On August 27, 1998, a female Emergency Medical Technician (EMT) was severely burned while performing a routine truck (ambulance) changeover. The changeover required the EMT (victim) to check all equipment, supplies, oxygen cylinders, and make any changes needed. The EMT had just started her evening shift and began to complete the changeover. She removed the Oxy-Caddy (bag which housed the oxygen resuscitator) from its storage compartment. She opened the top of the Oxy-Caddy to gain access to the regulator, placed it in a vertical position, and made three attempts to open the post valve to charge the regulator. Experiencing difficulties (valve was tightly closed), she placed her foot on the step of the patient compartment door and placed the cylinder against her leg and on the step to gain extra leverage to open the post valve. On the fourth attempt the regulator charged and immediately flashed, emitting a white ball of fire from the regulator. The victim pushed the regulator and cylinder inside the patient compartment as her clothes caught fire from the waist down. She then ran into the station's bay where she was met by the Corporal of the Emergency Medical Service (EMS) station who came out of the office when he heard a loud pop and the victim screaming. The EMTs inside the office immediately initiated patient care by dousing the victim with water as the Corporal called the fire department and an ambulance. The Corporal then exited the office to retrieve supplies from the truck only to witness the truck was fully engulfed in flames. Approximately 4 minutes later the fire department and ambulance arrived on scene. The truck fire was extinguished by the fire department as the victim was loaded into the ambulance and transported to a local hospital with burns to approximately 25 percent of her upper and lower extremities. NIOSH investigators concluded that, to reduce the risk of similar incidents, fire departments should: consider the use of oxygen regulators constructed of materials having an oxygen compatibility equivalent to brass ensure that the cylinder is placed in an upright position, 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 should be opened slowly and positioned away from the operator ensure that fire fighters are trained and aware of safe handling procedures pertaining to oxygen systems ensure that any components added to the regulator, such as gauge guards, are installed so that they do not block the regulator vent holes ensure that oxygen systems (cylinders and regulators) are stored in a cool area free of dirt, oils, and grease ensure that oxygen refilling 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 additionally, to reduce the risk of similar incidents, manufacturers should: ensure that they provide a warning pertaining not to occlude the vent ports on the regulator.