1. Report 09-673 Air Line Connection Failure Report Number: 09-673 Report Date: 07/13/2009 0927 Synopsis Equipment misuse leads to injuries.

2. #09-673 Event Description I hope this info helps prevent a similar type incident from occurring in your department. It seems sometimes no matter how much you brief or have procedures set in place, things still happen that leave you shaking your head. This is one of those times. We have a modified hose cap set up to fill fire hose with compressed air so it can be used as a flotation device during water rescue or for a boom during a Haz-Mat response. During the daily vehicle/equipment checkout, 2 firefighters decided that they were going to test it to determine if the threads on the airline coupling were long enough to work with (name deleted) SCBA air cylinders. Instead of connecting a regulator and using a fire hose, they just capped off the hose connection. When they opened the 4500 PSI air cylinder charging the high pressure line (the cylinder knob never made it more than a half turn) the cap set exploded like a mini pipe bomb into three pieces. One piece stayed in place, attached to the bottle. The larger of the two struck FF [A] in the right shin, and then hit FF [B] in the left shin. The smaller piece also hit FF [A] just below the first point of impact. Both individuals were taken to the hospital with injuries. FF [B] was cleared and returned to duty soon after. However serious these injuries may be, we had Saint Florian watching over us and are extremely lucky that they werent gravely injured. The sheer force of the larger piece of the equipment flying through the air could have killed someone.

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4. Lessons Learned The lesson learned today, besides the obvious of using a regulator when working with high pressure air, is really no matter how much training youve had, if youre unsure about something you should ask before you play. The chiefs decision regarding the incident is simple; this fire department went on an immediate safety stand down and we went through every truck, supply room, nook and cranny to ensure all equipment of similar build was removed. We will not use that type of equipment any more until we can procure an appropriate cap set specifically designed for that type operation with all the safety features built in. Therefore, we hope that further incidents of a similar nature will not occur. I hope this info helps prevent a similar type incident from occurring in your department.

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6. Discussion Questions 1.Is your apparatus equipped with a fabricated air line hose cap? 2. Does your department have a comprehensive, standardized training program that documents training for every piece of equipment in the inventory? 3. Does your department allow in-house creation of tools and equipment? 4. Is there a supervisory responsibility/accountability for the firefighters actions in this near miss? 5. Place this incident in your fire department. Would your department follow the same procedures as this department?

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