Official Sheriff’s Hyperbaric Explosion Report

CASE CLOSED?????

Below is the official Marion County Sheriff’s Report of the incident.  Included in the report is the cause of death (blunt force and thermal injuries).  The manner of death was accidental explosion.

Interesting enough, a comment made in the official report by another “tech” at a similar facility nearby states “THAT THERE REALLY IS NO CERTIFICATION TO ENABLE SOMEONE TO RUN SUCH A CHAMBER” (Whoa!!!!, wrong!  The NBDHMT has a certification for that; CLICK HERE TO SEE IT).

The 2nd statement was:  BRENDA MCDUFFEE RUNS THE CHAMBER AT THIS FACILITY AND EXPLAINED THAT SHE HAD BEEN TRAINED IN TEXAS.   SHE STATED THAT THE TRAINING INVOLVED IS NOT SO MUCH AS TO HOW TO RUN THE CHAMBER, BUT MORE OF THE EFFECTS OF THE CHAMBER ON THE HORSES. WHEN QUESTIONED AS TO STANDARD PROTOCOLS REFERENCE THE CHAMBER, SHE TOLD WRITER THAT THERE ARE NONE; HOWEVER AT THE FACILITY WHERE SHE WORKS THEY HAVE INITIATED THEIR OWN PROTOCOL THAT LISTS MEASURES TO ENSURE THE SAFETY OF THE HORSE AS WELL AS THE OPERATOR.

There are no standard protocols? Hmmm. I know that there are some NFPA requirements for Class C chambers.  Time will tell I am sure.

UPDATE:  In a press interview McDuffee stated: “The hyperbaric community is relatively small, we’re all very well connected and everyone keeps up on all the safety protocols,” said McDuffee of The Sanctuary. “This is probably the most safety minded piece of equipment that anyone running these type of chambers does. The protocol books are huge.”  Here is that press interview.

MY QUESTION IS: Are there protocols or not????

MARION COUNTY SHERIFF’S OFFICIAL FULL REPORT ON HYPERBARIC EXPLOSION

A Bomb Technicians View: Possible Methane Contribution to Hyperbaric Explosion

Below is an excerpt from a highly skilled and FBI trained bomb technician & Instructor who has been investigating fires and explosions for 22 years.  Thank you very much RED DIVER1 for the quick response.

FROM RED DIVER 1 Depending on the volume and pressure of each gas present at the time of the explosion, it MAYBE possible that a spark could produce an ignition of the gases to sustain a rapid deflagration or explosion causing the chamber to rupture as the direct result of gas overpressure.

Several factors must be present to support this theory. First off, the Lower Explosive Limit or LEL must be known. Wikipedia defines the LEL as the lowest concentration (percentage) of a gas or a vapor in air capable of producing a flash of fire in presence of an ignition source (arc, flame, heat). At a concentration in air below the LEL there is not enough fuel to continue an explosion. Concentrations lower than the LEL are “too lean” to explode but may still deflagrate (burn or rapidly combust).

The Upper Explosive Limit or UEL is the highest concentration or percentage of a gas or a vapor in air capable of producing a open flash of fire in the presence of an ignition source. In this case the possibility of a spark resulting from a metal horse coming into contact with another metal surface inside the chamber, could be sufficient to cause a rapid deflagration. The resulting gas overpressure would cause the chamber to violently rupture causing heat, fragmentation and a blast pressure wave in the immediate area.

Oxygen enriched atmospheres lower the LEL and increase the UEL. An atmosphere devoid of an oxidizer is neither flammable or explosive regardless of the fuel gas concentration. Increasing the fraction of inert gases in an air mixture raises the LEL and decreases the UEL (keep in mind the fire triangle).

Methane gas has a LEL of 4.4% (at 138 degrees C) by volume, meaning 4.4% of the total volume of the air consists of methane. At 20 degrees C the LEL is 5.1 % by volume. If the atmosphere has less than 5.1% methane, an explosion cannot occur even if a source of ignition is present. When methane (CH4) concentration reaches 5.1% an explosion can occur if there is an ignition source. LEL concentrations vary greatly between combustible gases.

To prove this theory, the volume, temperatures and partial pressures of the affected gases would have to be known values to identify the upper and lower flammability/explosive limits.

In summation, it would be possible for a rapid deflagration or explosion to occur if the explosive limits are within range.

BY,

RED DIVER 1

Bomb Tech Extraordinaire

Did Methane Contribute To The Hyperbaric Explosion on Fiday?

A comment from Steve Wood posted today on the blog states:

“The troubling part of this incident is that it was an explosion, and, at least based on press reports,there was not a fire that led to a structural failure (as in the 1996 Yamanachi Kosai fire in Japan).  Following a presentation on veterinary HBO at the UHMS meeting in Maui, a group of us were having a typical bar conversation, and during the discussion, we raised the potential risks of methane in veterinary chambers (the presenter had mentioned the use of HBO in treating GI-related issues in horses). Consider the explosive potential of a large methane release in an oxygen-pressurized (or air pressurized for that matter) chamber – the ignition energy is so low that even a very small static spark, much less than a steel-on-steel percussion spark, could trigger an explosive event.  Obviously, the jury is still out in this case, but I’d suspect that methane is a factor in this incident.”

Steve does bring up a great point with the Methane and LEL/UEL (Lower explosive levels and Upper explosive limits).  I spoke to a friend who happens to be an Arson and Explosives Investigator for the last 22 years in the L.A. County Sheriff’s Bomb Squad about this today and he agreed that even in normal non-hyperbaric conditions, the combination of 5 to 6% Methane, above 21% oxygen, a very small ignition source, and perfect conditions can cause an explosive event.  Now increase the amount of oxygen, seal it all up in a hyperbaric chamber, add double the amount of pressure and a huge spark and the result speaks for itself.  We are not saying this actually happened – but it is definitely a possibility and cannot be ruled out.

Here is some reference material on this subject: (If you are a safety director anywhere, this is great reference material to have around)

Avoiding Static Ignition Hazards in Chemical Operations

 

Investigation of Fire  & Explosion Accidents in the Chemical, Mining, and Fuel Industries (A manual, Kuchta)

 

Facts About Methane that are Important to Mine Safety

Gas Explosion Handbook (Combustion Properties of Fuel/Air mixtures)

As it stands, it may be quite some time before the details of what actually happened is released.

A couple of questions for the industry (Ron please post these questions on hyperbariclink.com as well if you do not mind)

1.  Does anyone remember exactly what happened in 2009?  The cause of the fire and death of two people?

2.  What caused the accident in 2009?  Where is the report from the investigating agency so that IDIOTS & WING-NUTS out there learn a little something before they make the same mistake again.

3.  Do animal chambers get some sort of FDA 510k pre-market notification?  The FDA regulates pet food, I could not find anything about HBO chambers for animals on their website.

4.  What are the manufacturing regulations for animal chambers?  PVHO stands for Pressure Vessel for HUMAN Occupancy, is there one for animals? PVAO? Catchy.

Looking forward to some great responses.

Still No Oversight Of Hyperbaric Oxygen Chambers?

In a published article back in Oct 2011 (phillyburbs.com), the author pointed out some very interesting things regarding the lack of regulations that are governing hyperbaric facilities, especially those not in a hospital setting. It is great to see that Tom Workman is still pushing for UHMS accreditation of hyperbaric facilities in and out of hospital settings (albeit, it is still seen as cost prohibitive by some hospital and free-standing centers). I believe that this accreditation is important and should be supported 100%.

In a very short span of three years, the hyperbaric community has suffered several accidents that have resulted in deaths unlike ever seen before in the United States. It is becoming apparent that either complacency, lack of training, lack of safety procedures, and quite possibly lack of luck combined with the exponential increase in hyperbaric chamber usage in the US as well as a lax regulatory system is causing more and more unfortunate hyperbaric events. The most unfortunate part of it is that these were not plastic gammow bag chambers – these accidents were solid hyperbaric chambers.

I do not understand why people want to “Bury” this negative smear on the “oh so perfect hyperbaric safety record” that we have enjoyed up to 2009. Shhh, keep it quiet and no one will pay us any attention and we can just continue to be complacent. Well there you have it, we have swept that 2009 accident under the rug and therefore NOTHING has changed. Unless we talk about it and contribute to increase and enforce the safety standards we will have more of these unfortunate events. I am sure even the “Good ol boys club” will agree with what I just said.

Take a look at RICHARD BARRY, CHT for example. Richard has been working tirelessly for almost 5 years (maybe more) that I know of to get some answers regarding flammability & materials testing inside the chamber in order to come up with a “NO FAIL” list of items including wound care dressings and supplies to MAKE HYPERBARICS SAFER! The UHMS committee that Richard oversees is called the UHMS Material testing Advisory Committee (MTAC) started in 2010 but Richard and I have discussed this at a very early stage (circa 2007 or so). Do you want to know how much the committee has to raise? $50k, and that’s just to start the process.

Now let us talk about how much he currently has raised in all this time, according to the Nov/Dec 2011 UHMS publication, Pressure – Richard has raised $14K. Surely we are a lot closer to the 50k mark but we sure are waaaaay off. More so than that, let us do some math and count the number of HBO chamber manufacturers and management companies around, surely each one can pony up $1,500.00 each right? Why haven’t they? Let us count how many hospital programs there are out there (last estimates were 1,000 hospital HBOT programs in the US right?), that would mean that each hospital program has to pony up $36.00 each (or 1/3 of a Medicare segment for HBOT).

Wake-up hyperbaric people, it is time to do your part and participate in “OUR OWN SAFETY” as well as those that we treat. No more willy-nilly fly-by-night operations, no more short cuts. Get accredited, give back to your profession, do it right the first time, and support the UHMS MTAC by sending a check to:

Undersea & Hyperbaric Medical Society

Re: Material Testing MTAC

21 West Colony Place, Suite 200

Durham, NC 27705 USA

I wish there was an easier way such as sending the money via PayPal – Richard please let me know if this is possible.

VHO2 (MFG of Chamber that exploded) Press Release from Jan 2012 & NBDHMT Recognizing Veterinary HBOT

Why the headline you say?  It so happens that the same company that manufactures the VHO2 chambers (yes the one involved in the accident) just last month released a press release regarding the approval of a CHT-V (Veterinary hyperbaric tech) certification by the NBDHMT.  This programs safety policies and competencies may have to be looked into / edited in order to satisfy OSHA’s requirement for safety when it comes to treating large animals in the chamber.

In the release it states:

“The NBDHMT in conjunction with a select committee of experts from the Veterinary Hyperbaric Medical Society- VHMS, (www.vet.utk.edu/vhms), has designed the Certified Hyperbaric Technologist-Veterinary (CHT-V) certification exam. Qualifying applicants who complete the required pre-requisite training will be able to sit for this internationally recognized title. This huge advance in training for veterinary hyperbaric specialists will help pave the way for quality control in treatment standards and safety of veterinary hyperbaric medicine”.

Should the NBDHMT put a hold on this program that was just launched a month ago?  I say that when the investigation is done and proper safety measures for those chambers are put into place, YES, the program MUST be on hold. 

People should wonder if the safety measures for treating large animals (especially horses) in the chamber were written/co-written with the help of the manufacturer, and if they sought any professional opinions from other “Hyperbaric Experts” in the field not involved in treating animals. 

If I was asked per se to assist to establish safety protocols for treating a horse in an HBO chamber I would have:

#1 Made sure no metals went into the chamber (this includes horse shoes), we do this to humans (we don’t even let earrings into the chamber let alone horse shoes made of metal).  Is it cost prohibitive? YES,  Does it Save lives? YES.

#2 Asses the animal, in this instance the horse (They do kick and kick hard).  Measure the PSI or impact of a kick and multiply that force by 10 and engineer something that can withstand that force.

#3 Refer to #1

READ THE PRESS RELEASE FROM PR.COM HERE

READ THE ANNOUNCEMENT FROM HYPERBARICLINK.COM HERE

Hyperbaric Manufacturer urges facilities to stop using chambers following explosion

(From CF New 13):  OCALA — 

The manufacturer of the hyperbaric chamber that exploded Friday, killing a veterinary employee and a horse, is urging facilities across the country to stop using them.

The move comes as the government launched a formal safety investigation Monday into the chambers and how they were being used at the Marion County equine rehabilitation center.

READ MORE HERE

(From HBOTECHBLOG.com): The manufacturers name is: VHO2 (Veterinary Hyperbaric Oxygen, Inc.)  They are based in Lexington Kentucky and have taken their website down (www.vho2.com), but not before we were able to get some of their information:

This is from their website:

Veterinary Hyperbaric Oxygen-VHO2 (formerly Equine Oxygen Therapy and Companion Animal Hyperbarics) is a Lexington, Kentucky based manufacturer and global distributor of hyperbaric oxygen chambers for horses and companion animals. This exciting adjunctive therapy has provided veterinarians with another option to significantly improve animal medical care, and has been used in the treatment of multiple conditions in the past decade.The results have been nothing short of remarkable.To achieve these results, VHO has developed the most successful and comprehensive set of treatment protocols in existence. These protocols were developed with experience gained after literally 30,000 PLUS treatments, but we don’t stop there. VHO is an avid supporter of the only veterinary specific; hyperbaric oxygen research projects currently being conducted by universities here in the USA.We firmly believe we build the safest, most advanced and most reliable chambers in the world. In fact, we can easily say that 100% of all chambers installed are fully functional and will continue to provide years of service. Not every hyperbaric manufacturer can say this.VHO does not just build and sell chambers; our goal is to provide you with one of the most technologically advanced tools available for your practice. We then become your support partner every step of the way, from engineering, technical and operational training by our experienced staff, to ensuring you receive ongoing veterinary resources.Hyperbaric Oxygen Therapy (HBOT) is a revolutionary medical technology, useful for the treatment of acute injuries as well as for the enhancement of healing chronic disorders in both small and large animals. Proven effective in human medicine, HBOT is used as an adjunct therapy to other medications and procedures. Clinical experience has shown that this same technology can be applied successfully to many medical conditions of animals. Both equine and companion animal medical therapy is often a composite of multiple medical treatments that complement each other, or individually contribute to part of the healing process, in order to accomplish the goal of recovery. HBOT gives the veterinary practitioner one more weapon in their arsenal to enhance tissue healing after injury from trauma, inflammation, or hypoxia-ischemia.

Veterinary Hyperbaric Oxygen (VHO2) Animal Hyperbaric Chambers VHO2 is a Lexington, Kentucky based manufacturer and global distributor of veterinary hyperbaric oxygen chambers for horses and companion animals (including dogs, cats, pigs and birds) and exotics (including turtles, alpacas, etc.). The use of hyperbaric oxygen therapy as an exciting adjunctive therapy has provided veterinarians with another option to significantly improve animal medical care, and has been used in the treatment of multiple conditions in the past decade. Known and identified by many names including Veterinary HBOT (Hyperbaric Oxygen Therapy), Veterinary Hyperbarics or even Animal / Veterinary Oxygen Therapy in some areas, the results of this modality have been nothing short of remarkable.

HERE IS A PRESS RELEASE FROM VHO2 IN JAN 2012 REGARDING A NEW CHAMBER INSTALLATION IN AUSTRALIA