Hyperbaric Chamber Fires: Lessons Lost

Hyperbaric chamber fires continue to occur with troubling frequency and have been uniformly fatal since all six occupants survived the Geisinger Medical Center, Pennsylvania, fire in April 1989. As devastating as these events are, there have been disturbing consequences on more than one occasion. One example is a failure of those who would be expected to ensure independent expert investigation to actually do so. Alternatively, if one was undertaken, for some reason its relevant findings did not enter the public domain. I don’t know about you, but I can’t think of a single reason compelling enough.

Institutions and governments have a moral and an ethical responsibility to formally investigate these tragic circumstances and not censure findings, no matter how embarrassing they may be to some. Failing in this responsibility leaves the health care delivery system, particularly its hyperbaric community, to worry and wonder, and potentially important lessons are lost.

When transparency prevails, events (plural here as invariably there are several) that contributed to the outbreak of fire, attempts made to extinguish it, and efforts directed at rescuing chamber occupants, can be systematically analyzed. It is this process that’s likely to serve, among other things, as a vital “lessons learned” opportunity. Examples may include a given facility’s fire safety plan being subsequently considered validated when measured against the report’s findings. Alternatively, it may identify some room for enhancement within that plan. Perhaps it could determine one or more shortcomings in what was otherwise considered to be an adequate plan, and gaps promptly reconciled. It might prompt a decision to run a fire safety drill to test aspects of an existing fire safety plan related to factors implicated in a fire’s investigative findings. Finally, it could identify chamber as built/as installed/as interconnected issues, not previously recognized, thereby leading to a degree of system “re-engineering”.

Clearly, much is to be gained when leaders act responsibly. When they don‘t, critical risk-mitigation measures are likely to go unaddressed or unenforced and the well-being of tomorrow’s hyperbaric patients and staff poorly served in the process. The most recent example of “when they don’t” relates to the March 2016 Jakarta Naval Hospital multiplace chamber fire in which four occupants succumbed. I worked my sources in Jakarta over the ensuing months and years to no avail. There has been an information black out from responsible authorities and only unvalidated tidbits of information to be found within the lay press. Apparently, the fire occurred immediately prior to commencing ascent. The chamber was equipped with a water deluge system yet various reports stated that “the operator tried using it, but it was too late’, “the operator failed to activate the deluge system”, “the deluge system was inoperable”, and “deluge system activated but inadequate to extinguish flames”. The implications associated with each of these possibilities in the context of lessons to be learned are enormous. Without public dissemination of expert analysis, we are left to worry and wonder. The precise cause of the fire is likewise unreported. The hospital declared that “it had complied with strict operating procedures”, but I think this unlikely. A highly regarded Australian hyperbaric chamber operator colleague was inspecting another chamber elsewhere in Indonesia at a later date. He came across a technician employed by a Jakarta-based chamber manufacturer. When asked if he had any insights into the cause, the technician said nothing but knowingly pointed to his cell phone. Apparently, when the personal lockers used by the chamber’s occupants were inspected one did not contain a cell phone. This was considered highly unusual given their prevalent use. One newspaper quoted a police official as saying, “attendants might have had no courage to check whether any of them (patients) were bringing matches or cell phones in to the chamber”. This was apparently in reference to a very senior military/government official among the dead and the prevailing culture of deference. This fire had occurred at a time when one cell phone make/model’s battery had more than once generated an exothermic reaction leading to spontaneous ignition.

A similar event occurred at Istanbul University Medical Center, Turkey, in July 1998. Fire broke out in their multiplace chamber and its three occupants, two decompression-injured divers and a physician attendant, perished. The chamber in question was circa 1947 vintage and not equipped with water deluge. Surprisingly, I received an email from the brother of the deceased physician in the days that followed, imploring me to help him determine how this tragedy could have happened. Again, the involved institution was tight lipped, and remains so more than three decades later. There is no indication that an expert investigation took place and if it did it has never seen the light of day. I have visited this institution on several occasions since and the subject of this fire is very much taboo. The best I could get was “Every professor blamed the other”.

So, what caused these fires? What aspect(s) of each institution’s fire safety plan had been violated? Or was there even an adequate fire safely plan? What, if any, attempts were made to extinguish the fire? What efforts were attempted to rapidly extricate the occupants? What critical details came to light in the immediate aftermath dealt? Sadly, we don’t know any of this, and are indeed left to worry and wonder.