EGLIN AIR FORCE BASE, Fla. -- Results of an Air Force Test Center commander directed investigation report on the fire suppression system incident that occurred last month at King Hangar were released Feb. 18.

The unintended activation of the fire suppression system at approximately noon Jan. 8 resulted in the death of a civilian contractor, while three other Eglin personnel were treated with inhalation injuries.

"This incident is very tragic as we lost a valuable member of our team, and it could have been prevented," said Maj. Gen. Arnold Bunch, the Air Force Test Center commander. "My reasons for implementing this investigation were to ensure a loss of life or injuries do not happen again. The investigation identifies a number of key areas for improved system performance and personnel training and awareness efforts."

The primary cause of the inadvertent High Expansion Foam discharge was a valve failure due to freezing water inside the pipes during historically low temperatures between Jan. 6 and Jan. 8. The combination of extended freezing temperatures followed by a rapid thaw resulted in burst pipes and leaks.

A wet-pipe sprinkler system Inspector Test Station broke creating a three inch icicle and slow leak. The wet pipe sprinkler system flow meter initiated the HEF discharge resulting in 17 feet of foam inside King Hangar. Five aircraft assigned to the 53rd Wing and 96th Test Wing were in the hangar when the HEF discharged.

The main reason for the fatality and injuries suffered as a result of the mishap was the loss of situational awareness and decisions made by the contractors to use the building elevator from the third floor to the first floor while the incident was ongoing. The resulting fatality and injuries occurred from the HEF filling up an elevator the victims were in and they were unable to find a way out of the facility.

"While we continue to grieve losing one of our own in this incident, I am confident we have solid technical information to inform our employees how to safely work in environments with fire suppressant systems and respond to any crisis that could occur," said Bunch.

The CDI made recommendations for implementation throughout AFTC to mitigate the risk of future incidents. Foremost among those the recommendations to minimize the possibility of inadvertent discharge were:

• Review automatic activation based on wet-pipe flow
• Improve understanding of the HEF sequence abort function to reduce the number of inadvertent HEF discharges
• Improve wet-pipe sprinkler systems in HEF equipped hangars to decrease their failure rates
• Tie HEF activation to wet-pipe flow plus an additional fire indicator such as a heat detection device is also a possibility to consider

The most important of all the recommendations is to improve training of all the fire suppression system operations, according to Bunch.

"What we learned from the CDI will pave the way forward for new safety and training standards across the Air Force Test Center enterprise in how we manage facilities with fire suppressant systems and how we prevent and respond to crisis incidents involving these systems," said Bunch. "We will share these findings with other AFMC (Air Force Materiel Command) and Air Force organizations so they can learn as well."

The Occupational Safety and Health Administration and Air Force Safety Investigation Board are still investigating the incident.

The CDI report can be found here.