A “Routine” Reminder: Incident proves there’s no such thing as a routine call

By D. Brady Rogers

Fire Chief Robert Rielage of the Wyoming (Ohio) Fire-EMS Department once wrote that “smells and bells” incidents can result in complacency and a failure to follow procedures, such as wearing proper personal protective equipment (PPE). Although safety should never be compromised, firefighters can be lulled into a false sense of security when “smells” have been the result of crayons melting on electric baseboard heat, or even bad food left in the refrigerator. “Bells” often involve low-battery alerts in CO and smoke detectors, but they’re also caused by computer games that have been left on too long or sounding alarm clocks.

How many times have police, fire and EMS heard that “no call is routine?” Risks to firefighters increase when the combined concepts from the sheer volume of “smells and bells” calls are seen as routine.

At 1006 HRS on Feb. 9, 2011, the Centerville-Osterville-Marstons Mills (Mass.) Department of Fire-Rescue & Emergency Services (C-O-MM Fire) received a call for an odor and people becoming ill at Centerville Elementary School. The incident would prompt the evacuation of more than 300 students and staff, the treatment and transportation of patients, and would involve agencies at the local, county and state levels.

 

During the incident at Centerville Elementary, responders at first couldn’t locate the source of the odor that was making people ill until they focused on an office photocopier. It was later found that the copier was leaking ozone into the building. Ozone concentrations as high as 0.56.ppm were detected at the laser printer exhaust. Photo iStock.

Dispatch & Arrival
C-O-MM Fire is one of five fire districts within the town of Barnstable on Cape Cod. A uniformed complement of 53 provides both fire and EMS (at the ALS level) from three stations that respond to an average of 3,800 calls annually. Minimal staffing includes a shift commander in a car and an officer and two firefighters in each station. The department is dependent on recall of off-duty personnel for multiple calls and major incidents.

Dispatch for this incident included the shift commander (Car 321), an engine (Engine 306), a quint (Ladder 307) and an ambulance (Ambulance 325). En route, Car 321 was advised that a fire alarm was also being received. With other calls in progress, an outside alarm for additional resources was requested.

On arrival at 1011 hours, Ladder 307, reported a two-story masonry commercial with “nothing showing” at Side A and the school evacuated; the fire alarm had been pulled to start the evacuation. The lieutenant from Ladder 307 was told of a strong “sweet, perfume-like odor.” Although it had dissipated, the principal said that upon entering the lobby, the smell was so strong he could “taste it,” and he immediately felt as if he was going to vomit. The school secretary, sitting in the lobby area, was complaining of difficulty breathing and chest discomfort.

The shift commander/Car 321 arrived at 1014 hours and assumed command. L-307 and Engine 306 began a primary search using multi-gas meters and thermal imaging cameras. During a previous incident at the school, firefighters found a leaking propane tank on Side C with the HVAC system circulating the odor; however, no leak was found during this incident. With temperatures in the 20s and concerns of exposure, the cafeteria was checked next so the children could be relocated there.

During the primary, a teacher and a few children began to feel sick. Two additional ambulances were requested. With two of C-O-MM Fire’s three ambulances committed to other calls, mutual aid ambulances were requested from neighboring Hyannis and Cotuit fire departments. The department’s EMS supervisor, a lieutenant/paramedic (EMS 323), arrived on location and was assigned both EMS and the accountability of the children. A Barnstable police lieutenant also arrived and was advised of the situation.

The Next Level: Hazmat
After more than an hour and no problems found, the incident commander (IC) and school officials discussed the possibility of an early dismissal, which would give time to determine the cause and resolution of the problem. Command felt that the psychological effect of the incident could result in staff or students feeling sick throughout the rest of the school day. School officials concurred and put its emergency evacuation plan into effect. The plan called for school buses to relocate students and staff to the nearby South Congregational Church. Dismissal would be done from there. The Barnstable Police would keep an officer with the school principal, another with the children, and others for traffic control or as needed. EMS 323 reported that two adults were transported to Cape Cod Hospital, but no children required treatment or transport.

As the media arrived, a press briefing was held reporting preliminary and precautionary actions. The media assisted in directing parents, telling them to go to the church rather than calling or reporting to the school, which also used its reverse 9-1-1 system to contact and advise parents.

The lieutenant from Ladder 307 recommended activation of the regional Massachusetts Department of Fire Services Hazardous Materials Response Team. Command concurred and a “Tier 1” hazard and risk assessment response was requested along with the Town of Barnstable’s Board of Health and Barnstable County’s Department of Health and Environment. An emergency response unit was dispatched from the Department of Environmental Protection. The Superintendent of the Barnstable public school system also arrived on scene.

Upon their arrival, the hazmat team further limited access to the interior of the school, requesting that all windows and doors be secured. The facilities manager shut down the HVAC to isolate the problem area. Command then performed a secondary search of the building, securing windows and doors, with interior crews confirming that all children had been evacuated.

Identifying the Source
The Barnstable County Health’s senior environmental specialist relayed that she had seen a similar problem during a previous incident at a different location and immediately suspected an ozone leak from the photocopier in the school’s lobby. Effective in cleaning and disinfecting, OSHA describes ozone as a nonflammable gas, while the EPA describes it as a toxic. As testing and analysis instruments were set up, an online search for ozone found that a sweet smell was normally detected at concentrations of 0.01 to 0.02 parts per million (ppm). Upon inhalation, it can cause dryness of the mouth, coughing and irritation of the eyes, nose, throat and chest. It may cause difficulty in breathing, headache and fatigue.

A Vermont Department of Health report on air quality listed possible sources of ozone as some types of laser printers, photocopiers, some types of “air cleaners,” such as electric or ion generators, and certain industrial processes, such as ozone treatment of bottled water.

According to the Aerias AQS IAQ Resource Center website, photocopiers create ozone through their “corona wires” applying a charge to the paper so the ink will cling to it. The average ozone emitted is 40 µg/copy. At peak production, it can be as high as 131 µg/copy. Ozone levels can reach dangerous levels in small, poorly ventilated areas. Newer models of copiers may reduce the amount of ozone produced.

Once instruments were in place, though not specific for ozone, baseline readings were taken. The photocopier was turned on and after making some 50 copies, a noticeable odor permeated the lobby. Particulates in the air rose substantially.

Ozone Incident Comparison
On March 21, 1991, the National Institute for Occupational Safety and Health (NIOSH) received a request from employees of the Immaculate Heart of Mary Church in Cincinnati to conduct a health hazard evaluation (HHE). The requestors were concerned about the indoor air quality in the church office, because four out of five office workers reported a variety of symptoms, including headaches, dizziness, confusion, nausea, eye irritation, and dry nose and throat, which they felt may have been related to the use of a photocopier and laser printer. Real-time ozone concentrations ranged from below the limit of detection (LOD) to 0.05 ppm in the breathing zone; all were below the NIOSH short-term exposure limit of 0.10 ppm. But ozone concentrations as high as 0.56.ppm were detected at the laser printer exhaust.

At the Centerville Elementary School, the odor description, location, the presence of the copier, symptoms of the victims and results from on-scene tests and analysis satisfied all agencies that the cause of the odor was an ozone leak from the photocopier.

Important: A strong smell of ozone could indicate that the ozone filter is clogged. Photocopiers should be vented to the outside and serviced regularly. The school’s photocopier had not been serviced since 2009. That said, even well maintained units, could emit detectable ozone concentrations if used in poorly vented areas. Although located in the lobby, which was considered an open area, testing found that actual air movement was relatively low. The superintendent ordered that the machine be removed from the school.

Not So Routine
Was this a major hazmat incident? No. But the lack of knowledge about ozone, or potential sources, created a delay in determining the cause of the incident. First-due units and the IC considered and looked at other sources, including CO and other gasses, such as propane. If only one person had complained of feeling ill, there’s a good possibility that the incident wouldn’t have been classified as a hazardous materials incident and that additional resources wouldn’t have been called and the problem wouldn’t have been identified. C-O-MM firefighters, school officials and even the members of the state hazmat team were surprised to learn the hazards associated with ozone and that photocopiers and printers are potential sources of ozone. After all; ozone is “that stuff in the atmosphere.”

This incident raises a couple questions: 1) Although there are no known statistics, how many fire or EMS responses may have been a result of exposure to ozone? And 2) was the patient who was treated for chest pain and difficulty breathing really a victim of ozone exposure? With equipment becoming more affordable and photocopiers and printers available most everywhere, the likelihood of ozone leaks and exposures will increase.

Lessons Learned
The use of the Incident Command System (ICS) helped keep this incident to a manageable level. As the event grew, so did the command system. Ultimately, with the involvement of other local, county and state agencies, the incident became a classic example of the National Incident Management System (NIMS), with all agencies working together. Over time, the problem was defined, tested and solved as a team.

This incident was the first emergency evacuation done within the Barnstable public school system. A debriefing conducted by the School Department found some minor changes that needed to be made in both internal incident and evacuation procedures, but school officials, along with police, fire and EMS, were pleased with the overall response.

Although the odor had dissipated upon arrival, first-due units and the IC should have been more aggressive in evacuating people from the school, and first responders should have been more diligent in their use of proper PPE, especially SCBA. Although the EMS supervisor was in communication with Barnstable C-MED, an early declaration of a mass-casualty incident may have prepared receiving hospitals if the incident suddenly escalated. Outside agencies also should have been called sooner. With very few people affected, it was easy to dismiss any serious concerns.

The result of this incident serves as a near-miss reminder. As stated earlier, the “smells and bells” incidents sometimes result in complacency and a failure to follow procedures, such as wearing proper PPE. This event, like so many others before it, serves as a reminder that no incident is routine.

D. Brady Rogers, a 34-year fire service veteran, serves as a captain with the Centerville-Osterville-Marstons Mills (Mass.) Department of Fire-Rescue & Emergency Services and served as the incident commander of the Centerville Elementary School incident. He has developed pre-incident and disaster response plans, run responses and standard operating guidelines for the department. Rogers holds a masters degree in Public Fire Administration and is an EFO graduate.



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