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No official cause has been given as multiple agencies continue to investigate last week’s blaze outside Adventist Health Castle hospital.

After a Honolulu ambulance fire injured a paramedic and left a 91-year-old patient dead last week, fire experts are theorizing that an electrical issue may have created a spark, ignited something flammable and spread quickly because of the oxygen tanks on board. 

It’s one possibility that would explain how the three essential ingredients for a fire – oxygen, heat and fuel – came together, said Walter Nugent, a former fire investigator who chairs the fire science department at New Jersey City University.

“ There had to be a few things that lined up, unfortunately, to allow this fire to start and have it spread as quick as it did,” he said. 

Waimanalo resident Fred Kaneshiro, who was being transported inside the ambulance, died at the scene of the Aug. 24 fire outside Adventist Health Castle hospital. Paramedic Jeff Wilkinson was critically injured and was being treated at the Straub Medical Center’s burn unit.

Multiple agencies are investigating, and no cause has been identified yet. But officials appear to be exploring the possibility of an electrical issue. The Bureau of Alcohol, Tobacco, Firearms and Explosives sent an electrical engineer from its fire research lab to assist in the investigation, KHON reported.  

It’s unclear whether equipment on board the ambulance or the vehicle itself was faulty. The county’s Emergency Medical Services department shared ambulance maintenance records with investigators. However, the division declined to share them with the public. Doing so could interfere with the investigation and lead to “speculative, incomplete, and unsubstantiated opinions and conclusions as to the cause of this event,” the division said in a statement.

“All federal, state and county stakeholders believe that the public and the families of the victims involved in this event deserve a complete and thorough investigation into the cause of the ambulance fire,” it added. “Upon the conclusion of the investigation, disclosable records will be released.”

Local emergency professionals reacting to the ambulance fire said they’d never seen anything like it . Indeed, ambulance fires are relatively rare — but not unprecedented. 

News reports from across the country in recent years show ambulance fires have occurred in many places, including North Carolina , Massachusetts , Maryland , Mississippi , New York , New Jersey , Texas , Virginia , and more than once in California . Officials have cited engine trouble, electrical issues and other mishaps in those cases. 

Photos and video of the Kailua blaze show flames coming from inside the ambulance cabin where the patient was located and not around the ambulance’s engine. That would suggest the fire began in the patient compartment, according to Nugent. 

The use of compressed oxygen tanks could’ve increased the percentage of oxygen in the air of the confined space, Nugent said. The oxygen enrichment alone can’t ignite a fire, Nugent said, but it does allow it to spread faster. 

“What’s going to matter is how high the oxygen content was in the area of whatever the heat source was,” he said. 

Jack Minassian , an associate professor of fire science at the University of Hawaii, offered the example of NASA’s Apollo 1 disaster in 1967 when a bundle of wires sparked in a pure oxygen atmosphere. Three astronauts who were aboard the spacecraft for a launch rehearsal were killed. 

A similar scenario may have occurred in Kailua, according to Minassian, who is not involved in the investigation. 

“ I would speculate that because the paramedic did not have enough time to save himself, he got burned, and he wasn’t able to save the patient, I believe there was probably a leak of oxygen inside and some kind of electrical sparks,” Minassian said. 

Honolulu ambulances carry all sorts of equipment that could potentially cause a spark, including laptops, radios and other battery-operated devices, according to Patty Dukes, the former chief for Honolulu Emergency Medical Services. 

There are also electrical fixtures you’d find anywhere, like lightbulbs and electric sockets, Nugent said. 

“Anything that has power running to it could fail,” Nugent said. “Any of those could, in theory, become a heat source.” 

Ambulances also carry defibrillators, which are meant to revive ailing patients with an electric shock but can ignite fires in an oxygen-enriched atmosphere when the paddles are not appropriately attached to the patient, according to the American Heart Association . 

For instance, the clothes of an ambulance patient in Connecticut caught fire when a paramedic attempted to restart her heart with a defibrillator in 2004, the Hartford Courant reported at the time . And last year, a woman in Texas was badly burned and died after hospital staff used a defibrillator on her, ABC News reported . The fire reportedly ignited as personnel tried to resuscitate her in the presence of an oxygen tank.

A similar case occurred at a different Texas hospital in 2019 when a defibrillator sparked while oxygen was left on, causing a fire that filled the hospital floor with smoke, according to the local news station.  

Whether the defibrillator was in use at the time of the incident in Kailua is unclear and EMS wouldn’t say. 

Still, the odds of ambulance equipment sparking a flame are generally low, according to Dukes. In her 40-year career, Duke said she’s never seen ambulance equipment generate smoke or ignite. Plus, EMS personnel are supposed to check the equipment in the ambulance every shift, she said. 

“I never saw a spontaneous combustion,” she said. 

Overall, fires happen in just a fraction of the millions of ambulance rides completed every year, most of which occur safely. Nugent said they’re not a reason to avoid calling 911 in an emergency. 

“I just wouldn’t want people to think the chance of a fire is so great in an ambulance that they’re less likely to call and go to the hospital,” he said.

“It’s not likely, and to possibly change your medical care or treatment would be more hazardous,” he added. “ This was a tragedy that although serious, is rare.”

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