Burn Injury Investigation Report Preparing a Live Fire Prop for Use Miami-Dade County Fire Rescue Department, November 18, 2011

Transcription

1 Burn Injury Investigation Report Preparing a Live Fire Prop for Use Miami-Dade County Fire Rescue Department, November 18, 2011 Florida Safety Investigation Report Prepared by the Safety Section Bureau of Fire Standards and Training Florida Issued: August 9, 2012

2 Safety Investigation Report I. Authority, Purpose, and Scope The Department of Financial Services, ("Division") is authorized by the provisions of Section , Florida Statutes, to investigate the causes of firefighter employee injuries. The purpose of this investigation is to enhance firefighter occupational safety and health in the State of Florida. The scope of this investigation is to determine the facts surrounding burn injuries sustained during the setup of this live fire training prop and make recommendations that would prevent future similar injuries. II. Background A firefighter received severe bums during the set-up of a portable outdoor live fire training prop. The victim was treated on scene by Miami-Dade County Fire-Rescue Department ("Miami-Dade") and transported to the hospital for further treatment. The scene was then secured for investigative purposes. Miami-Dade asked the Division to assist them with the investigation of the incident. A Detective with the Bureau of Fire and Arson Investigations and a Bureau of Fire Standards and Training Field Safety Representative were assigned to conduct the investigation with Miami-Dade. III. Methodology In conducting this investigation, the Bureau of Fire and Arson Investigations report, witness statements, interviews, applicable standards, manufacturer's representatives and photographs were used to ascertain the facts. III. Executive Summary On the morning of November 18,2011, three Miami-Dade Training Center instructors were assigned to prepare an outdoor training prop for a demonstration bum later in the day. The instructors held current and appropriate Florida certifications for the task assigned. The prop was a Car Fire Trainer made by Kidde Fire Trainers. The training center had the prop for about one and a half years. The prop uses propane in both vapor and liquid states for fuel. e While setting up the prop, there was a concern by two of the assigned instructors regarding whether the propane supply line connections were being made correctly. Miami-Dade's Facilities Manager was contacted for assistance. With his arrival and assistance, connections were completed. With all connections made and the prop's control box connected to an electrical source for power, vapor and liquid valves on the field were opened and propane was supplied to the prop. Moments after opening the field valves, an uncontrolled discharge of propane was detected and the valves were immediately shut down. After waiting for about two-three minutes for the gas to dissipate, two of the instructors approached the prop from different directions. The Miami-Dade County Fire Rescue 1 Bureau of Fire Standards & Training

3 approaching instructors were not wearing any protective clothing. The victim was close enough to touch the prop when gas in the area of the prop ignited. With his uniform shirt on-fire, he dropped to the ground in an attempt to extinguish himself. One of the instructors assisted him while the other went for help. The victim was treated on scene by Miami-Dade and transported to the hospital for bum treatment. IV. s 1. Of the three certified instructors assigned to set up the prop; One had documented training on the prop. The training was in June of2010. None of the instructors had ever operated the prop or set it up by themselves. 2. The Facility Manager, who was asked to assist, also received training on the prop in June of2010. His familiarity and experience with the prop was similar to that of the instructors. 3. Manufacturer's instructions were not consulted during the set-up. 4. No one claimed to know why the Control Pendant Pilot switch that activates the igniter for the propane fuel was found in the "On" position. One could assume from this finding that the Control Pendant Pilot switch was left in the on position from the last time it was used which would be a violation of Florida Statute (6)(2). 5. The prop connections, fittings and supply lines as configured by the manufacturer allow incorrect connections to be made. When connected incorrectly, as it was, propane was able to bypass the Control Pendant and flow unimpeded. 6. The victim did not know of the uncontrolled release, nor was he told. 7. After the uncontrolled release, no safety precautions, monitoring or protective gear was used to approach the prop. 8. A delay was identified in providing treatment to the victim. The instructor that went for medical equipment could not remember where the equipment was on the training ground and went to the administration building to acquire it. v. Recommendations Recommendation 1. Assignments regarding the set-up and operation of live fire training props should be restricted to those instructors who are trained, experienced and current with the specific prop. A system should be established to facilitate such selection. Recommendation 2. Establish a recurrent training program on the Kidde props to provide periodic refresher training to instructors and the facilities manager. The Miami-Dade County Fire Rescue 2 Bureau of Fire Standards & Training

4 properties, characteristics and safety considerations of the fuel being utilized should be included as part of the curriculum. Recommendation 3. Establish procedures and checklists for the set up, break down and operation of the props utilizing the Kidde Operator Manual for guidance. Require the checklists to be completed for every set up and take down. Recommendation 4. As part of the checklist for the set-up and break down of the prop, ensure that visual confirmation of the pilot switch being in the "Off' position is made prior to set-up and breakdown. Recommendation 5. Kidde Fire Trainers should consider redesigning their prop connections so that incorrect connections cannot be made. Recommendation 6. Establish a visual and or audible signal to make all personnel aware when propane is being supplied to the prop. Recommendation 7. Adhere to the Kidde manual with regard to the use of full personal protective equipment when working near or approaching the props once gas flow has been established. Miami-Dade County Fire Rescue 3 Bureau of Fire Standards & Training

5 Burn Injury Investigation Report Preparing a Live Fire Prop for Use Miami-Dade County Fire Rescue Department, Florida November 18, 2011 Prepared by the Safety Section Bureau of Fire Standards and Training Florida Submitted by: Charles F Brush, Manager, Safety Section, BFST Approved by: Barry Baker, Chief, Bureau of Fire Standards & Training Approved for distribution by: ~ H~:' ~orida Miami-Dade County Fire Rescue 4 Bureau of Fire Standards & Training