HETA 99-0062-2804
Newark Fire Department
Newark, New Jersey
Kevin C. Roegner, M.P.H.
Joel E. McCullough, M.D., M.P.H., M.S.
This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally
applicable. 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/reports
This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally
applicable. 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/reports
This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally
applicable. 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/reports
This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally
applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.
This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally
applicable. 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/reports
applicable. 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/reports
ii
PREFACE
The Hazard Evaluations and Technical Assistance Branch (HETAB) of the National Institute for Occupational
Safety and Health (NIOSH) conducts field investigations of possible health hazards in the workplace. These
investigations are conducted under the authority of Section 20(a)(6) of the Occupational Safety and Health
(OSHA) Act of 1970, 29 U.S.C. 669(a)(6) which authorizes the Secretary of Health and Human Services,
following a written request from any employer or authorized representative of employees, to determine
whether any substance normally found in the place of employment has potentially toxic effects in such
concentrations as used or found.
HETAB also provides, upon request, technical and consultative assistance to Federal, State, and local
agencies; labor; industry; and other groups or individuals to control occupational health hazards and to prevent
related trauma and disease. Mention of company names or products does not constitute endorsement by
NIOSH.
ACKNOWLEDGMENTS AND AVAILABILITY OF REPORT
This report was prepared by Kevin Roegner and Joel McCullough of HETAB, Division of Surveillance,
Hazard Evaluations and Field Studies (DSHEFS). Field assistance was provided by Greg Kinnes, DSHEFS.
Desktop publishing was performed by Denise Ratliff. Review and preparation for printing were performed
by Penny Arthur.
Copies of this report have been sent to employee and management representatives at the Newark Fire
Department; the International Association of Fire Fighters (IAFF), Department of Occupational Health and
Safety; IAFF Local 1860; and the New Jersey Public Employees Occupational Health and Safety Program.
This report is not copyrighted and may be freely reproduced. Single copies of this report will be available
for a period of three years from the date of this report. To expedite your request, include a self-addressed
mailing label along with your written request to:
NIOSH Publications Office
4676 Columbia Parkway
Cincinnati, Ohio 45226
800-356-4674
After this time, copies may be purchased from the National Technical Information Service (NTIS) at
5825 Port Royal Road, Springfield, Virginia 22161. Information regarding the NTIS stock number may be
obtained from the NIOSH Publications Office at the Cincinnati address.
For the purpose of informing affected employees, copies of this report shall be posted
by the employer in a prominent place accessible to the employees for a period of 30
calendar days.
iii
Highlights of the NIOSH Health Hazard Evaluation
Evaluation of American Ref-fuel Incident
In December of 1998, 37 Newark Fire Department (NFD) fire fighters were exposed to irritant gasses during
a response to a fire at American Ref-fuel (AR). Following the incident, the IAFF asked NIOSH to investigate
the events leading to fire fighters’ exposures, and to review the medical care received by the fire fighters after
the incident.
What NIOSH Did
# Interviewed fire fighters who responded to AR
about the response and their symptoms.
# Looked at medical records, radio
communication logs, fire fighter incident
reports, and NFD procedures.
# Went to AR to see the area where the incident
occurred.
What NIOSH Found
# Most fire fighters at the scene had some degree
of irritation to their eyes, throat, or lungs.
# Fire fighters were likely exposed to chlorine gas
and nitrogen trichloride, and possibly very low
levels of phosgene.
# Fire fighters were initially provided with wrong
information about the contents of the fire.
# The hazardous materials (HAZMAT) company
was committed to the incident in fire mode, so
no HAZMAT response could be made.
# Not using self-contained breathing apparatus
(SCBA) all the time, poor communications, and
poor building ventilation made exposures
worse.
# The treating physicians in the hospital
emergency rooms were aware of the fire fighter
chemical exposure, but did not know the
specific substances.
# The number of medical tests varied among
hospitals, but this difference did not appear to
cause worse health outcomes.
What the Newark Fire Department
Can Do
# Better enforce SCBA use at the scene of a fire.
# Minimize gaps in HAZMAT coverage.
# Improve communication with local hospitals.
# Better educate fire fighters on decontamination
procedures.
# Better integrate surveillance medical records
with acute occupational health services.
What the Newark Fire Department
Fire Fighters Can Do
# Use better judgement when removing SCBA at
the fire scene.
# Follow two-in, two-out rule.
CDC
CENTERS FOR DISEASE CONTROL
AND PREVENTION
What To Do For More Information:
We encourage you to read the full report. If you
would like a copy, either ask your health and
safety representative to make you a copy or call
1-513/841-4252 and ask for
HETA Report # 99-0062-2804
iv
Health Hazard Evaluation Report 99-0062-2804
Newark Fire Department
Newark, New Jersey
February 2000
Kevin C. Roegner, M.P.H.
Joel E. McCullough, M.D., M.P.H., M.S.
SUMMARY
On December 22, 1998, the National Institute for Occupational Safety and Health (NIOSH) received a request
for a health hazard evaluation (HHE) from the International Association of Fire Fighters (IAFF) on behalf of
fire fighters from the Newark Fire Department (NFD) to assess the incident response procedures followed
during a fire in a refuse waste-to-energy facility (American Ref-fuel) on December 17,1998, in Newark, New
Jersey. The IAFF indicated that several of the fire fighters responding to the incident were subsequently
hospitalized due to smoke and chlorine gas inhalation.
NIOSH investigators conducted a site visit to the NFD on April 12-13, 1999, and again on June 24, 1999.
NIOSH personnel conducted private interviews with several NFD fire fighters who responded to the incident
and reviewed several incident-related records provided by the NFD, including the department’s standard
operating procedures (SOPs) and medical records. Self-administered questionnaires were distributed to fire
fighters who were not present on the days of the NIOSH investigation. In addition to the medical interviews
and questionnaires, medical records were reviewed from five hospitals where the fire fighters received
medical care, and from the occupational medicine provider for the NFD. NIOSH investigators also visited
American Ref-fuel.
On December 17, 1998, the NFD received a report of a fire in the refuse pit of American Ref-fuel. The fire
was declared a hazardous materials incident as information became known that the fire had involved chlorine
bleach cleaner which, according to the product’s material safety data sheet, would liberate chlorine and
phosgene as decomposition products. Fire fighters used the plant’s showering facilities for decontamination
purposes before all of the 37 responding fire fighters were sent to area hospitals for evaluation.
The medical survey showed that most fire fighters at the scene experienced some degree of acute upper
respiratory tract irritation, and many experienced lower respiratory tract irritation as well. Fifteen had
persistent symptoms at 24 hours, and 13 had symptoms at the time of the NIOSH investigation. Based on the
combustion of chlorine-containing cleaner, the fire fighters’ exposures probably consisted primarily of irritant
gases, such as chlorine and nitrogen trichloride.
Medical records revealed that the treating physicians were aware that the fire fighters were exposed to
chemicals at a fire and were concerned about the inhalation of toxic fumes and smoke. However, neither fire
fighters nor treating physicians knew what specific toxins were present. The symptoms of the fire fighters
were consistent in the different hospitals, however the diagnostic tests performed differed. The university-
based hospital performed the most diagnostic tests on the fire fighters. The other hospitals performed fewer
tests, but this did not appear to result in a greater rate of adverse health outcomes.
v
The elements leading to fire fighter exposures at the waste-to-energy plant on December 17, 1998, are
complex and multi-factorial in nature. Clearly, fire fighters did encounter exposures to irritant gasses at
the scene. The NFD approached the incident in fire mode, when in fact, a hazardous materials
(HAZMAT) response approach would have been more appropriate.
Most fire fighters suffered irritant symptoms that were the result of exposures to irritant gases at
American Ref-fuel. For those fire fighters who had recovered at the time of the NIOSH investigation or
did not develop symptoms, it is unlikely that this exposure will result in further health problems. Those
who developed more significant respiratory symptoms were being evaluated by health care providers.
Several recommendations are offered for improving fire fighter health and safety, including
recommendations for better integration of fire fighter medical surveillance information with acute care
occupational medicine providers, better personal protective equipment (PPE) usage, and filling gaps in
HAZMAT coverage.
Keywords: SIC 9224 (Fire Protection), fire fighters, firefighters, incident command system, ICS,
self–contained breathing apparatus, SCBA, hazardous materials
TABLE OF CONTENTS
Preface ............................................................................. ii
Acknowledgments and Availability of Report .............................................. ii
Highlights of the NIOSH Health Hazard Evaluation......................................... iii
Summary ...........................................................................iv
Introduction ......................................................................... 1
Background ......................................................................... 1
Methods ............................................................................ 2
Evaluation Criteria.................................................................... 3
Smoke Inhalation.................................................................. 3
Chlorine......................................................................... 4
Phosgene ........................................................................ 5
Nitrogen Trichloride ............................................................... 6
Incident Command System (ICS) ..................................................... 6
Findings and Discussion ............................................................... 7
Preplanning and Information......................................................... 7
Incident Command System (ICS) ..................................................... 7
Hazardous Materials Response Unit ................................................... 8
Safety Management................................................................ 9
Training........................................................................ 10
Communications ................................................................. 10
Respiratory and Other Personal Protective Equipment (PPE) .............................. 10
Medical ........................................................................ 11
Conclusions ........................................................................ 14
Recommendations ................................................................... 14
References ......................................................................... 16
Glossary of Medical Terminology....................................................... 19
Health Hazard Evaluation Report No. 99-0062-2804 Page 1
INTRODUCTION
On December 22, 1998, the National Institute for
Occupational Safety and Health (NIOSH) received
a request for a health hazard evaluation (HHE)
from the International Association of Fire Fighters
(IAFF). This HHE request was submitted on
behalf of fire fighters from the City of Newark
Fire Department (NFD) to assess the incident
response procedures used during a fire in a refuse
waste-to-energy facility (American Ref-fuel) on
December 17, 1998, in Newark, New Jersey. The
IAFF reported that 37 fire fighters responded to
the incident, and that several of the responders
were subsequently hospitalized due to smoke and
chlorine gas inhalation. The IAFF requested that
NIOSH review the response procedures used
during this incident, investigate the potential
chemical exposures that may have occurred, and
determine the health effects that fire fighters may
experience from the exposure.
In response to this request, NIOSH investigators
conducted a site visit to the NFD on April 12-13,
and again on June 24, 1999. On April 12, an
opening conference was held to discuss the
incident and the nature of the request with
representatives of the NFD and IAFF Local 1860.
During the remainder of the site visit, private
interviews were held with NFD fire fighters and
command staff who responded to the incident, and
copies of several NFD standard operating
procedures (SOPs) and other pertinent records
were obtained for review.
This report summarizes response procedures as
they affected the health and safety of the fire
fighters, including the Incident Command System
(ICS) and safety management. This report also
discusses decontamination of fire fighters, assesses
the level of care received by fire fighters at area
hospitals, and provides recommendations.
BACKGROUND
The NFD employs 735 uniformed fire fighters, and
serves a geographic area of 23 square miles. The
department operates four shifts (tours), and is
divided into four battalions. Each tour works an
average of 42-hours per week on a schedule of
two, 10-hour shifts on duty followed by a day off,
then two, 14-hour shifts, followed by three days
off. Shift changes occur at 0800 hours (hrs) and
1800 hrs. In 1992, the NFD initiated a policy of
rotating four apparatus companies (one from each
battalion) out of service on each tour. Truck 8 was
retired from service in 1997, and the number of
companies rotating out of service was reduced to
three. In response to a working structural fire, the
NFD will dispatch four engines, two trucks, a
Battalion Chief (BC), a Deputy Chief (DC), a
Safety Officer (SO), a rescue unit, and a rapid
intervention team to the fire scene.
On December 17, 1998, the NFD responded to a
fire alarm at the eleven-story, American Ref-fuel
plant located in an industrial area outside of
downtown Newark. The facility was constructed
in 1990, and is segmented into several areas, each
designed to play a role in converting non-
hazardous waste into energy (Figure 1). At the
west end of the facility is a large, open tipping
hall, where trucks enter to deposit loads into the
refuse pit. The refuse pit measures 280 feet (ft.)
across, by 90 ft. front to back, by 45 ft. deep. The
open space above the refuse pit spans several
stories and is occupied by two 20-ton grappling
cranes. The cranes, which are remotely operated
from each of two control rooms that overlook the
pit, homogenize the waste and move it from the pit
and drop the waste into the waste charging hopper
(7
th
story). Once in the hopper, refuse is fed into
the furnace. Heat generated by the combusting
solid waste produces steam in a waterwall boiler,
the pressure from which is used to drive a turbine
generator. The plant is licensed to accept non-
hazardous waste.
Page 2 Health Hazard Evaluation Report No. 99-0062-2804
At 2008 hrs, December 17, 1998, the NFD
received a 9-1-1 telephone call reporting a fire in
the refuse pit of the waste-to-energy facility. A
full assignment, consisting of four engine
companies, two truck companies, a rescue
company, a BC, a DC, and an SO was dispatched
to the scene. Engine Company 16 (EC16) was the
first to arrive at 2012 hrs. In fire fighter interviews
it was reported that plant employees indicated to
arriving fire fighters that there were two fires: a
fire on the seventh floor and a fire in the refuse pit.
Truck one, the company which is also the
hazardous materials (HAZMAT) unit company,
was the second due truck for the response, and it
arrived on site early in the incident. Several
companies ascended the stairs and elevators to
search for the reported fire on the seventh floor.
They were, however, unable to locate a fire on the
seventh floor. The BC arrived at the scene at 2017
hrs. The DC arrived at the scene at 2025 hrs, at
which time he established a command post on the
first floor. During most of the incident, it was un-
clear what was burning in the pit. When the BC
and DC inquired about what was burning, plant
employees indicated that it was garbage. Several
fire fighters reported that the incident was
complicated by an intermittent heavy smoke
condition, which limited visibility into the refuse
pit and across the upper floors. Fire fighters
indicated that the smoke appeared white to
yellowish-green, and would ebb and bank with the
intermittent performance of ceiling exhaust fans
located above the pit. The fire was declared under
control at 2238 hrs, at which time it was declared
a hazardous materials incident as information
became known that the fire had involved chlorine-
containing cleaner. The cleaner had been sent to
the facility for disposal. The product’s material
safety data sheet, which reportedly was made
available late into the incident, indicated that the
cleaner would liberate chlorine and phosgene as
decomposition products. Fire fighters used the
plant’s showering facilities for decontamination
purposes before all of the 37 responding fire
fighters were sent to area hospitals for evaluation.
METHODS
NIOSH investigators visited the NFD on two
occasions, and the waste-to-energy plant to obtain
information. During the first visit, NIOSH investi-
gators held an opening conference with the local
IAFF representative and representatives of the
NFD. This meeting was arranged to discuss the
structure and staffing of the NFD, review the
incident chronology and the procedures used
during the response, and review actions of the fire
department subsequent to fire fighters raising
concerns about possible exposures to chlorine and
phosgene. The NIOSH investigators spent addi-
tional time during the two days interviewing fire
fighters and command personnel who responded to
the incident and reviewing incident-related records
provided by the NFD. These records included the
incident chronology report, transcripts of radio
communications during the incident, SOPs
followed by the NFD, and various other records
pertaining to this incident. The NIOSH
investigators also requested copies of the
command reports submitted by each apparatus
captain and others who assumed command
functions to the NFD. During the second visit,
NIOSH investigators inventoried the hazardous
materials response unit and spoke with the on-duty
captain of that unit. This meeting was followed by
a visit to American Ref-fuel where NIOSH
investigators met with the plant manager and
viewed the area where the incident occurred.
Telephone interviews were conducted with NFD
personnel not available during our site visit. The
incident response reports, transcripts from NIOSH
interviews with fire fighters, and other pertinent
information were used to reconstruct events and
procedures used during the incident.
On April 12-13, confidential interviews were
conducted with fire fighters who were present at
the scene of the incident. The fire fighters who
responded to the incident and were at work on the
days of the NIOSH investigation were interviewed
by NIOSH investigators. Also, self-administered
questionnaires (accompanied with NIOSH-
Health Hazard Evaluation Report No. 99-0062-2804 Page 3
addressed and postage-paid envelopes) were
distributed by a union representative to fire
fighters who were not present on the days of the
NIOSH investigation. The fire fighters were asked
about their job activities at the scene, their use of
personal protective equipment (PPE),
decontamination procedures, the amount of time at
the scene spent with and without PPE, health
symptoms that began at the scene, persistent health
symptoms, and the medical care they received. In
addition to the medical interviews and
questionnaires, medical records from the five
hospitals where the fire fighters received medical
care, and from the occupational medicine provider
for the department, were reviewed.
EVALUATION CRITERIA
Fire fighters work in varied and complex environ-
ments that increase their risk of on–the–job death
and injury. Every day, fire fighters in the United
States are injured in the line of duty.
1
According
to the IAFF, 45 professional fire fighters died in
the line of duty in 1998, and an additional 39
professional fire fighters died as a result of
occupational diseases directly related to fire
fighting.
2
When compared to data compiled for
private industry by the Bureau of Labor Statistics
(BLS), the incidence of fire fighter job-related
injury is nearly 4.5 times that of workers in private
industry; 32.4 percent (%) of fire fighters were
injured in 1998 compared to only 7.1% of private
industry workers.
2
In terms of severity, fire fighter
injuries caused 4,342 lost work hours per 100
workers.
2
Fire fighters face many health hazards,
including: inhalation of a wide variety of toxic
combustion products; chemical exposures by
direct skin and eye contact; physical hazards,
including heat, cold, noise, and falling objects; and
exposure to carcinogenic chemicals or combustion
products. The hazardous exposures most relevant
to the American Ref-fuel incident are discussed in
further detail below.
Smoke Inhalation
Smoke is the volatilized product of combustion. It
varies according to temperature, oxygen availa-
bility, and composition of the material being
burned.
3
The inhalational toxins in smoke are
chemicals in the form of gases, vapors, aerosols,
particulate, and fumes.
4
Upon combustion,
synthetic and natural polymers may produce
respiratory irritants (nitrogen and sulfur oxides,
aldehydes, halogenated compounds, and organic
acids), simple asphyxiants (carbon dioxide,
oxygen-deficient atmospheres), and cellular
asphyxiants (carbon monoxide, hydrogen
cyanide).
5
Each component of smoke may contribute to
respiratory damage in different ways. Although
smoke inhalation is often referred to as a
pulmonary burn, true thermal injury to the lower
respiratory tract appears to be unusual. The upper
airway is very effective in protecting against injury
by heat below the tongue (the trachea and
bronchial tubes). Even in the absence of
recognizable symptoms or disease, fire fighters
often have subclinical effects that may persist for
weeks or months, as evidenced by both restrictive
and obstructive lung changes on spirometry
testing.
6
The irritant gases and asphyxiants generated
during combustion account for virtually all of the
clinically recognized respiratory effects of smoke
inhalation. Most of the irritant gases that cause
direct pulmonary injury are highly reactive acids
or bases which, upon inhalation and hydration
within the lung, result in the denaturation or
oxidation of cellular components.
5, 6
Highly water-
soluble agents, such as ammonia, sulfur dioxide,
hydrogen fluoride, or acrolein, cause injury to the
proximal airway and mucosa, and their noxious
nature is more likely to be recognized by exposed
persons. By contrast, agents with intermediate or
lower water solubilities (e.g., phosgene or nitrogen
oxides) are more likely to result in subtle
presentations, with delayed onset of respiratory
damage. In this instance, fewer warning symptoms
Page 4 Health Hazard Evaluation Report No. 99-0062-2804
may result in prolonged exposures and damage to
distal airways and alveolar membranes.
5, 6
The vast majority of inhalation victims (90% to
95%) acutely complain of shortness of breath,
cough, or hoarseness. Symptoms such as cough,
sore throat, or hoarseness suggest upper airway
injury and the potential for life-threatening airway
obstruction. Shortness of breath and wheezing
suggest lower respiratory tract damage. Headache,
nausea, vomiting, dizziness, confusion, chest pain,
palpitations, and loss of consciousness may
suggest systemic poisoning or simple asphyxiant
effects. The age of the victim and past medical
history are important risk factors for the
development of inhalation injury. Those with
asthma or chronic respiratory diseases may be
more susceptible to the effects of irritant gas
inhalation.
3
All victims of smoke inhalation should begin
treatment with supplemental oxygen, which should
be adjusted based on arterial blood gases and
clinical history. The observation period for
asymptomatic patients without significant risk
factors for chronic obstructive pulmonary disease
or coronary artery disease is 4 to 6 hours. Those
who remain asymptomatic during the observation
period can be discharged from the health care
facility with appropriate follow-up instructions.
7
If initial clinical findings are minimal, but there is
a history of smoke inhalation, arterial blood gases
(ABGs) should be obtained. ABGs, which usually
include carboxyhemoglobin levels, are an essential
early part of nearly every evaluation of a fire
fighter with smoke inhalation.
8
Although pulse
oximetry is a convenient way to continuously
monitor oxygenation in patients, it is unreliable or
falsely normal in patients who have
dyshemoglobinemias (e.g.,
carboxyhemoglobinemia or methemoglobinemia)
because it measures only oxygen dissolved in the
blood and not the status of tissue oxygenation. In
patients who have altered hemoglobin, the pulse
oximetry does not reflect the impaired oxygen
carrying or delivery capacity of the red cells.
Pulse oximetry does not distinguish between
carboxyhemoglobin (COHb) and oxyhemoglobin
(O
2
Hb). In these situations, a Co-oximeter should
be used to measure specific levels of hemoglobins
that are unable to transport oxygen efficiently.
9
A thorough eye exam in the emergency department
is indicated for those suspected of having smoke
inhalation injury or exposure to corrosive
substances. Eyes contaminated by smoke,
aerosols, and particulates should be treated
similarly to splash injuries and liberally irrigated
with plain water or normal saline. A thorough eye
exam should be performed following irrigation.
Ophthalmologic consultation is indicated in those
presenting with more than minor complaints or
physical findings.
8
Chlorine
Chlorine is a yellow-green gas with a sharp or
pungent odor at room temperature. Chorine is
only slightly soluble in water, but on contact with
moisture it forms hypochlorous acid (HClO) and
hydrochloric acid (HCl). The unstable HClO
readily decomposes, forming oxygen-free radicals.
Because of these reactions, water substantially
enhances chlorine’s oxidizing and corrosive
effects.
10
Chlorine’s odor and irritant properties generally
provide adequate warning of hazardous concen-
trations. However, prolonged, low-level exposures
can lead to olfactory fatigue and tolerance of
chlorine’s irritant effects. Mucous membrane
irritation may occur at 0.2 to 16 parts per million
(ppm); eye irritation occurs at 7 to 8 ppm, throat
irritation at 15 ppm, and cough at 30 ppm.
11
Inhalation of high concentrations of the gas causes
necrosis of the lining of the trachea and bronchi as
well as pulmonary edema, emphysema, and
damage to the pulmonary blood vessels. Exposure
to 500 ppm can be lethal over 30 minutes, while
1000 ppm can be lethal within a few minutes.
12
The severity of the damage to the respiratory tract
is determined by the concentration and duration of
Health Hazard Evaluation Report No. 99-0062-2804 Page 5
exposure. With high exposures, laryngeal edema
with signs of obstruction of the breathing
passages, acute tracheobronchitis, and chemical
pneumonitis have been described. Following
acute exposure to chlorine gas, both obstructive
and restrictive lung disease may occur.
11
Moderate
to severe exposure often results in residual
pulmonary dysfunction, most notably
hyperreactive airways and low residual volumes.
The pulmonary function usually returns toward
baseline within 7 to 14 days. Although complete
recovery generally occurs, symptoms and
prolonged pulmonary impairment may persist,
especially after massive chlorine exposures.
13,14
Reactive airways dysfunction syndrome (RADS)
may occur. Chronic exposure may cause moderate
reduction in pulmonary function and corrosion of
the teeth.
14
Chlorine may irritate the skin and can cause
burning pain, inflammation, and blisters. Direct
contact with liquid chlorine or concentrated vapor
causes severe chemical burns. Low concentrations
in air can cause burning discomfort, spasmodic
blinking or involuntary closing of the eyelids,
redness and tearing of the eyes. Corneal burns
may occur at high concentrations.
10, 15
Exposure to elevated levels of chlorine should be
terminated as soon as possible by removal to fresh
air. The skin, eyes, and mouth should be washed
with large amounts of water.
15
A 15- to 20-minute
wash may be necessary. If irritation, pain, swell-
ing, or tearing persists, medical care should be
sought as soon as possible. Contaminated clothing
should be removed and isolated. Contact lenses
should be removed to avoid prolonged chemical
contact with the eyes.
12
Phosgene
Phosgene is a colorless gas with an odor similar to
musty hay. It may be formed by the “cracking” of
chlorinated hydrocarbon molecules at high
temperature. Phosgene may be a decomposition
product of other chlorinated chemicals. Phosgene
reacts with moisture and slowly forms HCL and
carbon dioxide.
16
Inhalation is the major route of phosgene
exposure. The onset of severe respiratory distress
may be delayed for up to 72 hours depending on
the concentration and duration of exposure.
Olfactory fatigue may occur.
17
The low irritant
properties of phosgene are not sufficient to warn
individuals of toxic concentrations. This allows
deep inspiration of high concentrations, causing
HCl to form in the lower respiratory tract.
18
HCl
can damage surface cells and cause cell death in
the bronchi and bronchioles. This causes
congestion and pulmonary edema, which may be
quickly fatal. Direct toxicity to the cells leads to
an increase in capillary permeability, resulting in
large shifts of body fluid and decreasing plasma
volume. Early symptoms of overexposure include
chest constriction, painful breathing, and bloody
sputum. Respiratory and circulatory failure are the
common clinical findings in cases of phosgene
poisoning that result in death.
16, 17
If the patient survives the initial 48 hours after
exposure, recovery is likely. Sensitivity to irritants
may persist, resulting in bronchospasm and
chronic inflammation of the bronchi. Lung tissue
destruction and scarring may lead to chronic
dilation of the bronchi and increased susceptibility
to infection (bronchiectasis). Also, pulmonary
fibrosis and emphysema may develop after chronic
exposure.
18
Phosgene may also damage the skin and eyes.
When phosgene gas contacts moist or wet skin, it
may cause irritation and erythema. High air con-
centrations can also cause corneal inflammation
and cloudy vision. Eye damage beyond the initial
irritation is uncommon in vapor exposure.
16, 17
Treatment measures would include moving the
patient to fresh air and monitor for respiratory
distress. Monitoring for 12 to 24 hours after
exposure has been recommended. Exposed areas
Page 6 Health Hazard Evaluation Report No. 99-0062-2804
should be washed thoroughly with soap and water.
Exposed eyes should be irrigated with copious
amounts of tepid water for at least 15 minutes. If
irritation, pain, swelling, lacrimation, or photo-
phobia persists, the patient should be seen in a
health care facility.
16, 17
There is no evidence that
phosgene is either carcinogenic or teratogenic.
17
Nitrogen Trichloride
Nitrogen trichloride (NCl
3
) is a brownish-yellow
gas with a pungent, offensive chlorine-like odor.
It is the most irritating of the chloramines and can
impart an odor at concentrations above 0.02 ppm.
19
It is the by-product of several reactions, including
the reaction between chlorine and nitrogenated
substances. NCl
3
decomposes to ammonia and
hypochlorous acid. Hypochlorous acid reacts
rapidly with ammonia to form monochloramine.
20
NCl
3
is a strong irritant, but little else is known
about its toxicology. Exposure to its fumes pro-
duces excess tearing, irritation of the mucous
membranes of the respiratory tract, and nausea.
The acute inhalation toxicity of NCl
3
is similar to
that of chlorine.
20
Animal studies have found that the respiratory
tract is the primary site of damage in rats exposed
to NCl
3
. Rats exposed for prolonged periods to
concentrated NCl
3
died of pulmonary edema. No
chronic health effects have been demonstrated in
humans exposed to these fumes.
21
Incident Command System
(ICS)
Management of fire department day–to–day
activities is usually vested in a Fire Chief or other
titled person who serves as the commander of the
fire suppression forces and their activities,
including the safety of the fire fighters.
22
To assist
in the management (especially in the operation,
coordination, and effectiveness) of wide–scale fire
suppression activities, a system has been
developed for controlling personnel, facilities,
equipment, and communications. This system is
known as the ICS.
23
This is a system of unified
command and control designed to assure the
smooth implementation of operational procedures
by all agencies on scene in a coordinated manner.
24
A further refinement of the ICS by fire service
organizations addresses all types of emergency
incidents and includes performance criteria for the
components of a system that incorporates specific
safety and health objectives. This has been
developed into a nationally recognized standard
known as the Incident Management System
(IMS).
25
Some common components of an IMS
are: modular organization, integrated
communications, common terminology, unified
command structure, and consolidated action
plans.
26
The National Fire Protection Association
has documented the consequences of operating
without such an IMS which have resulted in
numerous deaths and injuries of fire fighters.
27
The National Fire Service has also published
model procedures for an IMS that is specific for
high–rise fire fighting.
28
In establishing and utilizing the IMS, the first
priority must be life safety.
29
The responsibility
for this priority issue is that of the officer in
command of the emergency incident.
27,29
The
incident commander is responsible for the overall
safety of all members and all activities occurring
at the scene. The Fire Chief, however, bears the
ultimate responsibility for the safety and health of
all members of the department.
FINDINGS AND
DISCUSSION
Preplanning and Information
First due companies (companies who respond first)
commented in their interviews with NIOSH that
they had previously been to American Ref-fuel for
preplanning exercises. Through this preplanning
Health Hazard Evaluation Report No. 99-0062-2804 Page 7
they were familiar with the facility. Some fire
fighters indicated that the plant’s management had
always been very accommodating during such
visits and forthcoming with information about the
process and facility. One fire fighter indicated that
a trust had been fostered through these visits. It
was also suggested that second and third due
companies did not have this preplanning at the
facility, and extending preplanning to include
second and third due companies in light of
companies rotating out of service would be
beneficial.
Under Title III of the Superfund Amendments
Reauthorization Act (SARA), the owner or
operator of a facility is required to disclose the
presence of hazardous chemicals if they are kept
on the property at greater than a threshold
quantity. This reporting is to be carried out
annually through Tier I or Tier II reporting as
indicated in 40 CFR part 370 of the Code of
Federal Regulations (CFR). SARA Title III, Tier
II reporting is retrospective; facility operators are
required to report quantities of hazardous materials
on site during the preceding year. The cleaner
present in American Ref-fuel’s refuse pit would
need to be reported under Tier II, but not until
March 1999. Although the reporting requirements
are a good means for emergency response
personnel to receive information about chemicals
at a facility, the reporting system would typically
not provide responders with such information
about chemicals that are on site for the first time.
This system, though beneficial, would not have
been effective for preplanning in this case.
Although the main ingredient of the cleaner,
sodium dichloroisocyanurate, would be classified
as a hazardous waste, the composite mixture does
not meet the definition. The material reportedly
meets the definition of a non-hazardous waste.
This may have been a source of mis-
communication between plant employees and fire
fighters as to the contents of the fire.
Based on fire fighters’ reports, there seemed to be
confusion throughout the incident as to the
location and contents of the fire. Much of the
confusion stemmed from misinformation provided
by employees of American Ref-fuel. When the
first engine arrived on the scene, fire fighters noted
that employees of the facility had begun to apply
water to the refuse pit with a 1-inch hose line.
They prepared to augment this effort with a 2 ½-
inch hose line. While they were preparing for this,
the BC arrived on the scene and reportedly was
informed by an American Ref-fuel employee that
there was a fire on the seventh floor rack. The BC
asked the employee what was burning and was told
that it was just garbage; however, several fire
fighters reported that they had smelled a chlorine-
like odor during the incident. One fire fighter
remained with the engine to man the hose line
while the other fire fighters and the BC proceeded
to the seventh floor in search of the fire that was
reported there. Fire fighters were unable to locate
a fire on the seventh floor.
Incident Command System
(ICS)
The NFD operates under the ICS. Department
programs reviewed by NIOSH are consistent with
the ICS. The department’s SOPs indicate that the
NFD has established a succession of command
based on rank. That is, command is initially
assumed by the first ranking person/officer on
scene. A command post is set up and its location
and the incident commander are identified to the
dispatcher. Command is passed along to the next
higher ranking officer that arrives, including the
deputy fire chief and fire chief. According to
reports, this system was followed during the
incident.
When the BC arrived at the scene he assumed a
mobile command. This allowed the BC to operate
in the command role while he moved around the
scene to size up the incident. Reportedly this
approach is commonly used in the NFD for full
alarm responses. When the DC arrived on the
scene, he established the command post in an
office area on the first floor. The DC indicated
Page 8 Health Hazard Evaluation Report No. 99-0062-2804
that he particularly liked this location because the
office had a telephone system which he could use
to communicate with fire fighters in various
locations in the facility. At some point into the
incident, the BC recommended that the DC
relocate the command post to the seventh floor.
The rationale for this recommendation is unclear.
The DC started to the seventh floor to determine if
a relocation of the command post would be
beneficial. As the DC ascended the stairs he
reportedly encountered a strong chlorine odor on
the third floor. At this time, the DC decided to
stop, and to keep the command post at the ground-
floor office location.
Interviewed fire fighters indicated that they were
always aware of who was in command during the
incident. One fire fighter further indicated that the
DC takes a strong command and that it is clear that
he is making the decisions.
Hazardous Materials
Response Unit
The HAZMAT response unit consists of a four- or
five-person company and two apparatus (a
response apparatus and spill/decontaminaton
apparatus). This unit is housed at the fire station
located at 188 Mulberry Street. Two persons bring
the spill/ decontamination apparatus, and two or
three persons bring the response apparatus to
HAZMAT scenes. The HAZMAT team is
augmented with a rescue unit (Rescue 1), which
responds to all full alarms, and a fire company
trained to conduct the decontamination. In
addition to being the designated HAZMAT
response, the HAZMAT company responds to fire
calls. The company will respond to a fire in a
ladder truck (truck 1), as they responded to this
incident. This approach leaves a two-fold gap in
HAZMAT response coverage. First, the
HAZMAT response team, while occupied fighting
the fire, is unavailable to efficiently respond to a
concurrent HAZMAT incident at a different
location within the city. Second, as was the case
at American Ref-fuel, if the incident commander
at the scene of the fire determines that the hazards
of the incident dictate a change in response
approach from fire mode to HAZMAT mode, the
HAZMAT team may already be
committed/contaminated. The former Captain of
the HAZMAT company indicated that there have
been situations where the company was enroute (in
fire mode) and has had to turn truck 1 back and get
the HAZMAT apparatus.
Gaps in HAZMAT coverages were compounded
during the American Ref-fuel incident due to the
NFD’s policy of rotating companies out of service.
In January of 1997, truck 8 went from being
rotated out of service on the second tour to being
retired from service. Having a truck company out
of service increases the area that the other truck
companies, including truck company 1, are
expected to cover. A full alarm will trigger two
truck companies to respond. Interviewed fire
fighters indicated that, given the location of
American Ref-fuel, truck company 8 would have
been the second due to the incident scene.
Because, however, truck company 8 is out of
service, truck company 1 became second due. The
result of this is the latter of the two gaps in
coverage discussed above; a HAZMAT response
was compromised when the company was
committed to the incident scene in fire mode.
Although the incident was declared HAZMAT
only at the very end, any attempts to make the
declaration sooner would have been complicated
by the fact that the HAZMAT company was
already committed to the scene and potentially
contaminated with the chemicals involved. This
deficiency was manifest in the make-shift
decontamination procedures used at the incident.
The Newark Hazardous Materials Annex indicates
that the NFD is the lead agency for hazardous
materials emergency responses, and that the NFD
will handle the initial response to HAZMAT
incidents. Meeting this responsibility requires the
NFD to be fully prepared to respond to a
HAZMAT incident at any time. Ideally, this
requirement would be met by providing fire
companies solely dedicated to hazardous materials
Health Hazard Evaluation Report No. 99-0062-2804 Page 9
response, rather than a company that responds in
either fire mode or HAZMAT mode, depending
upon early indications about the incident. Accord-
ingly, incident commanders would have the option
to change from a fire to HAZMAT mode without
the logistical concerns of having no HAZMAT
team readily available.
Safety Management
The IMS encourages the delegation of authority,
but not responsibility, for the safety function at an
incident to a fire fighter or other competent person,
who is specially trained and knowledgeable in safe
emergency operations.
30
The failure to delegate
may cause conflict between the positions of
command and safety. IMS guidelines generally
recommend that the command officer, who is
responsible for managing the incident on the
strategic level, establish and operate from a
stationary command post as soon as possible after
arriving on the scene.
29
In contrast, the delegated
SO must routinely observe operations at the scene
of an incident. This means he must have full
authority to move around the incident scene (fire
ground) to observe and control safety concerns.
29
This safety officer would also have the emergency
authority to stop and/or prevent unsafe acts. If the
department safety officer is also routinely
responsible for other tasks, an assistant SO may
need to be designated to address incident safety
functions.
The NFD has a policy for
dispatching an incident
safety officer to all full alarm fires. The policy
gives the SO the authority to correct safety and
health hazards, immediately if they are deemed to
be an imminent hazard to personnel, and through
the incident commander if they are not deemed to
be an imminent hazard. Consistent with National
Fire Protection Association (NFPA) 1500
standard, the NFD places general responsibility for
fire fighters’ safety and health with the Fire Chief
or incident commander.
An SO was dispatched to this incident. There is
not much documentation indicating what actions
the SO took during the incident. The SO’s
incident report indicates that he worked to assure
that companies remained intact. NIOSH
investigators interpret this to indicate that the SO
was working to keep companies accountable for
their members. It was indicated to NIOSH through
interviews that some fire fighters roamed free
during the incident and were isolated from their
company. The recent revision of the Occupational
Safety and Health Administration’s (OSHA)
respiratory protection regulation (29 CFR
1910.134), as adopted by the New Jersey Public
Employees Occupational Safety and Health
(PEOSH) program, includes measures designed to
protect fire fighters while working inside burning
buildings.
31
The rule, referred to as a “double
buddy system” or more commonly the 2 in/2-out
rule, states that whenever fire fighters enter a
burning structure, they must do so in teams of at
least two and remain in direct voice or visual
contact with each other at all times. Also, at least
two other fully equipped and trained fire fighters
must remain outside the structure to monitor those
inside and be prepared to rescue them. This
regulation was not in effect at the time of the
incident, but the practice is a good safety
precaution that has been followed by many fire
departments prior to the date on which the
regulation came into enforcement.
Training
The training requirements for persons who will
engage in hazardous materials response activities
are outlined in 29 CFR 1910.120 (q).
32
This
paragraph states that the training shall be based on
the duties and the functions to be performed by
each responder of an emergency response
organization. Five levels of training are outlined
in the paragraph: 1) first responder awareness
level, trained to initiate an emergency response
sequence by notifying the proper authorities of the
release; 2) first responder operations level, trained
to protect persons, property or the environment
Page 10 Health Hazard Evaluation Report No. 99-0062-2804
from the effects of a hazardous material release;
3) hazardous materials technician, trained to
assume an offensive role in stopping the release;
4) hazardous materials specialist, provide support
to hazardous materials technicians; 5) on scene
incident commander, assume control of the
incident beyond the first responder awareness
level. Trainers who teach any level of training
shall have satisfactorily completed a training
course for teaching the subjects they are expected
to teach, such as the course offered by the National
Fire Academy.
Communications
Fire department communications can be
ineffective or even completely unusable in a
high–rise building.
28
At some locations within a
high–rise building it is difficult to send or receive
messages using portable radios. Successful radio
transmission may become intermittent as the
sender or receiver of a radio message moves
within the building.
28
The NFD used portable radios during the incident.
They also had the use of an on-site telephone
system that was used to call to the seventh floor
from the command post. It was indicated to
NIOSH investigators that portable radio communi-
cations were poor at times during the incident.
This was evidenced in radio transcripts when the
BC attempted to communicate information about
the contents of the fire to the DC. Reportedly,
about 25 minutes into the incident, an employee of
the plant approached the BC on the seventh floor
and indicated to the BC that the plant had received
a shipment of Drano® that day and that this was
the material that was burning. At this time, the BC
attempted to notify the DC of this information via
portable radio. At 2030 hrs, 18 minutes after the
first company had arrived on site, the BC indicated
to the DC, “One of the workers reports they had a
load of Drano® come in today”......no response
from the DC. “One of the workers reports that the
substance was Drano®, a large amount came into
the plant today.”....no response from the DC. The
radio transcripts show no further mention of the
Drano®. Transcripts documenting telephone
communications were not available.
Respiratory and Other
Personal Protective
Equipment (PPE)
Because the smoke was not very dense at times
during the incident, and the crane operation rooms
seemed to be isolated from the smoke, a few fire
fighters at the scene reported that they felt
comfortable removing their self–contained breath-
ing apparatus (SCBA) in certain areas of the
facility. While a properly operating SCBA worn
by a well-trained individual offers adequate
protection against smoke and chemical inhalation,
even brief exposure without respiratory protection
may present a health hazard. Fire fighting requires
strenuous physical exertion, which increases
oxygen demand and respiratory rate and thus
increases the risk of exposure to inhalational
toxins and hypoxia.
33
Although fire fighters are
equipped with respiratory protective equipment, it
is not always used, especially during the final
extinguishment or overhaul phases, when smoke
intensity and assumed exposures are thought to be
low. Inadequate respiratory protection at the fire
scene is an important risk factor in the
development of toxicity from smoke inhalation.
34
One study reported that 70% of fire fighters
remove their mask at some time during knockdown
and that as many as 30% wear their masks less
than half the time.
35
A fire fighter’s complete turnout gear typically
worn during a fire incident consists of a helmet,
hood, turnout coat, turnout pants, boots, gloves,
and a SCBA with a personnel alert safety system
(PASS) device. SCBA’s provide the highest level
of protection against inhalation exposures, even in
atmospheres considered immediately dangerous to
life and health. Turnout gear is made of fire-
resistant material that will provide protection
against flashover temperatures up to 1500 degrees
Fahrenheit (°F) for brief periods. Although
turnout gear has the ability to withstand some
Health Hazard Evaluation Report No. 99-0062-2804 Page 11
types of chemical contact, during a chemical fire
it may not provide protection against chemical
exposure. Skin exposure is very likely because
turnout gear material is not impermeable to many
chemicals. Currently, PPE made of a material that
is both fire- and chemical-resistant does not exist.
Following the incident, turnout gear was tested for
surface contamination by wetting the surface and
using litmus paper. This would indicate if there
was surface contamination present on the gear that
was either an acid or a base. The tests indicated
that the surfaces were neither acidic nor basic.
According to interviewed fire fighters, the gear
was placed in truck one after the incident and
returned to the fire stations the following morning.
Reportedly, the gear was replaced with clean
turnout gear a few days later. Some fire fighters
indicated they had worn the turnout gear in the
interim. The use of chemically-contaminated gear
may result in skin irritation when worn by fire
fighters at other fire scenes.
36
The NFD uses a
Quartermaster system to supply fire fighters with
their gear. Elements of a Quartermaster system
should include the replacement, repair, laundering,
and decontamination of turnout gear. If feasible,
an adequate supply of replacement turnout gear
should be made available to fire fighters while
necessary replacement, repairs, or laundering is
rendered.
Medical
Confidential interviews were obtained from 20 fire
fighters, and self-administered questionnaires were
completed by an additional 8 fire fighters (37 fire
fighters were at the scene). The average amount of
time spent at the scene was 3.7 hours (range: 2 - 6
hours). The average amount of time spent at the
scene without respiratory protection was 2 hours
(range: 0.25 to 5.50). Twenty-one fire fighters
(75%) reported that they smelled a chlorine-like
odor while they were at the scene. All reported
that they wore SCBA for some amount of time at
the scene. The most common symptom reported
was burning or irritation of the eyes (18
participants, 64%). The next most common
symptoms were throat irritation or hoarseness (15,
54%) followed by cough (12, 43%). Eight fire
fighters (29%) reported a burning sensation in
their chest. Three fire fighters (11%) reported that
they began wheezing at the scene. Five fire
fighters (18%) reported that they developed no
symptoms at the scene or afterward.
Decontamination of the fire fighters occurred after
it was determined that the scene was a hazardous
materials incident. Decontamination took place in
the shower facilities of American Ref-fuel. All
fire fighters reported that they decontaminated
themselves by showering with water from 2 to 10
minutes. In addition to showering, 7 (25%)
reported that they flushed their eyes with water
while in the shower. There were complaints that
the water was too cold and this decreased the
decontamination time. They also reported that
there was an inadequate number of towels to dry
themselves and inadequate clothing to protect
against the cold weather. Many fire fighters
continued to wear their under garments while in
the shower.
The 37 fire fighters were transported to five local
hospitals. Most were transported by emergency
medical services (EMS), but others drove
themselves to the hospital. Twenty-two hospital
medical records from the five hospitals were
reviewed. The number of medical records
received from each hospital ranged from three to
five. These records revealed that the treating
physicians were aware that the fire fighters were
exposed to chemicals at a fire, and the physicians
were concerned about the inhalation of toxic
fumes and smoke. However, it was unclear to the
treating physicians in most circumstances what
specific toxins were present at American Ref-fuel.
Several medical records specifically mentioned
“possible phosgene” and “possible chlorine gas
exposure.”
Fire fighters’ symptoms were consistent in the
different hospitals; however, the extent of
diagnostic testing differed. The university-based
hospital performed the most diagnostic tests on the
Page 12 Health Hazard Evaluation Report No. 99-0062-2804
fire fighters. The tests included chest x-rays
(CXR), electrocardiograms (EKG), arterial blood
gases (ABG), pulse oximetry, carboxyhemoglobin
levels, methemoglobin levels, serum electrolyte
levels, and complete blood counts (CBC).
Pulmonologists were also consulted for further
evaluation of the fire fighters’ pulmonary status.
The fire fighters were monitored for a median of
24 hours to assess late pulmonary effects of the
inhaled exposures.
The other hospitals performed consistently fewer
tests. One hospital performed only pulse
oximetry, while others performed pulse oximetry
plus carboxyhemoglobin level or chest x-ray.
Some hospitals contacted the New Jersey Poison
Control Center, while others did not. These
hospitals did not perform prolonged monitoring to
assess the late pulmonary effects of the inhalation
exposures. In the non-university hospitals, the fire
fighters were monitored a median of 3.75 hours.
Two of the 37 fire fighters were admitted to
separate hospitals from the emergency
departments. The hospitalizations were reported
to be the result of the inhalation exposure at the
scene. One of the fire fighters was hospitalized for
five days and the other for six days. A third fire
fighter had persistent respiratory symptoms, and
he was placed on limited duty for 3 weeks and
continued to take medications for his respiratory
condition at the time of the NIOSH interview (4
months later).
Several fire fighters had persistent symptoms for
several days to weeks. The most common persis-
tent symptom was burning eyes. Several reported
that they saw an ophthalmologist for their eyes and
were given antibiotic drops. One fire fighter
reported that he did not remove his contact lenses
at the scene and his eye symptoms persisted up to
the time of the NIOSH interview. Others
complained of persistent burning in their chests
and coughing, which lasted a few days to a week
after the incident.
Seven fire fighters made an appointment to be seen
at the occupational medicine provider for the NFD.
Five medical records were reviewed from this
clinic. Chest x-ray and pulmonary function tests
(PFT) were ordered on all five fire fighters. Two
of the PFT’s showed evidence of mild obstructive
disease, and the others were normal. There were
no comparison PFT’s that were available.
Surveillance examinations, including PFT’s, are
performed at another clinic and not at this clinic.
Three fire fighters had more severe lower
respiratory tract injury. One of these fire fighters
had a severe viral infection on the day of the
incident, and perhaps this illness could have made
his respiratory tract more vulnerable to the irritants
that were present. The reason the other two
developed more severe symptoms is unclear. They
may have received a higher dose of the irritant
gases, but their description of their job activities,
PPE, and location does not differ significantly
from those with less severe pulmonary injury.
The medical evaluation of fire fighters differed by
hospital. The university-based hospital performed
consistently more tests than the other hospitals.
The evaluations at the university-based hospital
were consistent with recommendations and
guidelines on medical evaluation of fire fighters
after exposure to toxic substances and smoke.
5,
6,7,8,9,10, 15,34
However, from our interviews and
review of the medical records, it appears that the
differences in the medical evaluations did not
result in worse clinical outcomes among the fire
fighters receiving fewer tests. Thus, it is likely
that most fire fighters did not receive sufficient
doses of the toxins to cause significant pulmonary
or systemic health effects; however, this
information was not known at the time of the
hospital evaluations.
Appropriate diagnostic studies for symptomatic
patients with smoke inhalation and asymptomatic
patients with significant risk factors (from history
of exposure and past medical history) include
pulse oximetry, arterial blood gas (ABG) analysis,
chest x-ray, electrocardiogram and cardiac
Health Hazard Evaluation Report No. 99-0062-2804 Page 13
monitoring, and carboxyhemoglobin (COHb)
level.
6
Carboxy-hemoglobin level is important
because it is the most direct biological measure of
exposure to carbon monoxide (CO). COHb levels
should be measured in all patients with smoke
inhalation and cannot be inferred reliably from
clinical signs and symptoms. Elevated COHb
level should raise the concern for CO poisoning as
well as potential exposure to other smoke
inhalation toxins, such as coexisting asphyxiants
and irritants.
4
Chest radiographs are a low-yield procedure and
are commonly normal in the early course of smoke
inhalation.
5, 6
Most often, abnormal findings such
as local, patchy, or diffuse infiltrates are not
evident until 24 to 36 hours after exposure.
37
Subtle findings such as perivascular haziness, peri-
bronchial cuffing, bronchial wall thickening, and
subglottic edema may be apparent within 24 hours
of exposure. Serial chest x-rays may be useful in
monitoring severe smoke inhalation.
38
Pulmonary function testing can aid in the medical
evaluation of patients with toxic pulmonary
insults. Pulmonary function testing is an
informative but underutilized source of diagnostic
information in the acute setting. Obstructive
ventilatory defects, characterized by reduced
expiratory flow volumes and flow rates are early
findings that are related to primary airway injury.
Also, these abnormalities generally precede chest
x-ray findings or arterial blood gas alterations and
permit early identification of patients at increased
risk for more severe subsequent pulmonary
disease.
5, 6
In 1992, University of Medicine and Dentistry of
New Jersey (UMDNJ) Robert Wood Johnson
Medical School, in conjunction with U.S. Public
Health Service, Division of Employee
Occupational Health, and the New Jersey
Department of Health, produced “Guidelines for
the Emergency Management of Firefighters.”
39
These guidelines were produced to assist
emergency departments and other health care
providers to recognize and treat various conditions
for which a fire fighter is occupationally at risk.
These guidelines were written because toxic
exposures in fire fighters are not often recognized,
and morbidity and mortality may be lessened
through early recognition and treatment of medical
problems.
Subsequent to the testing performed in the acute
care setting, few fire fighters had additional
medical tests performed to assess the long term
health effects of their exposures at American Ref-
fuel. Seven fire fighters reported that they were
evaluated by the department’s occupational health
provider. The most persistent health concern was
burning eyes which lasted several weeks after the
incident. Also, a few fire fighters had persistent
pulmonary symptoms. However, the surveillance
medical evaluations were performed by another
health care provider. This information was not
available to the occupational medicine provider
when they were evaluated after the American Ref-
fuel incident because the two providers do not
routinely share medical records unless requested.
The surveillance information would be helpful to
determine if there were differences between
current and previous evaluations, such as
pulmonary function tests.
The decontamination procedures at American Ref-
fuel were not consistent with guidelines. It was
fortunate that the shower facilities were available
at the facility. Skin decontamination was
acceptable in most cases, but there was inadequate
flushing of the eyes in most cases. Most fire
fighters reported that they were not aware that they
should flush their eyes with water. Guidelines
recommend flushing the eyes for at least 15
minutes after such exposure, and this may take
place during showering or at other early phases of
the delivery of health care.
10, 15
CONCLUSIONS
The elements leading to fire fighter exposures at
American Ref-fuel on December 17, 1998, are
complex and multi-factorial in nature. Clearly,
Page 14 Health Hazard Evaluation Report No. 99-0062-2804
fire fighters did encounter exposures to irritant
gasses at the scene. The NFD approached the
incident in fire mode, when in fact, a hazardous
materials response approach would have been
more appropriate. The reasons for using a fire
mode at the scene stem largely from
misinformation provided to the arriving fire
fighters about the true nature of the materials
involved. Early into the incident, the BC was
provided information about the chemical nature of
the fire. This information would have provided
justification for revising the strategy employed.
Efforts by the BC to communicate this information
to the DC via portable radio were unsuccessful. It
is not known if this information was
communicated in person or via the American Ref-
fuel telephone system. Controls, which should
have limited exposures, either failed or were
circumvented. Exhaust ventilation at the plant was
reported to have operated only intermittently,
occasionally allowing the smoke and gas to
concentrate in the areas where fire fighters were
working. This intermittent smoke condition,
coupled with several reports of fire fighters
removing their respiratory protection during the
incident, ultimately led to the inhalation of
harmful concentrations of smoke and gas.
Most fire fighters suffered irritant symptoms that
were the result of their exposures to irritant gases
at American Ref-fuel. Those fire fighters who did
not develop symptoms or who had recovered are
unlikely to develop health problems in the future
because of this exposure. These irritant gases may
produce chronic respiratory diseases, but only in
those with high exposures and severe acute
symptoms. The fire fighters who suffered more
severe injuries continued to receive medical care
at the time of the NIOSH investigation.
Health care providers were uncertain of the
specific exposures of the fire fighters, even when
they were discharged from the emergency
departments. Obtaining fewer medical tests did
not appear to adversely affect the health outcome
of the fire fighters who received care at those
hospitals. However, following the guidelines
developed by the New Jersey Department of
Health for evaluating fire fighters after acute
respiratory exposures would be preferable in the
future. Decontamination procedures were less
than optimal at the scene. Inadequate flushing
may have resulted in persistent irritation of the
eyes in some fire fighters. Also, the persistent
irritation may be due to the initial chemical injury
to the mucous membranes of the eye.
RECOMMENDATIONS
The following recommendations are based on the
findings of this survey, previous HHEs, and the
current scientific literature. These recommen-
dations are intended to reduce the potential for
work-related injuries and illnesses to fire fighters
of the NFD.
1. The NFD should ensure personnel are trained
to handle the duties and functions they may be
called upon to perform in a hazardous materials
response. These training requirements are outlined
in 29 CFR 1910.120 (q). At a minimum, all mem-
bers of the fire department should be trained to the
first responder awareness and operations level.
Members of the HAZMAT team should be trained
to the hazardous materials technician level.
Anyone who may be called upon to assume
incident command over a hazardous materials
response should be trained to the on scene incident
commander level. This should include all captains
of the HAZMAT unit and chiefs. This training
should be followed up with annual refresher
training as indicated in 29 CFR 1910.120 (q).
2. Department records indicated that the
responsibility for HAZMAT operations did not
consistently fall with one person. Rather, respon-
sibility for HAZMAT operations and/or training
appears to have shifted among a few different
persons. There should be a clear line of command
for the administrative aspects of the HAZMAT
operation. This person should have ultimate
responsibility for assuring that the HAZMAT unit
is stocked with appropriate and operational
Health Hazard Evaluation Report No. 99-0062-2804 Page 15
equipment, which is maintained in good working
order. Clear command over all HAZMAT tours
should be established to assure consistent and
adequate training beyond the training provided by
the individual HAZMAT captains.
3. Fire fighters may often face chemical
exposures when responding to incidents such as
the American Ref-fuel chemical fire because they
lack appropriate protective equipment. No PPE
currently exists that will protect against both fire
and the chemical exposures associated with such
an incident. To reduce the likelihood of fire
fighters sustaining undue chemical exposures
during these types of incidents, all fire fighters
should properly wear all PPE while in established
hazard zones (i.e., hot, warm, and cold).
4. The Newark Hazardous Materials Annex
indicates that the NFD is the lead agency for
hazardous materials emergency responses. Ideally
this requirement would be met by providing fire
companies who are solely dedicated to hazardous
materials response, rather than a company that
responds in either fire mode or HAZMAT mode,
depending upon early indications about the
incident. An increase in resources would need to
be directed to HAZMAT in order to meet the
increased staffing a dedicated unit would require.
Short of providing a fully dedicated HAZMAT
unit, the NFD should consider modifying response
protocol so that HAZMAT companies are less
likely to be occupied by fire calls. For example,
not having truck company 1 respond as first or
second due to a fire would offer the IC the option
to change from a fire mode without having
compromised the HAZMAT company.
5. Reports indicate that some fire fighters were
alone at times during the incident. The SO’s
report suggests that he was trying to follow a
double buddy system or some other form of
accountability. The NFD should implement and
enforce a fire fighter accountability consistent with
PEOSH’s two-in-two-out rule.
6. Immediately following fire suppression and
overhaul activities involving chemical fires, all
potentially contaminated PPE should be
thoroughly inspected, tested, and laundered in a
timely fashion. Fire fighters should also be
instructed to promptly discontinue the use of any
potentially contaminated PPE and equipment.
Whether a Quartermaster system or an Allowance
system is used, an adequate supply of backup
equipment should be available to fire fighters.
36
7. Since fire fighting is a highly hazardous
occupation, safe work habits and use of PPE is
strongly emphasized. During a fire incident, the
assigned Safety Officer must have full authority to
move around the scene to observe and address
safety and health hazards, including such unsafe
practices of not wearing respiratory protection in
hot and warm zones. At future fire incidents, the
Safety Officer should enforce the use of all
necessary PPE in hot and warm zones and also
identify other unsafe practices on the fireground.
8. The NFD should consider issuing a written
“Alert” to small businesses to inform them about
fire protection issues, including emergency
response preplanning and the importance of
reporting any chemical storage and use at their
facility to the fire department. Businesses should
be encouraged to report the initial or intermittent
use of chemicals, which the NFD would be
unaware of until the subsequent SARA III
reporting period.
9.9. Communication between the NFD and local
emergency departments and hospitals should be
improved. At this point there is no standard
procedure to relate fire fighter exposure
information from the NFD to local hospitals. This
could be accomplished by assigning a liaison
between the fire department and the hospital(s).
10. Fire fighter medical surveillance information
should be better integrated with acute care
occupational medicine services. The medical sur-
veillance examinations will have baseline health
results. Acute changes in health conditions may
Page 16 Health Hazard Evaluation Report No. 99-0062-2804
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3. Nelson GL [1987]. Regulatory aspects of fire
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4. Lui D, Olson KR [1991]. Smoke inhalation.
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5. Orzel RA [1993]. Toxicological aspects of
firesmoke: polymer pyrolysis and combustion.
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6. Haponik EF [1993]. Clinical smoke inhala-
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7. Teixidor HS, Rubin E, Novick GS, Alonzo
DR [1983]. Smoke inhalation: radiographic
manifestations. Radiol 149:383-7.
8. Gochfeld M, Szenics J, Boesch R, Fontus H
[1992]. Guidelines for the emergency
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be noticed more readily if this information is
available to the acute care provider. This could be
accomplished by making surveillance information
readily available to the occupational medicine
provider who provides acute medical care.
11. Decontamination procedures stress the impor-
tance of flushing the eyes and other exposed
mucous membranes when exposed to contaminants
capable of causing damage in those parts of the
body.
12. In the aftermath of acute chemical exposure,
fire fighters should undergo exams to determine if
they have any acute health effects related to that
exposure. The components of the exams should be
determined by the nature of the chemical exposure.
13. Although the NFD conducted an internal audit
of their communications systems in 1997, which
determined that the portable radios used by the fire
department were “state of the art” and that there
was “little that could or should be done to improve
their performance,” the NFD should periodically
review the radio technology available that may
serve to improve communications in high-rise
structures and update the departments communi-
cations equipment as more effective radios become
available.
REFERENCES
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15. Poisindex® [1999]. Toxicological Manage-
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hazardous materials incidents. Vol. III, Medical
management guidelines for acute chemical
exposures. Agency for Toxic Substances and
Disease Registry. Washington DC: U.S. Govern-
ment Printing Office.
17. Proctor NH, Hughs JP, Fishman ML [1996].
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4
th
ed. New York, NY: Van Nostrand Reinhold.
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CO.
19. Kroschswitz MH, ed. [1993]. Chloramines
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20. Barbee SJ, Thackara JW, Rinehart WE
[1983]. Acute inhalation toxicology of nitrogen
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21. Massin N, Bohadana AB, Wild P, Hery M,
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developing fire protection services for the public.
Boston, MA: National Fire Protection
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Emmitsburg, MD: U.S. Federal Emergency Man-
agement Administration, U.S. Fire Administration,
National Fire Academy, NFA–ICS–SM.
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handbook. Quincy, MA: National Fire Protection
Association, p. 711.
25. NFPA [1990]. Standard on fire department
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National Fire Protection Association, NFPA 1561–
1990.
26. IFSTA [1998]. Essentials of fire fighting. 4th
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occupational safety and health. Quincy, MA:
National Fire Protection Association, NFPA 1500–
1987.
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high–rise fire fighting. 1
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Fire Protection Publications, Oklahoma State Uni-
versity, National Fire Service Incident
Management Consortium.
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National Fire Protection Association.
30. Oklahoma State University [1983]. Incident
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State University.
31. CFR [1998]. OSHA 29 CFR 1910.134.
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Printing Office, Office of the Federal Register.
32. CFR [1999]. OSHA 29 CFR 1910.120.
Hazardous Waste Operations and Emergency
Response. Code of Federal Regulations.
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33. Terrill JB, Montgomery RR, Reinhardt CF
[1978]. Toxic gases from fires. Science 200:
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35. Jankovic J, Jones W, Burkhart, Noonan
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(IAFF), Indianapolis, IN. HETA 97-0034-2683.
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37. Teixidor HS, Rubin E, Novick GS, Alonzo
DR [1983]. Smoke inhalation: radiographic
manifestations. Radiol 149:383-7.
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chest radiograph after acute smoke inhalation.
Clin Radiol 39(1):33-7.
39. Gochfeld M, Szenics J, Boesch R, Fontus H
[1992]. Guidelines for the emergency
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Occupational Health, UMDNJ- Robert Wood
Johnson Medical School, Piscataway, NJ.
Glossary of Medical Terminology
Airways. Any part of the respiratory tract (e.g., lungs and windpipe) through which air passes during
breathing.
Alveoli. Microscopic air sacs in the lungs in which gas travels between the blood and the lung.
Arterial blood gas. A procedure that measures the oxygen content, carbon dioxide content, and the pH in
arterial blood.
Asphyxiant. An agent, especially a gas, that will cause the insufficient intake or utilization of oxygen.
Asthma. A chronic health condition in which constriction of the bronchial tubes occurs in response to
irritation, allergy, or other stimuli.
Atelectasis. Partial collapse of the lung.
Bronchiectasis. Chronic dilation of a bronchus or bronchi, with a secondary infection that usually involves
the lower portion of the lung.
Health Hazard Evaluation Report No. 99-0062-2804 Page 19
Bronchus ( bronchi). Large division of the windpipe that carries air to and from the lungs.
Bronchiole. A small diameter airway branching from a bronchus.
Bronchitis. Inflammation of the mucous membrane of the bronchial tubes, usually associated with persistent
cough and sputum production.
Bronchospasm. Contraction of the smooth muscle of the bronchi, causing narrowing of the bronchi. This
narrowing increases the resistance of air flow into the lungs and may cause a shortness of breath and
wheezing.
Bronchotracheitis. Inflammation of the membrane lining of the bronchi and trachea.
Carboxyhemoglobin. Compound formed in the blood from hemoglobin upon exposure to carbon monoxide.
Complete blood count. Enumeration of the components of the whole blood, such are red blood cells and
white blood cells.
Conjunctiva. The delicate mucous membrane that covers the exposed surface of the eyeball and lines the
eyes.
Conjunctivitis. Inflamation of the conjunctiva; can result in redness, irritation, and tearing of the eye.
Co-oximeter. A device that is used to measure oxygen saturation in samples of arterial blood. It uses at least
four wavelengths of light and is capable of distinguishing oxyhemoglobin, deoxygenated hemoglobin,
carboxyhemoglobin, and methemoglobin.
Cornea. Transparent membrane that covers the anterior part of the eye.
Corrosive. A substance with the ability to destroy the texture or substance of a tissue.
Decontamination. The process of removing hazardous material from exposed persons and equipment.
Dermal. Relating to the skin.
Dermatitis. Inflammation of the skin.
Dyspnea. Shortness of breath; difficult or labored breathing.
Edema. Accumulation of fluid in the body cells or tissues; usually identified as swelling.
Electrocardiogram (EKG). A record of the electrical activity of the heart.
Electrolytes. Ionized salts in the blood. Commonly measured electrolytes include sodium, potassium,
chloride, and bicarbonate.
Page 20 Health Hazard Evaluation Report No. 99-0062-2804
Emphysema. A chronic lung disease characterized by increase in size of air spaces beyond the terminal
bronchiole with destructive changes in their walls.
Hemoglobin. The iron-containing pigment of red blood cells. Its function is to carry oxygen from the lungs
to the tissues.
Hypoxia. Condition in which below normal levels of oxygen are present in the air, blood, or body tissues.
Inadequate warning property. Characteristic (e.g., odor, irritation) of a substance that is not sufficient to
cause a person to notice exposure.
Irritant. An agent which produces an inflammatory reaction upon contact.
Lacrimation. Secretion of tears, especially in excess.
Larynx. The enlarged upper end of the trachea below the root of the tongue.
Methemoglobin. A transformation product of hemoglobin in which normal iron is oxidized. Methemoglobin
contains oxygen that if firmly bound to the oxidized iron, which prevents release of oxygen to the tissues.
Necrosis. Death of one or more cells or a portion of a tissue or organ.
Obstructive lung disease. Increased resistance to the passage of air in and out of the lung due to narrowing
of the bronchial tree.
Ocular. Pertaining to the eye.
Olfactory fatigue. Temporary loss of the sense of smell due to repeated or continued stimulation.
Oxidation. To increase the positive valence (usually by adding oxygen), or to decrease the negative valence
(usually by the loss of electrons).
Photophobia. Unusual intolerance of light, usually painful.
Pneumonitis. Inflammation of the lungs.
Pulmonary. Concerning or involving the lung.
Pulmonary edema. Accumulation of excess fluid in the lungs that impairs gas exchange; usually due to
either increased pulmonary artery pressure or leaky pulmonary capillaries.
Pulmonary function test. A procedure that measures the flow of air through the lungs.
Pulse oximeter. Photoelectric device for determining the amount of oxygen in the blood. Usually done by
measuring the amount of light transmitted through a translucent part of the skin.
Health Hazard Evaluation Report No. 99-0062-2804 Page 21
Reactive airways dysfunction syndrome. Increased or excessive constriction of the bronchial tubes in
response to chemical exposure.
Respiratory. Pertaining to breathing.
Rhinitis. Inflammation of the mucous membranes of the nose.
Routes of exposure. The manner in which a chemical contaminant enters the body (e.g., through the lungs
or gastrointestinal tract).
Secondary contamination. Transfer of a harmful substance from one body (primary body) to another
(secondary body), potentially permitting adverse effects to the secondary body.
Stridor. A harsh, high-pitched respiratory sound often heard in acute respiratory obstruction.
Toxic. Having the ability to harm the body especially by chemical means.
Trachea. The tube that runs from the larynx to the bronchial tubes. Also called the windpipe.
Wheezing. A whistling or sighing sound resulting from narrowing of the respiratory passages.
For Information on Other
Occupational Safety and Health Concerns
Call NIOSH at:
1–800–35–NIOSH (356–4674)
or visit the NIOSH Web site at:
www.cdc.gov/niosh
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