The definitive academic analysis of hyperbaric chamber fires, spanning 73 years from 1923 to 1996, documented 77 deaths across 35 fires worldwide.1 Every single fatal fire occurred in an oxygen-enriched atmosphere above 28%. Chambers pressurized with air produced the only survivors. These facts, established by Sheffield and Desautels in a landmark 1997 paper in Undersea and Hyperbaric Medicine, remain the foundation of modern hyperbaric fire safety.
Total Documented Hyperbaric Chamber Deaths Worldwide
The Sheffield and Desautels 73-year analysis (1923-1996) is the most comprehensive peer-reviewed record of hyperbaric chamber fires ever published.1 It documented:
| Category | Fires | Deaths |
|---|---|---|
| Diving bells | 2 | ~4 |
| Recompression/decompression chambers | 8 | ~26 |
| Clinical hyperbaric chambers | 25 | ~47 |
| Apollo Command Module (pressurized) | 1 | 3 |
| Hypobaric chambers | 3 | 2 |
| TOTAL (73 years) | ~41 | 82 |
“From 1923 to 1996, a 73-year analysis documented 77 fatalities in 35 hyperbaric chamber fires, with zero fatalities in clinical chambers in North America.”, Sheffield and Desautels, Undersea and Hyperbaric Medicine, 19971
Deaths documented in 35 hyperbaric chamber fires over 73 years (1923-1996), per the Sheffield peer-reviewed analysis1
Primary Causes of Death: The Fire Triangle
The Sheffield analysis identified two conditions present in every fatal fire:1
- An oxygen-enriched atmosphere above 28% O2
- Abundant burnable material present in the chamber
No exceptions. Chambers pressurized with air (below 23.5% O2) produced the only survivors. This single data point is the scientific foundation for why clinical hard chambers using 100% oxygen carry fundamentally different fire risk than soft chambers operating with ambient air.
| Era | Primary Ignition Source |
|---|---|
| Pre-1980 | Electrical equipment malfunction |
| Post-1980 | Prohibited items brought into chamber by occupants |
Notable Incidents Timeline
| Date | Location | Deaths | Details |
|---|---|---|---|
| 1997 | Milan, Italy | 11 | Fire in multiplace HBOT chamber; 10 patients + 1 nurse |
| 1998 | Istanbul University, Turkey | 3 | 1947-vintage chamber; no water deluge system present |
| 2009 | Florida, USA | 2 | Grandmother + 4-year-old boy; non-certified chamber during off-label cerebral palsy treatment |
| 2016 | Jakarta Naval Hospital, Indonesia | 4 | Electrical short circuit; sprinklers and emergency systems failed |
| January 31, 2025 | Oxford Center, Troy, Michigan | 1 | 5-year-old Thomas Cooper. 1 injury (his mother). CEO and safety manager charged with second-degree murder and involuntary manslaughter. |
| July 2025 | Lake Havasu City, Arizona | 1 | Walter Foxcroft, 43, died in fire at his own clinic |
“Every fatal hyperbaric chamber fire on record occurred in an oxygen-enriched atmosphere above 28%. Chambers pressurized with air produced the only survivors.”, Sheffield and Desautels, 19971
The UHMS Mishap Database: Broader Totals
The UHMS Chamber Experience and Mishap Database covers a wider scope than the Sheffield fire analysis, including all types of chamber incidents (not just fires) and all chamber types (hyperbaric, hypobaric, diving bells).2
- Total incidents documented (75 years): 113
- Total deaths: 135
- Total injuries: 50
- Fire as cause: 81 of 113 incidents were fire-related
Total deaths in all hyperbaric chamber incidents over 75 years (1923-~1998), per the UHMS Mishap Database2
Context: Chinese Data and the Human Factor
A separate analysis of 38 accidents in Chinese medical hyperbaric chambers (Wen 2009) found:3
- 77 deaths, 8 injuries across 38 incidents
- 82.61% of accidents caused by violation of operating rules or dereliction of duty
- 17.39% caused by equipment malfunction
- 77.78% occurred in pure oxygen chambers; 22.22% in air chambers
The human factor data from China mirrors the post-1980 Sheffield findings for North America: the overwhelming majority of modern hyperbaric chamber deaths are preventable and result from protocol violations, not equipment failure.
Non-Fatal Side Effects: What the Data Shows
Deaths are the most extreme outcome but not the most common risk. In the largest safety analysis ever conducted, covering 1,529,859 HBOT treatments at Healogics wound care centers from 2012 to 2015, the overall adverse event rate was 0.68% per treatment.4 Zero deaths occurred in this dataset.
The most common adverse events are:5
- Middle ear barotrauma: 9.2% of patients (most mild; 42.8% of cases self-resolve)
- Ear pain or discomfort: Up to 17% of patients (transient, not permanent damage)
- Oxygen toxicity seizure: Fewer than 0.05 per 1,000 treatments at standard pressures
- Temporary visual changes (myopia): Reversible within weeks after completing treatment
- Pneumothorax: 1 confirmed case in 1,529,859 treatments
The August 2025 FDA Safety Warning
Following the 2025 incidents in Michigan and Arizona, the FDA issued a formal letter to health care providers in August 2025 warning about fire risks associated with HBOT devices, citing “recent reports of fires that resulted in serious injuries and deaths.”6 The FDA letter reinforced the requirement to follow all instructions for safe use and to ensure patients remove all prohibited items before entering any chamber.
How Modern Facilities Prevent Deaths
The NFPA 99 Chapter 14 requirements for accredited HBOT facilities directly address the causes identified in the Sheffield analysis:7
- Fire suppression systems that activate within 3 seconds
- 2-hour fire-rated construction materials
- 100% cotton or approved fabric only, no synthetics
- Comprehensive screening for all prohibited items before every session
- Continuous oxygen monitoring with automatic shutoff
- Designated on-site Hyperbaric Safety Director at all programs
The pattern across fatal incidents is consistent: deaths occur when these protocols are absent, ignored, or circumvented. At facilities operating in full compliance with NFPA 99 and PVHO-1 standards, the fire fatality risk is extraordinarily low.
- Sheffield PJ, Desautels DA. “Hyperbaric and hypobaric chamber fires: a 73-year analysis.” Undersea and Hyperbaric Medicine. 1997;24(3):153-164. PMID: 9308138
- UHMS Chamber Experience and Mishap Database. uhms.org/images/Safety-Articles/uhms_mishap_data_report_desa.pdf
- Wen Q. “Analysis of 38 accidents and the investigation of safety management about medical hyperbaric oxygen chamber in our country.” Chongqing Medicine. 2009.
- Jokinen-Gordon H, Barry R, Watson B, Covington DS. “A retrospective analysis of adverse events in HBO therapy (2012-2015): Lessons learned from 1.5 million treatments.” Advances in Skin and Wound Care. 2017. doi:10.1097/01.ASW.0000508712.86959.c9. PMID: 28198743
- Voigt A et al. “Systematic Review of Otologic Adverse Events in Hyperbaric Oxygen Therapy.” Undersea and Hyperbaric Medicine. 2025. doi:10.22462/736. PMID: 41429031
- FDA. “Follow instructions for safe use of HBOT devices, letter to health care providers.” August 2025. fda.gov
- NFPA 99 Health Care Facilities Code, Chapter 14 (Hyperbaric Facilities). 2024 Edition.
- Hadanny A et al. “The safety of hyperbaric oxygen treatment, retrospective analysis in 2,334 patients.” Undersea and Hyperbaric Medicine. 2016. PMID: 27265988
- Zielinski E et al. “Fire in the Hyperbaric Chamber: Review of the Literature.” Polish Hyperbaric Research. 2023. doi:10.2478/phr-2023-0020
Medical Disclaimer
The content on BaricBoost.com is for informational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.
Author
Seph Fontane Pennock is the founder of BaricBoost.com and Regenerated.com, a clinic directory for regenerative medicine serving 10,000+ providers across the United States. He previously built and sold PositivePsychology.com, which grew to 19 million users and became the largest evidence-based positive psychology resource on the web. Seph brings direct experience as an HBOT patient, having completed protocols at clinics across three continents while navigating mold illness, systemic inflammation, and autoimmune conditions. His treatment journey includes hyperbaric oxygen therapy, peptide protocols, NAD+ therapy, and consultations with specialists from Dubai to Cape Town to Mexico. This combination of entrepreneurial track record and lived patient experience shapes everything published on BaricBoost.com. Every article is grounded in peer-reviewed research, informed by real clinical encounters, and written for patients making high-stakes treatment decisions. Seph's focus is on bringing transparency, scientific rigor, and practical guidance to the hyperbaric oxygen therapy space.
