the training center. The NIOSH team observed the firedepartment team inspect, record, and videotape each piece ofequipment and clothing.On the morning of April 21, the NIOSH team met with unionrepresentatives and the fire department liaison investigatorto discuss the purpose of the NIOSH investigation.
Page 8 - Health Hazard Evaluation Report No. 94-0244-2431On the afternoon of Aprilseveral fire fighters whoincident, including thosethose who assisted in the21, the NIOSH team interviewedwere on the scene the night of thewho were first respondents, andrescue.On April 22, the NIOSH team met with the fire director,deputy fire director, and the fire department liaisoninvestigator. The NIOSH team requested permission toinspect, conduct a records review, and tour the respiratormaintenance facility. The NIOSH team was accompanied to therespirator maintenance facility by the fire department'sfive-member investigative team appointed by the Director offire services.After leaving the respirator maintenance facility, the NIOSHteam requested a second site visit to the fire scene. Thefive-member investigative team accompanied the NIOSH teamduring this site visit. After the site visit to the firescene, the NIOSH team accompanied the fire departmentliaison investigator to the training center to makearrangements to ship the respirators back to the NIOSHlaboratory in Morgantown, West Virginia, for furtherevaluation.The observation made by the NIOSH team during theinvestigation was that the SCBA are sent to the Air-MaskMaintenance Shop only when they malfunction. The NIOSHinvestigation team requested information documenting theprocedure by which SCBA are returned to the Air-MaskMaintenance Shop for regularly scheduled preventativemaintenance and testing to ensure that they continue tofunction as a NIOSH-approved SCBA. The existence of such aprocedure could not be supported by documentation.The overall documentation and record keeping for the AirMask Maintenance Shop was also deficient. The NIOSHinvestigation team requested any records pertaining tomaintenance, standard-operating procedures, test procedures,test equipment calibration records, and test results ofrespirators used by the fire department. The only recordsthat were obtained were handwritten on a 5- by 7-inch yellowpad of writing paper and on a xerox copy of an Air-MaskRepair and Maintenance Form. The only Air-Mask MaintenanceForm that was obtained for any of the four SCBA shipped toNIOSH for testing was for SCBA #77 and dated 11/8/93. Theonly indication of maintenance on this form was ahandwritten note which said "Adj. lever arm assem." and wassigned by the repair person. Notations in the yellownotepad were dated from 11/16/92 to 04/21/94, and generallyconsisted of the date, the SCBA number, the regulator serial
Page 9 - Health Hazard Evaluation Report No. 94-0244-2431number, and either a brief description of the maintenanceperformed, or an "OK." This yellow notepad appeared to be adaily log of the repair person's activities and not a recordof routine or preventative maintenance.Cause of Death:The medical examiner listed the cause of death for the twofire fighters as follows:Fire Fighter No. 1 - Asphyxia - smoke inhalationCarbon Monoxide level in blood at 7.7%Fire Fighter No. 2 - Smoke and Carbon Monoxide InhalationCarbon Monoxide level in blood at 17.4%V.RECOMMENDATIONS/DISCUSSIONRecommendation #1: The fire department should conductfrequent retraining of fire personnel on fire departmentpolicies and procedures so that proper procedures areinstinctive under emergency and stress conditions. [8,9]Discussion: The Memphis Fire Department written policy onhigh rise fires was reviewed, and the policy states "at notime will the team take the elevator to the fire floor."The lights on the annunciator board in the lobby indicatedthat there was possible trouble on the ninth and tenthfloors. Although this location had been the scene ofseveral false alarm calls in the past, and it was assumedthis was another routine call, the fire fighters had twowarnings that there was a fire on the ninth floor: lobbycommand radioed that smoke was observed coming from theninth floor window, and the hallway was filled with smokewhen the elevator doors opened. Five fire fighters went upthe elevator to the ninth floor, and one fire fighterreturned to the ground floor with the hotel (standpipe)pack. The lobby command should have been alerted that fourfire fighters were on the ninth floor with no fire fightingequipment, thereby, alerting fire command that a rapidintervention team needed to be assembled.Recommendation # 2:The fire department should develop andimplement written maintenance procedures for the selfcontained breathing apparatus (SCBA) [3-5, 7]Discussion:From the information gathered on thisinvestigation, it appears that the respirator maintenanceprogram is deficient. The observation is supported by the
Page 10 - Health Hazard Evaluation Report No. 94-0244-2431NIOSH evaluation and testing of four SCBA's from the MemphisFire Department used in this incident (see Appendix). Eachof these four SCBA failed at least two of five performancetests that were conducted by NIOSH to determine if the SCBAwere in an approved configuration and met the performancerequirements of Title 30, Code of Federal Regulations,Part 11.The fire department should develop a comprehensive recordkeeping system that includes the following:1)A written procedure that establishes a policy forreturning each SCBA to the Air-Mask Maintenance Shop ona regular basis for preventive maintenance. Thisprocedure should provide for a tracking system thatensures the SCBA will be returned at the properintervals. Title 30, CFR, 11.2(a) states thatrespirators . shall be approved for use in hazardousatmospheres where they are maintained in an approvedcondition and are the same in all respects as thosedevices for which a certificate of approval has beenissued . The MSA Inspection and MaintenanceProcedures for the Ultralite II and Custom 4500Pressure Demand Air Masks, page 6, states that MSArecommends the regulator be tested at least once a yearand overhauled at least once every 3 years.2)Establish a record keeping system that will record theresults of:a) Regular calibration of the MSA test equipment asrecommended by the Inspection and MaintenanceProcedures for the Ultralite II and Custom 4500Pressure Demand Air Masks on page 4.1, Flow TestingSection.b) Performance tests conducted on a regular basis.c) Any repairs made during both routine preventativemaintenance and necessary maintenance on SCBA taken outof service.These records should identify the SCBA and regulatoridentification numbers, test equipment identificationnumbers, date, a description of the service actionincluding parts (and part numbers) involved, andidentification of the repair person.3)Establish a record keeping system for tracking the SCBAcylinders to ensure that the cylinders are hydro-
Page 11 - Health Hazard Evaluation Report No. 94-0244-2431statically retested and recertified every three yearsas required by DOT in 49 CFR 179.34(e)(13) and NIOSH in30 CFR 11.80(a).
Page 12 - Health Hazard Evaluation Report No. 94-0244-2431Recommendation #3: The fire department should ensure thatfire command always maintains close accountability for allpersonnel at a fire scene. [6, 8, 9, 11]Discussion: Accountability for all fire fighters at a firescene is paramount, and one of the fire commands' mostimportant duties. The question was asked at the fire scene,"Where are the 7's?" This should have been a signal thatthe 7's were not accounted for, and should have generated anemergency search response. One method of accountabilitywould be a buddy or team system, whereby, if any part of ateam is not accounted for, fire command is notifiedimmediately, signaling that a potential life-threateningproblem may exist.Recommendation #4: The fire department should mandate thewearing and use of the PASS devices when fire fighters areinvolved in fire fighting, rescue, or other hazardousduties.[8]Discussion: The PASS (Personal Alert Safety System) deviceis a small electrical device worn by the fire fighter andwill emit a distinctive audible alarm if the fire fighter ismotionless for more than 30 seconds. Both fire fightervictims were wearing the device, however, neither device hadbeen activated.Recommendation #5: Municipalities should review, and amendwhere necessary, existing elevator codes to ensure that theyrequire both Phase I (recall) and Phase II (fire fightercontrol) for all elevators having a total travel distancegreater than 25 feet. [1, 2]Discussion: Fire fighter entrapment by the action ofautomatic elevators is a recognized hazard in the fireservice. Many years ago, elevator codes and installationpractices were changed to minimize the danger that firefighters would be trapped in elevators and to facilitatetheir safe use for access to a fire on an upper floor.American Society for Mechanical Engineers (ASME) standardswere developed to require Phase I (recall), and Phase II(fire fighter control) for all elevators. This ensures thatin an emergency, the fire fighter has control of theelevator.VI.REPORT DISTRIBUTION AND AVAILABILITYCopies of this report may be freely reproduced and are notcopyrighted. Single copies of this report will be availablefor a period of 90 days from the date of this report from
Page 13 - Health Hazard Evaluation Report No. 94-0244-2431the NIOSH Publications Office, 4676 Columbia Parkway,Cincinnati, Ohio 45226. To expedite your request, include aself-addressed mailing label along with your writtenrequest. After this time, copies may be purchased from theNational Technical Information Service (NTIS), 5285 PortRoyal, Springfield, Virginia 22161. Information regardingthe NTIS stock number may be obtained from the NIOSHPublications Office at the Cincinnati address. Copies ofthis report have been sent to:VII.1.Charles E. Smith, Director, Division of Fire Services,65 S. Front Street, Memphis, TN 38103-2498.2.Billy Chitwood, Union Representative, Memphis FireDepartment, 5950 Lamar, Memphis, TN 38118.3.Richard M. Duffy, Director, OHS, IAFF, 1750 New YorkAvenue, Washington, D.C. 20006.4.Commissioner, Tennessee Department of Health andEnvironment, 344 Cordell Hull Building and Fifth AvenueNorth, Nashville, TN 37219.5.Commissioner, Tennessee Department of Labor, 501 UnionBuilding, Suite A - 2nd Floor, Nashville, TN 372430655.REFERENCES1.American Society of Mechanical Engineers. ASME A17.1 1990, Safety Codes for Elevators and Escalators (asamended), Section 211, American Society of MechanicalEngineers, New York, NY2.American Society of Mechanical Engineers. ASME A17.3 1990, Safety Code for Existing Elevators and Escalators(as amended), American Society of Mechanical Engineers,New York, NY3.29 Code of Federal Regulations 1910.134, RespiratoryProtection.4.30 Code of Federal Regulations 11, RespiratoryProtective Devices, Tests for Permissibility, Fees.5.49 Code of Federal Regulations 173, Shippers-GeneralRequirements for Shipments and Packaging.
Page 14 - Health Hazard Evaluation Report No. 94-0244-24316.Morris, Gary P., Brunacini, Nick., Whaley, Wynn;Fireground Accountability: The Phoenix System, FireEngineering, Vol. 147, No. 4, April, 1994.7.National Fire Protection Association. NFPA 1404,Standard on Fire Department SCBA Program, National FireProtection Association, Quincy, MA.8.National Fire Protection Association. NFPA 1500,Standard on Fire Department Occupational Safety andHealth Program, National Fire Protection Association,Quincy, MA.9.National Fire Protection Association. NFPA 1561,Standard on Fire Department Incident Management System,National Fire Protection Association, Quincy, MA.10.National Institute for Occupational Safety and Health.Guide to Industrial Respiratory Protection , DHHS[NIOSH] Publication No. 87-116.11.National Institute for Occupational Safety and Health.Health Hazard Evaluation Report, InternationalAssociation of Fire Fighters, Sedgwick County, Kansas,HETA 90-395-2121.VIII. AUTHORSHIP AND ACKNOWLEDGEMENTSReport Prepared by:Ted. A. Pettit, M.S.Acting ChiefTrauma Investigations SectionDivision of Safety ResearchTim R. Merinar, M.S.Acting ChiefCertification and QualityAssurance BranchAir-Supplies Respirator SectionDivision of Safety ResearchFire DepartmentProcedures Review:Richard M. RonkFire Protection EngineerInformation Management andDissemination ActivityDivision of Safety Research
Page 15 - Health Hazard Evaluation Report No. 94-0244-2431Figure:Karl Snyder, Ph.DAgricultural EngineerSafety Controls SectionProtective Technology BranchDivision of Safety ResearchPaul MooreSafety EngineerTrauma Investigations SectionSurveillance and FieldInvestigations BranchDivision of Safety ResearchEditorial Review:Paul KeaneWriter-EditorInformation Management andDissemination ActivityDivision of Safety Research
Page 17 - Health Hazard Evaluation Report No. 94-0244-2431APPENDIXMay 12, 1994Acting Chief, ASRS/CQABConformance Investigation of Self-Contained Breathing Apparatusfrom Memphis, Tennessee, Fire Department. TN-07073Ted A. Pettit, Acting Chief TIS, SFIBThrough: Acting Chief, SFIBActing Director, DSRChief, CQABBackgroundIn a letter dated April 15, 1994, Mr. Richard M. Duffy,International Association of Fire Fighters, requested that theNational Institute for Occupational Safety and Health (NIOSH)examine the self-contained breathing apparatus (SCBA) worn andused by two Memphis, Tennessee, fire fighters at the time oftheir deaths. A copy of the letter from Mr. Duffy is attached asAttachment One.On April 19, 1994, Mr. Ted Pettit, Acting Chief, TraumaInvestigations Section, and I traveled to Memphis to investigatethe circumstances involving the fire fighter fatalities, and toexamine the respirators involved. At the time of the incident,the fire fighters were part of fire fighting operations on theninth floor of an eleven-story apartment building located inMemphis, Tennessee.Part of the investigation in Memphis centered on the inspectionof the SCBA and their shipment to NIOSH in Morg
elevator door, allowing the door to close and the elevator to return to the ground floor, with Fire Fighter No. 3 still inside. Note: This elevator was not equipped with fire fighter control. Fire Fighters No. 1, No. 2, No. 4 and No. 5 entered the small ninth floor lobby (see Fi
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