HONOLULU (KHON2) — It’s our first look at the final report on the Honolulu Emergency Medical Services ambulance fire that killed a patient and critically injured a paramedic last year.

It’s still not known what ignited the blaze, but the head of EMS said changes have already been made to make sure it does not happen again.

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The ambulance was transporting a 91-year-old patient who was hooked up to a breathing device called a CPAP. The final report said the fire started when paramedic Jeff Wilkinson connected the air hose to a portable oxygen tank.  

“There was a bright flash of light, a loud pop that caused the person, the EMT driving the ambulance, their ears to ring; and then, Jeff said immediately the whole ambulance went on fire,” said Dr. James Ireland, Emergency Services Department Director.

The report said the fire started in the regulator of the portable tank but could not determine what ignited it. Ireland said it’s possible that contaminants might have been in the regulator or inside the tank.

“We are really focusing on making sure the regulator stays free of contaminants. We actually ordered all new regulators for portable oxygen cylinders just out of an abundance of caution,” said Ireland.

The important thing now is to make sure that the ambulance has come to a full stop before transferring the patient from one oxygen tank to another. Ireland said it’s safer for a few good reasons.

The back doors will also have to be opened so it’s easier for the paramedic and the patient to get out if a fire starts.

“When I talked to Jeff about this, the whole ambulance was full of fire. He couldn’t get out the side door, and he had to feel his way to the back to find his way by his hands to get those doors open,” said Ireland.

He added that oxygen filling up the ambulance will also be released when the doors open. Crews are also required to turn on the exhaust fan when oxygen is being used.

Ireland said he’s confident that they’re doing everything they can to prevent another tragedy. He’s also sharing the lessons learned with other first responders around the country.

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We reached out to the union for EMS workers, United Public Workers, which sent us a statement that said, “We will work with all stakeholders to ensure that our members have the appropriate training, equipment and support to perform their duties safely and effectively.”