Background: There have been over 30 incidents of oxygen resuscitator fires over the last 6 years, causing severe burns to a number of fire fighters, emergency medical service personnel, health care workers, and patients. The National Institute for Occupational Safety and Health (NIOSH) was requested to investigate three such incidents.
Methods: NIOSH conducted site investigations of the incidents, and the requesters also sent the involved oxygen resuscitators to a forensic engineering company for a causal analysis.
Results: The investigated fires were associated with aluminum regulators, all from one manufacturer, on compressed pure oxygen cylinders. The investigations indicated that the cause of the fires was an initial small ignition in the high-pressure area of the aluminum regulator, which then consumed itself in a massive burnout.
Conclusions: Aluminum regulators used with high-pressure oxygen systems are subject to rare, but potentially catastrophic combustion in normal use. Replacement of such regulators with those made of more fire-resistant materials or designs, as well as education and improved safety practices are needed to reduce this hazard.
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