On June 12, 1998, one male fire fighter (the victim) was severely burned when an oxygen regulator flashed while he was performing a routine check of the equipment. The victim had just started his morning shift, and was performing the daily routine equipment check on the Engine to which he was assigned. Checking through the equipment, he pulled the airway supply bags from the Engine airway equipment compartment. Department procedures required him to open the oxygen cylinder post valve, check the cylinder's pressure to verify it was sufficiently full for service, close the cylinder's post valve, and then release the oxygen remaining in the regulator. As the victim lifted the oxygen cylinder from the airway supply bag, he opened the oxygen post valve and the system immediately flashed, releasing two 4-foot flames from the regulator. His clothes ignited from the waist up as he turned and fell to the ground. Fire fighters who were washing the Engine witnessed the incident and used a garden hose to extinguish the flames. On-duty fire fighters/paramedics administered medical treatment to the victim, who received first-, second- and third -degree burns over 36% of his body. He was transported to a local trauma center from where he was later air-lifted to a burn center. NIOSH investigators concluded that, to reduce the risk of similar incidents, fire departments should: use oxygen regulators constructed of materials having an oxygen compatibility equivalent to that of brass ensure that the cylinder is placed in an upright position, and that the cylinder post valve is pointed in a safe direction (away from the operator) and opened then closed before the regulator is attached to the cylinder ensure that when opening a cylinder post valve with the regulator attached, it is opened slowly and pointed away from the operator and other people ensure that fire fighters are trained in and aware of safe handling procedures pertaining to oxygen systems ensure that oxygen systems (cylinders and regulators) are stored in a cool area free of dirt, oils, and grease ensure that oxygen re-filling stations and maintenance areas where oxygen equipment is serviced, are in a locked, air-conditioned room that is clean and free of dirt, oils, and grease ensure that any components added to the regulator, such as gauge guards, are installed so that they do not block the regulator vent holes.