United States Nuclear Regulatory Commission - Protecting People and the Environment

Information Notice No. 84-34: Respirator User Warning: Defective Self-Contained Breathing Apparatus Air Cylinders

                                                 SSINS No.: 6835           
                                                 IN 84-34

                                 UNITED STATES
                         NUCLEAR REGULATORY COMMISSION
                     OFFICE OF INSPECTION AND ENFORCEMENT
                            WASHINGTON, D.C. 20555

                                April 23, 1984

Information Notice No. 84-34: RESPIRATOR USER WARNING: DEFECTIVE SELF-  
                                 CONTAINED BREATHING APPARATUS AIR CYLINDERS

Addressees:

All nuclear power reactor facilities holding  an  operating  license  (OL) 
or construction permit (CP), research and test  reactor  facilities,  fuel 
cycle licensees, and Priority 1 material licensees.

Purpose:

This information notice is intended to alert licensees of a serious defect 
in self-contained breathing apparatus (SCBA) hoop-wrapped aluminum air 
cylinders rated at 4,500 psi, manufactured under the Department of
Transportation  (DOT) Exemption DOT-E 7235. During refilling operations at
a  fire  department,  one cylinder  ruptured  and  injured  one  person.  The 
National   Institute   of Occupational Safety and Health (NIOSH) has issued
a Respiratory Users  Notice, in concert with a  DOT  Federal  Register 
Notice  limiting  filling/operating pressure of the affected cylinders to
4,000 psi until further notice.

NRC regulations require that only NIOSH-certified respiratory equipment 
shall be used as emergency devices. Licensees are expected to review the
information  for applicability to their facilities respiratory protection
program and  take actions, as required, to maintain NIOSH and DOT 
certifications  for  affected equipment and to minimize the probability of 
catastrophic  cylinder  failure. Further NRC action may occur after the
DOT/NIOSH evaluations are completed and  reviewed by the staff. No written
response to this notice is required.

Description of Circumstances

The NRC recently has learned of a serious defect in certain SCBA air
cylinders  that caused a rupture of a high-pressure (4,500 psi) air cylinder 
(rated  for 30-minute service) manufactured by Luxfer Limited in 1978 for
Scott  Aviation. On February 4, 1984, a Scott 4.5 cylinder ruptured at the
neck area  during  a routine refilling at a New York City fire station. The
air charging hose  that was still attached to the ejected  cylinder 
material,  struck  the  attending fireman. Although not seriously injured,
the fireman was severely  bruised  in the shoulder area, transported to a
nearby hospital, and treated and  released the same day. The fireman was
fortunate that a flying metal fragment  did  not hit him. This cylinder was
not subject to an earlier product recall  discussed below.


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                                                 IN 84-34
                                                 April 23, 1984            
                                                 Page 2 of 3

On October 11,  1983,  the  NRC  reported  in  IE  Information  Notice 
83-68, "Respirator User Warning: Defective  Self-Contained  Breathing 
Apparatus  Air Cylinders," that several identical Luxfer  cylinders 
manufactured  since  mid 1982 for Scott and other vendors, had developed
cracks around the  neck  area. Two of these cylinders had ruptured. A product
recall directed at  a  specific manufacturing batch of these hoop-wrapped
cylinders had been initiated at that  time.

Discussion:

In response to the recent New York City event and other evidence  of 
cylinder cracking, the DOT Office of Hazardous  Material  Regulation  has 
amended  the exemption to limit the filling pressure for  all  high  pressure 
(4,500  psi) composite hoop-wrapped cylinders manufactured under Exemption
DOT-E 7235.  The Federal Register Notice (49 FR 39, p. 7182--see Attachment
1), issued  by  DOT February 27, 1984, states that

  Persons owning, using, or otherwise having control over  cylinders  marked 
  DOT-E 7235-4500, must limit the filling pressure to 4,000 psi, and  reduce
  to 4,000 psi the pressure in cylinders already charged. (emphasis added)

NIOSH issued a Respirator User Notice on February 29, 1984 (see Attachment
2),  which establishes interim actions to  be  taken  by  all  users  in 
order  to maintain a revised NIOSH certification for the units effective 
until  further DOT action, at which time the certification may  be 
reaffirmed,  revised,  or revoked. Under this temporarily revised
certification (unit rated  as  a  "not less than 25-minute" device), each
user should

1.   Refill and operate all Luxfer 4,500 psi, 30-minute, hoop-wrapped
aluminum  cylinders at the reduced pressure of 4,000 psi.

2. Follow the instructions provided  by  Luxfer  for  immediate  removal 
from service and physical examination of affected cylinders manufactured
before May  1981.

General recommendations (p. 3 of Attachment 2), issued by NIOSH,  offer 
users sound advice for further reducing the  probability  of  cylinder 
catastrophic failure and, thereby, increasing worker safety.

The interim actions, established by DOT and NIOSH, must be carefully 
observed to continue the NIOSH certification of the unit as a "not less than
25-minute"  device. However, licensees also are reminded that Section III.H
of 10 CFR  50, Appendix R (Fire Protection Program for  Nuclear  Power 
Facilities  Operating Prior to January 1, 1979), requires a rated operating
air supply of  at  least 30-minutes for all SCBA provided for  use  by  fire 
brigade,  damage  control parties, and control room personnel. If any
affected cylinders are  fulfilling 10 CFR  50,  Appendix  R,  requirements, 
then  appropriate  compensatory  air supplies must be provided. Licensees may
choose to request temporary exemption  from the 30-minute-rated supply
requirement in 10 CFR 50 by  contacting  their appropriate NRC licensing
office.


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                                                 IN 84-34
                                                 April 23, 1984            
                                                 Page 3 of 3

To provide further information, copies of Scott Aviation and Survivair
warning  letters to their customers are attached (Attachments 3 and 4). If
you have any  questions concerning this problem, please call the number
listed on the appropriate customer warning letter or contact the Regional 
Administrator  of  the appropriate NRC Regional Office or this office.



Edward L. Jordan, Director
Division of Emergency Preparedness 
and Engineering Response
Office of Inspection and Enforcement

Technical Contacts: J. E. Wigginton, IE
                    (301) 492-4967

                    L. Hendricks, RES
                    (301) 443-7675

Attachments:
1. DOT Federal Register Notice
2. NIOSH Respirator Users Notice
3. Scott Aviation Letter
4. Survivair Letter
5. List of Recently Issued IE Information Notices


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                                                 Attachment 2
                                                 IN 84-34
                                                 April 23, 1984

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Disease Control
National Institute for Occupational
Safety and Health--ALOSH
944 Chestnut Ridge Road
Morgantown, WV 26505

February 29, 1984

                            RESPIRATOR USERS NOTICE

             Reduced Service Pressure and Physical Examination of
            4500 psi Hoop-wrapped Aluminum Cylinders Manufactured by
             Luxfer USA Ltd., 1995 3rd Street, Riverside, CA 92507.

The National Institute for Occupational Safety and  Health  (NIOSH)  has 
been informed of two recent actions which affect the continued safe use  of 
Luxfer 4500 psi hoop-wrapped aluminum cylinders and  the  certified  status 
of  self contained breathing apparatus incorporating them in their
assemblies.

(1) The Department of  Transportation  (DOT)  has  announced  in  the 
Federal Register that in order to accomplish a reduction in the  sustained 
stress  in 4500  psi  hoop-wrapped  aluminum  cylinders  manufactured  by 
Luxfer   under Exemption DOT-E 7235, the maximum cylinder charging pressure
must  be  reduced from 4500 to 4000 psi, effective February 28, 1984. This
restriction does  not apply to 4500 psi fully-wrapped aluminum cylinders.

(2) Luxfer USA Ltd. has determined that some 4500 psi/DOT-E 7235  hoop-
wrapped aluminum cylinders manufactured prior to May, 1981,  may  rupture 
or  develop longitudinal cracks in the threaded section of the  cylinder 
neck.  All  such cylinders with manufacturing dates before May,  1981, 
should  be  immediately examined in accordance with Luxfer's instructions
which may be  obtained  from the self-contained breathing apparatus 
manufacturer.  Cylinders  manufactured after May, 1981, should be examined
during the normal hydrostatic test.

The following self-contained breathing apparatus certified by the Mine 
Safety and Health Administration (MSHA) and NIOSH, incorporate 4500 psi/DOT-
E 7235 hoop-wrapped aluminum cylinders manufactured by Luxfer:            

Manufacturer       Approval No.   Model No.

AGA                TC-13F-133     4530
Clifton Precision  TC-13F-136     7010421-1, -2, -3, -4
  (Bendix)
MSA                TC-13F-142     473640, 473645
National Draeger   TC-13F-119     4059-200, -201, -202, -203, -204, -205,
-206 Siebe Gorman       TC-13F-99      014422.16
Scott              TC-13F-73      900450-00, -01, -30,-31
                   TC-13F-76      900455-00, -01, -10, -11 -20,-21,-30,    
                                  -31, -40, -41, -50, -51 
USD                TC-13F-82      9045-20, -22; 9845-20, -22               
                   TC-13F-108     9840-00, -01, -02, -03,--20,-21, -22, -23 
                                  9841-21, -23

.

                                                 Attachment 2
                                                 IN 84-34
                                                 April 23, 1984
                                                 Page 2 of 3
                         Reduction of Service Pressure

Users of self-contained breathing  apparatus  incorporating  any  Luxfer 
4500 psi/DOT-E 7235 hoop-wrapped aluminum cylinders (including  those 
manufactured before and after May, 1981) should immediately reduce  the 
pressure  in  such cylinders from 4500 to 4000 psi. Pressure reduction may
be safely accomplished  by  attaching  the  cylinder  to  a  self-contained 
breathing  apparatus  and following   the   breathing   apparatus  
manufacturer's   instructions    for depressurization until the cylinder
pressure has reached 4000 psi. DO NOT OPEN  THE VALVE OF ANY PRESSURIZED
CYLINDER THAT IS NOT ATTACHED TO A SELF-CONTAINED  BREATHING APPARATUS OR
OTHER DEVICE THAT  WILL  SAFELY  CONTAIN  THE  RELEASED PRESSURE. When
depleted  Luxfer  4500  psi/DOT-E  7235  hoop-wrapped  aluminum cylinders are
recharged after use, the maximum pressure of 4000 psi  must  not be exceeded.

                      Status of MSHA/NIOSH Certifications
The reduction in maximum service pressure from 4500 to 4000  psi  affects 
the MSHA/NIOSH certification of the  self-contained  breathing  apparatus 
to  the extent that they will no longer meet the service time requirements
of Title 30  Code of Federal Regulations  Part  11  for  a  30-minute 
duration  apparatus. Therefore it is necessary for NIOSH to temporarily
revise  the  certifications for these apparatus to continue their certified
status. After consideration of  the several factors involved in the maximum 
pressure  reductions,  NIOSH  has decided to temporarily reduce the
certification rated service time for each of  the apparatus listed above,
from 30 minutes to not less than 25  minutes.  The revised certifications
will be effective until further action is taken by DOT,  at which time they
will be further revised,  canceled,  or  made  official  by publication in
the Federal Register. This temporary change does not  otherwise affect the
certifications of these apparatus.

Respirator users  should  immediately  take  the  reduced  service  time 
into consideration in their  continued  use  of  the  apparatus.  NIOSH  will 
also temporarily modify the certification to the extent of  continuing  to 
require the remaining service time indicator to continue to function within
the  range of 20 to 25 percent of the original 30-minute service time rating. 
Therefore, users will observe no change in the amount of  service  time 
remaining  after initial activation of the remaining service time indicator,
and will have  the usual service  time  available  for  escape  from  an 
atmosphere  immediately dangerous to life or health.

                       Physical Examination of Cylinders
Users of self-contained breathing  apparatus  incorporating  any  Luxfer 
4500 psi/DOT-E 7235 hoop-wrapped aluminum cylinders should immediately
observe  the manufacturing date of each such cylinder. This date is either
stamped  on  the cylinder neck or is printed on a label  which  appears  on 
the  side  of  the cylinder under the outer filament  wrapping.  Hoop-
wrapped  cylinders  may  be identified by lack of filament winding on the
bottom and  neck  areas.  Luxfer recommends that each  of  their  4500 
psi/DOT-E  7235  hoop-wrapped  aluminum cylinders  manufactured  before  May, 
1981,  be  removed  from  service,   be completely  depressurized,  devalved, 
and  examined  according  to   Luxfer's instructions which may be obtained
from the self-contained breathing apparatus  manufacturer. Contact the
respirator manufacturer or distributor if  you  have not received the
necessary instructions. Cylinders manufactured after May,  1981, should be
examined during the normal hydrostatic test.
.

                                                 Attachment 3              
                                                 IN 84-34
                                                 April 23, 1984            
                                                 Page 1 of 1

February 24, 1984                   

Dear Customer,

Luxfer USA Limited is the manufacturer of the 30-minute duration  hoop-
wrapped high pressure cylinder, Scott P/N 802239-01, which  is  used  in 
Air-Pak  4.5 self-contained breathing apparatus.  A  copy  of  their  letter 
to  us  dated February 23, 1984 regarding this cylinder is attached.

In view of the situation outlined in the Luxfer letter, it is imperative 
that you immediately follow the instructions contained in that letter
including:

- To reduce the service  pressure  on  all  30-minute  4500  psi  hoop-
wrapped cylinders to 4000 psi immediately and to take whatever steps are
necessary  to assure future fillings will not exceed 4000 psi.

- To visually inspect all 30-minute 4500 psi hoop-wrapped cylinders as soon
as  possible after receipt of Luxfer's recommended inspection procedure.

NOTE: These recommended actions are limited to the one cylinder, the 30-
minute  hoop-wrapped 4500 psi cylinder, Scott P/N 802239-01, used in Scott's 
4.5  Air Paks. If you have any questions, please contact Mr. Dennis  Browner 
at  (716) 683-5100 - Ext. 314.

Be assured of our continuing interest in safety and in your full 
satisfaction with Scott Aviation and our products.  We  will  keep  you 
informed  on  this matter.

Cordially,


Lincoln C. Bailey
Vice President
Sales & Marketing
Health/Safety Products


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                                                 Attachment 4              
                                                 IN 84- 34
                                                 April 23, 1984            
                                                 Page 1 of 2

                               February 29, 1984

                             URGENT SAFETY NOTICE

Dear Survivair Distributor:

We have been notified  by  Luxfer  and  NIOSH  of  two  (2)  recent 
accidents involving Scott 4500 psi  hoop  wrapped  aluminum  cylinders 
manufactured  by Luxfer. Whereas no Survivair cylinders have been  involved 
in  any  accident, Luxfer has determined that some 4500  psi  DOT  E7235 
hoop  wrapped  aluminum cylinders may rupture or develop longitudinal cracks
in the  threaded  section of the cylinder neck. And even though the threaded
section  of  the  Survivair cylinders are significantly different from the
Scott cylinders that have  been involved in these accidents, you are urged
at the direction of the  Department of Transportation, NIOSH, Luxfer  and 
Survivair  to  immediately  reduce  the service pressure of all Survivair
hoop wrapped cylinders  in  your  possession bearing DOT E7235 on the
cylinder neck from 4500 psi to 4000 psi. You are also  urged to contact all
your customers of these  cylinders  and  likewise  advise them to immediately
reduce the service pressure to 4000 psi.

We have been informed by NIOSH that this reduction in  service  pressure 
will not void NIOSH certification. However, users should take the  reduced 
service time into consideration in their continued use of the apparatus. OSHA
has also  informed NIOSH that it will permit use of apparatus with a not 
less  than  25 minute service time rating until further resolution of the
problem.

Please advise your customers that this reduction in service pressure to 4000
psi will reduce the service time of the Mark I and Mark 2  high  pressure
units from 30 minutes to approximately 26 minutes.

This notice does not affect or request  any  action  on  any  other 
Survivair cylinders other than those bearing DOT E7235. These cylinders are
only used in  Survivair's Mark I (since 1978) and Mark 2 High  Pressure,  30 
minute  units. (since 1983).


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                                                 Attachment 4              
                                                 IN 84-34
                                                 April 23, 1984            
                                                 Page 2 of 2

A more detailed letter of explanation to follow.  Your  immediate  action 
and follow up in bringing this matter to the attention of your customers or 
known users of these  cylinders  is  greatly  appreciated.  Failure  to  do 
so  may potentially result in serious bodily injury, death, and/or property
damage.

Should you need any  further  information  on  this  matter  please  call 
the Survivair Marketing Department at 714/540-8010.

Sincerely,

Michael M. Chapman
Vice President, Marketing



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