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| Investigation on October 15, 1999, at the start of the 0700 hours shift, a fire fighter was conducting a check of the equipment on Engine 4. The fire fighter pulled the LIFEPAK® 500 automated external defibrillator (AED) from the engine, took it inside, and placed it on a table to perform a routine check. The fire fighter turned on the unit, and the Light Emitting Diode (LED) readout flashed on then shut off. He took the unit back to the engine and attempted to turn it on, however, nothing happened. The fire fighter informed the Assistant Chief of the problem and demonstrated what had occurred. He turned the unit on, and the LED readout indicated the battery should be replaced. The Assistant Chief and a Captain took the AED into a small office to attempt to determine the problem. The AED was placed on a desk, and the Assistant Chief pulled the lithium battery pack to check the expiration date, which was 2004. The battery pack was replaced in the AED, and when the unit was turned on, an explosion or battery rupture occurred. |
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| The explosion or battery rupture blew out the back of the AED, and it was reported by the Assistant Chief and Captain that the concussion blew the Assistant Chief out the office door onto the floor and blew the Captain against the office wall. The office was filled with white acrid smoke which made breathing difficult. The Assistant Chief reported that he received flash burns to the left arm, a sprained left wrist, and an injured back, and the Captain reported that he suffered upper respiratory inflammation from the acrid smoke. Both fire fighters were transported to a local hospital, treated, and released. According to the State Fire Marshal’s report and interviews that were conducted, the lithium battery pack, which is located in the rear of the unit, either exploded or ruptured. The explosion or rupture blew the rear of the unit apart and sent pieces flying throughout the room. |
| The explosion or rupture projected the AED in an upward trajectory. Three other documented incidents involving this company’s AED units have occurred. According to the manufacturer, all three incidents were unwitnessed, and the explosion or rupture was contained by the soft carrying case. No injuries were reported in any of these incidents. The manufacturer of this unit, Medtronic Physio-Control, has reported there have been 4 battery pack failures in 30,000 battery packs that are in use over the last 3 years. (reference 79) |
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