Monthly Briefing March 2026

It seems unlikely that the authoritative investigative report into the apparent cause and contributing factors pertaining to the Troy, Michigan, fatal hyperbaric chamber fire will be published anytime soon. This delay appears related to ongoing legal proceedings and efforts to preserve their integrity. The downside to this delay, of course, is that information gained, and potential lessons learned, is yet to enter the public domain. 

There are, however, several insightful factors that can be gleaned from fire department personnel who attended the scene, comments made by the state Attorney General, and expert testimony during pre-trial court hearings. I will not dwell on the now widely appreciated fact that facility personnel egregiously failed to physically ground the young victim as an apparent and inexcusable operational policy at the offending facility. This critical safety failure has been front and center during many discussions in the fire’s aftermath. What I will comment on are a couple of less obvious factors that also represent teaching moments.

The first is that the child’s mother, in her desperate attempt to open the chamber door, suffered several thermal burn injuries. This was due to the enormous amount of heat generated by the fire and conductive properties of the chamber’s metal components, including the door handle assembly. In fact, the heat was so intense that it melted/vaporized some of the stainless-steel mesh screen through which oxygen flow exits the chamber. Depending on the type of stainless steel involved, the temperature required to achieve this effect would be in the order of 1,400C/2,500F.

So, lesson learned number 1. A pair of heat-resistant gloves should be available within every hyperbaric facility that incorporates a monoplace chamber(s). In fact, this recommendation has already been incorporated into the National Board’s hyperbaric facility accreditation program. Be sure to keep these gloves on while extracting the tray/gurney assembly.

In terms of glove selection, the only guidance we are aware of is that of the American National Standards Institute/American Society of Testing and Materials. They have a rating system based upon how long a gloved hand can be in contact with a heated surface for 15 seconds without causing second degree burns. Level 5 represents their highest rating at 320C/608F. Two example heat-resistant glove types are attached. Many others are available, and it is not the intent of the National Board to promote any one product over another. The first is the Uline HeatGuard, which sells for US$22.00, and is rated at 500C/932F. The second is a Qualatherm QRP heat and cold resistant model. It is rated at 760C/1,400F and sells for US$187.00 and up. Both products clearly exceed the Level 5 standard. Think about size options when ordering, as some models tend to come in only large/extra-large.

A second and unique observation related to what occurred after the fire self-extinguished (once oxygen was fully consumed), which happened fairy quickly after it first erupted. When the door was finally opened, the flammable material within the chamber, still in a superheated state, immediately re-ignited as the room’s surrounding oxygen-bearing air atmosphere was drawn inwards. This served to further delay occupant extraction, threaten nearby personnel and, in the most tragic of circumstances, demonstrate a perfect practical example of the Fire Triangle, namely its oxygen requirement. Flammable material that had ceased to burn once oxygen was no longer present re-ignited when air entered the chamber and reestablished the fire triangle.

Lesson learned, number 2. Don’t be misled that extinguishing efforts are no longer necessary prior to accessing the occupant. Anticipate chamber internal contents re-ignition. An ABC-Class fire extinguisher, required by code in hyperbaric facilities, should be immediately available prior to opening the door and personnel must be properly trained in how to activate it and how to use it. During the Troy fire, the chamber operator apparently did not.

A couple of monoplace chamber fire caveats to end this Month’s Briefing. Immediately shut off the oxygen on the chamber rather than running over to the zone valve or the chamber’s wall oxygen supply valve. Stand clear of the chamber door. In the Troy case, superheated gases ruptured the seal and escaped into the room, dislodging ceiling panels in the process. When opening the door anticipate escaping superheated gas and smoke, so wear a smoke hood while doing so.

Should additional information become available, the National Board will be sure to get it out to you.

Dick Clarke, President

National Board of Diving & Hyperbaric Medical Technology

Uline HeatGuard                Qualatherm QRP