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Fatal chamber fires are utterly devastating events. If anything good can come of them, however, it is a comprehensive root cause analysis. In this way, factors that led to the fire allow the hyperbaric discipline to fine tune existing, or develop new, policies and procedures to mitigate against similar operational failures. It is factors, not factor. Almost without exception, a sequence of events will have led to a fire. It is doubly tragic, therefore, when the results of such an analysis remain unpublished.
This is precisely what has occurred with the 2016 Jakarta, Indonesia fire. All four occupants of one of the naval hospital chambers succumbed. This fire raised several questions, none answered, at least in the public forum. I have a physician friend and colleague who works in Jakarta. As much as he tried, he was unable to obtain a copy of any form of formal documentation relating to the circumstances surrounding the fire. Again, this is very unfortunate and very irresponsible. As difficult as it to acknowledge failings that may prove embarrassing, all future hyperbaric chamber occupants deserve access to this information. Interestingly, I did receive some unofficial insight in recent weeks. The source was an engineer associated with the chamber’s manufacturer. While not authorized to discuss the events surrounding this fire, he did confide that one of the patients, a very senior military officer, had apparently taken a cell phone into the chamber. This appeared to be the ignition source. Why the installed deluge system was not activated is also publicaly unknown. One local newspaper had reported, “It was too late to use it”. We can take that statement for what it’s worth.
Dick Clarke, President
National Board of Diving & Hyperbaric Medical Technology