242 Air Medical Journal 31:5

AbstractLithium-ion batteries provide more power and longer life

to electronic medical devices, with the benefits of reducedsize and weight. It is no wonder medical device manufactur-ers are designing these batteries into their products. Lithiumbatteries are found in cell phones, electronic tablets, com-puters, and portable medical devices such as ventilators,intravenous pumps, pacemakers, incubators, and ventricu-lar assist devices. Yet, if improperly handled, lithium batter-ies can pose a serious fire threat to air medical transportpersonnel. Specifically, this article discusses how lithium-ion batteries work, the fire danger associated with them,preventive measures to reduce the likelihood of a lithiumbattery fire, and emergency procedures that should be per-formed in that event.

Case ReportAn air medical helicopter was dispatched to a rural com-

munity hospital for a 17-year-old boy with a self-inflictedgunshot wound to the head. On arrival, the flight team foundan intubated patient who was being bagged by the hospitalanesthesiologist. Computed tomography scan of patientshead indicated a severe brain injury.

The flight paramedic immediately began preparing thepatient for transport, whereas the pilot installed an oxygenregulator on the D tank to provide oxygen gas to a DraegerOxylog 3000 ventilator. The pilot then placed the oxygentank inside the ventilator bag diagonally with the regulator

sticking out of the top of the bag. As the flight nurse was set-ting up the ventilator, a pop-hiss was heard, and thick, graysmoke was seen emanating from the ventilator bag. The pilotquickly removed the oxygen bottle from the bag. Smoke con-tinued to billow from the bag, triggering the hospital firealarms. The flight nurse looked into the ventilator bag andnoted the nylon pouch that housed the spare lithium ventila-tor battery was smoking. He removed the spare batterypouch, which contained an original equipment manufacturer(OEM) battery (Molicel model MC202C). The flight nursedropped the pouch to the floor, before kicking it out of theroom. A local emergency medical services person subse-quently kicked the battery pouch into the ambulance bay,whereupon it immediately erupted into flames. It was snuffedout with a dry-chemical fire extinguisher. On finishing thetransport, the flight nurse called the local fire chief only tolearn that the battery was still hot and smoking 1 hour laterand had continued to erupt into flames until it was eventuallyextinguished with water. Figure 1 shows a normal lithium-ion(Li-ion) battery. Figures 2-4 show the significant damage thatresulted from the described Li-ion battery fire.

Discussion All batteries work by converting chemical energy into electrical

energy and are a necessity to portable electronic equipment.Batteries are broadly categorized as either disposable or recharge-able batteries and can be further subclassified based on theirchemical makeup (ie, metal hydrides, lithium nickel, lithiummanganese, and lithium cobalt).1 Lithium is the lightest of allmetals, has the greatest electrochemical potential, and providesthe largest energy density for its weight. The amount of powerand capacity a battery can deliver will depend on several factors:the amount and type of electrolyte and electrode material in thecell, magnitude of the current, the allowable terminal voltage,temperature of the battery during discharge, and the rate of dis-charge. Manufacturers determine battery capacity by multiplyingthe maximum current a battery can deliver for 20 hours at 68F(20C). Thus, a battery delivering a maximum current of 10amps for 20 hours would have a rating of 200 Ah (Amp hours).

How Li-ion Batteries Work

Lithium batteries can either be disposable one-time use orrechargeable multi-use batteries. The Li-ion battery is arechargeable battery that has gained popularity because of itscompactness, light weight, high electrical capacity, no memory

CASE STUDY

Lithium Battery Fires: Implications for AirMedical TransportFrank Thomas, MD, MBA,1,2 Gordon Mills, RN,1 Robert Howe,3 and Jim Zobell, RN1

1. Intermountain Life Flight, Salt Lake City, Utah

2. Critical Care Medicine, University of Utah School of Medicine, Salt LakeCity, Utah

3. Clinical Engineering, Intermountain Medical Center, Salt Lake City, Utah

Address for correspondence:Frank Thomas, MD, Intermountain Life Flight, 250 N 2370 W, Salt Lake City, UT84116, frank.thomas@imail.org

AcknowledgmentsThe authors thank Federal Aviation Administration Special Agent James Berkfor his thoughtful and helpful review of this manuscript.

1067-991X/$36.00Copyright 2012 by Air Medical Journal Associateshttp://dx.doi.org/10.1016/j.amj.2011.12.003

effect, and a slow self-discharging rate ( 5% per month). Notall Li-ion batteries are alike. Type of positive electrode, nega-tive electrode, and electrolyte used will affect performance, lifespan, safety, specific power, specific energy, and costs of vari-ous Li-ion batteries.

All Li-ion batteries are made up of 3 general components2:the positive electrode, consisting of either lithium manganeseoxide, lithium cobalt, lithium nickel oxide, or lithium ironphosphate; the negative electrode, consisting of lithiumgraphite, lithium carbon, lithium titanate, lithium silicon, orlithium germanium; and the electrolyte, a nonaqueous salt ororganic solvent used as the Li carrier between the positiveand negative electrodes. The electrolyte also acts as an insula-tor to negatively charged electrons, preventing their move-ment between the positive and negative electrodes within thebattery. Thus, movement for electrons can only occur throughan external electrical circuit that connects the positive andnegative electrodes.

When the Li-ion battery is being electrically recharged(Fig. 5A), the charger sends electric current to the batteryspositive terminal and into the positive electrode. This forcesthe lithium ions (Li) attached to the positive electrode tomigrate through the electrolyte, where they attach to thenegative electrode as stored electrochemical energy. At thesame time, negatively charged electrons flow from the posi-tive electrode through an external circuit into the negativeelectrode. When no more Li-ions will flow from the positiveelectrode to the negative electrode, the battery is fullycharged and ready to use (Fig. 5B). This process creates anelectrochemical driving force between the positive and neg-ative electrodes within the battery, known as the terminalvoltage. The listed voltage on a fully charged battery indi-cates the maximal electrochemical energy that can safely bestored within the battery. For example, a 1.5-volt batterywould have a maximum terminal voltage of 1.5 voltsbetween the positive and negative terminal, whereas a 4.0-volt battery would have a maximum terminal voltage of 4.0volts between the positive and negative terminals.

Activating the On switch of a portable electronic devicecompletes an external circuit between the batterys positiveand negative electrodes (Fig. 5C). Because of the need toseek electrical neutrality (ie, a zero voltage differencebetween the electrodes), the lithium ions, attached andstored on the negative electrode, began migrating back tothe positive electrode. At the same time, the negativelycharged electrons migrating from the negative electrodepower the electrical device as they make their way to thepositive terminal and electrode. As the Li-ions and the elec-trodes move back to the positive electrode, the battery con-tinues to discharge, and the terminal voltage drops. Onceall of the Li-ions have moved back to the positive terminal,the battery is fully discharged and will require rechargingbefore it can be used again (Fig. 5D).

Lithium manganese oxide batteries represent 80% of Li-ionbatteries currently used. However, lithium cobalt batteriesprovide a higher capacity (140 mA-h/g) and therefore alonger runtime than lithium manganese oxide (100 mA-h/g)batteries. Thus, cobalt Li-ion batteries are preferred overmanganese lithium batteries for light, portable electricaldevices. A typical Li-ion cobalt battery can generate 1.8 timesthe voltage of a lead-acid battery, nearly 3 times the voltage ofa typical nickel-based battery, and twice the voltage of a com-parable-sized lithium manganese oxide battery.3

Lithium Battery Fires

Fire is a major risk when using disposable or recharge-able lithium batteries.4 Fires can occur when a battery cellis damaged, punctured, or becomes overheated because ofeither overcharging or external heat. The separator thatprovides isolation between the anode positively chargedelectrode and negatively charged electrode is often only 20to 25 m thick. This makes Li-ion batteries highly suscep-tible to damage by outside forces. When a high-capacitylithium cell is damaged, it can short circuit to create arapid electrical discharge that quickly overheats the dam-aged cell. Lithium cells can also become unstable when

243September-October 2012

Figure 1. Normal Li-ion battery. Figure 2. Damaged battery after Li-ion runaway fire.

their temperature exceeds specified temperature limits. Aparticular drawback to lithium cobalt batteries is that theybecome unstable at much lower temperatures(130C/302F) than lithium manganese oxide batteries(250C/482F). This makes lithium cobalt batteries moresusceptible to rising temperatures.

The cellular damage of even one lithium cell can havedisastrous consequences. As one cell becomes unstable andoverheats, it emits flaming gases. The high heat of the fail-ing cell then causes each adjacent cell to overheat. This cre-ates more flaming gases as subsequent cells areincorporated into a chain reaction, known as a thermalrunaway. Interestingly, the more fully charged a Li-ionbecomes, the lower the thermal runaway temperature.Within minutes of a thermal runaway, the entire battery canbecome an explosive flaming inferno. Human injury hasoccurred when Li-ion thermal runaways have occurredwith portable electronic devices.5,6

From March 20, 1991 until May 18, 2011, the FederalAviation Administration (FAA) is aware of at least 113 airincidents involving smoke, fire, extreme heat, or explosionfrom batteries.7 These included lead, nickel, alkaline, as wellas Li-ion batteries. A United States Department ofTransportation analysis found that 27% of aviation batteryincidents involved lithium batteries. Of these incidents, 75%resulted from a short-circuit, 11% unintended activation ofdevices, 4% because of improper handling, and 13% fromother causes.8 Most of these fires occurred in the airport or incargo hubs and were the result of damage or an electricalshort. However, such fires during flight have resulted in cata-strophic events. A recent fatal accident report involving a Li-ion battery runaway fire depicts this point.

On September 3, 2010 a UPS Boeing 747-400F departedDubai International Airport (DXB) on a scheduled cargoflight to Cologne (CGN), Germany. Twenty-two minutesinto the flight, level at 32,000 feet, the flight crew advisedBahrain Air Traffic Control (BAH-C) that the fire warningsystems for the cargo compartments indicated an onboard

main deck fire. The crew declared an emergency andrequested a return to DXB as soon as possible. The crewfurther informed BAH-C that there was smoke in thecockpit and that the ability to view the primary flightinstruments and radio frequency selection controls hadbecome degraded. Due to the obscured visibility in thecockpit, the crew stayed on the BAH-C frequency for theduration of the return flight back to DubaiAs the air-craft approached DXB runway 12 left (RW12L), the air-craft overflew the DXB northern boundary at 4500 ft andat a speed of 340 Kts. Following the airport over flight,BAH-C, through a relay aircraft, advised the flight crewthat Sharjah Airport (SHJ) was available to the airplanesleft about 10 miles away. The aircraft reduced speed, andentered a shallow descending right turn to the south ofDubai Airport before radar contact was lost. The aircraftcrashed 9 nm south of DXB on a military installation.9

Both pilot crewmembers died on impact.Since 2008, the U.S. Pipeline and Hazardous Materials Safety

Administration has placed restrictions on lithium batteries con-tained within checked or carry-on luggage for passengerflights.10,11 These same restrictions apply to air medical trans-ports. Specifically, these restrictions prohibit the packing ofuninstalled spare lithium batteries in checked luggage. Somedevices with nonremovable batteries (iPhone, iPad, and otherbrands of laptops) may be exempt from this rule. There is norestriction on the number of disposable metal lithium batteries apassenger can carry on, provided their content is not more than2 g lithium per battery (AA, AAA, 123, CR123A, CR1, CR2,CRV3, CR22, 2CR5, and so forth). For rechargeable Li-ion bat-teries, passengers are restricted to no more than 8 g lithium(approximately 100 Wh) per Li-ion battery. The Wh for an Li-ion battery most often can be found imprinted on the batterycasing. Two additional spare Li-ion batteries per person mayalso be carried, provided their lithium content does not exceed25 g lithium per battery. Any lithium batteries exceeding theserestrictions must be shipped as Class 9 MiscellaneousHazardous Material.12

244 Air Medical Journal 31:5

Figure 3. Damaged Li-ion battery case. Figure 4. Damaged oxygen E-tank.

245September-October 2012

Lithium Fire PreventionTo reduce the above fire concerns, Li-ion manufacturers have

developed several methods to reduce the risk and impact ofthermal runaway high current surges.13 First, circuit interrup-tion devices are now being incorporated into Li-ion batteries.These devices open an alternative electrical path if an electricalsurge causes the internal cell pressure to exceed 150 psi. Second,safety vents are being incorporated into the battery design. Thesevents open and expel hot gases when an excess increase in thecells pressure is detected. Third, electronic protection circuits arebeing employed that will immediately cut the charging currentflow if any cell is outside the upper or lower charge limitation orif the batterys upper and lower temperature limitations areexceeded. Fourth, to prevent fires from cheaper, poorly con-structed, after market lithium batteries placed into certainportable devices, some manufacturers are now using a secretcode that only allows usage of approved portable batteries.Finally, to reduce external battery damage, battery manufacturersare continuing to develop stronger, puncture-resistant lithiumbattery casings. With the addition of these manufacturer safetyfeatures, the failure rate of Li-ion batteries is now estimated in therange of 1 in 10 million batteries.14

Despite these manufacturing initiatives to reduce the likeli-hood of lithium battery fires, there are additional proceduresthat medical transport crews can do to further prevent alithium battery fire.

1. Never use aftermarket batteries or chargers.13 In otherwords, use only the batteries and chargers specified bythe manufacturer. In the attempt to reduce costs, there

may be a temptation to purchase after market batteriesor chargers. Although cheaper, these devices may bepoorly manufactured with few, if any, of the above man-ufacturing safety features. Likewise, some after marketchargers do not terminate the recharge of the batterycorrectly, increasing the risk for an Li-ion fire. The bat-tery that caught fire in our case report was an approvedOEM battery and was not an aftermarket battery.

2. Never use a trickle charger. Trickle chargers cannot beused on lithium batteries because of the possibility ofovercharging the battery.

3. Know that Li-ion batteries require a specific way of charg-ing.14 In the past, Li-ion batteries could not be fast-charged and needed at least 2 hours to fully charge.However, newer generation Li-ion batteries may befully charged in 45 minutes or less. Some Li-ion vari-eties can reach 90% capacity in as little as 10 minutes.Li-ion batteries are very specific in the amount ofcharge they can absorb. Damage to a battery can occurif it is charged beyond acceptable limits. Therefore,charging of Li-ion batteries should only be performedwith the manufacturers specified charger.

4. Protect spare batteries from external damage in a nonconduc-tive container.15 Although Molicel regulatory informationspecifically states, Do not crush, puncture, incinerate,immerse in water or heat over 100C,16 no guidance isgiven regarding protective cases. Because our battery wasstored in a soft case, it was susceptible to external damage.Therefore, it is imperative that spare Li-ion batteries bestored in a hard protective case that reduces the likelihoodof external damage. Since our experience cited above, allof our spare Li-ion batteries are now placed into a pro-tected plastic Pelican case during transport (Fig. 6).

5. Do not charge Li-ion batteries above or below recommendedtemperature.17 Properly working chargers should pre-vent the recharging of Li-ion batteries when the temper-ature limitations are exceeded. Li-ion batteries shouldbe charged within a temperature range of 0 to 45C (32to 133F) and discharged within a temperature range of-20 to 60C (-4 to 140F). Li-ion batteries should neverbe charged below freezing temperature. Under freezingconditions, permanent plating of metallic lithiumoccurs on the positively charged electrode. This platingmakes the battery more susceptible to vibration orother stressful conditions. Newer advanced chargershave features to prevent plating and may be preferablewhen Li-ion batteries must be charged in subfreezingconditions. However, check with the electronic deviceand battery manufacturers before using these advancedchargers. Bottom line, to ensure proper charging,always charge and discharge the battery within themanufacturers temperature specifications.

6. Discard any charger or battery if it gets excessively warm.Little or no heat should be generated during an Li-ionbattery charge. Discarding a warm charger or battery

Figure 5. How Li-ion batteries work.

will ensure that near thermal runaway does not occurin the future.

7. Store Li-ion batteries away from temperature extremes.Because Li-ion batteries are sensitive to higher or lowertemperatures, devices containing Li-ion batteries andspare Li-ion batteries should never be left in an aircraftor environment where they may be exposed to eitherelevated or freezing temperatures.

8. Avoid placing Li-ion batteries near metal objects. Unlessthe electrodes are shielded, metal objects that come incontact with both electrodes can cause a short circuitand arching. Both of these situations can result in athermal runaway.

9. To prolong Li-ion battery life,18 discharge the battery to40% capacity and store in a cool environment (eg,refrigerator, but not freezer).

10. Never allow a Li-ion battery to fully deplete.19 Excessivelydepleting an Li-ion battery can shut off its protectioncircuit, making it more susceptible to a future thermalrunaway.

11. Avoid charging Li-ion batteries during flight. Thermal run-away can occur during recharging; therefore, rechargingof an Li-ion battery during flight should be done onlyin extreme cases. It is better to fly with a backup batteryin a protective case.

12. Never open or disassemble the battery. Damage to the bat-tery while opening or disassembling an Li-ion batterycan trigger a thermal runaway.

Emergency Procedures in the Event of a Lithium BatteryFire

Despite preventive measures, the possibility of an Li-ionfire exists. How these fires are handled will depend on wherethe fire occurs. The following provides a general outline ofemergency procedures that should be considered in the eventof an Li-ion battery thermal runaway.20,21

1. If possible, evacuate any nonessential personnel from thearea. This will reduce the likelihood of additional injuryto others.

2. Immediately and continuously douse an excessively warmor smoldering battery with a nonflammable, non-electrolyticsolution (eg, water, soda). This will quickly cool the bat-tery before other cells have a chance to overheat. If pos-sible, avoid electrolytic solutions (normal saline orRingers lactate) to prevent electrical arcing between theelectrodes. As our case report shows, even after the ini-tial battery fire was suppressed, the battery againunderwent a thermal runaway and reignited. Check thebattery or device temperature every 5 minutes. If it isbecoming warm, again continuously irrigate with water.Remember, Li-ion battery fires are chemical fires thatcan easily reignite if not continuously cooled with anon-electrolytic solution.

3. When possible, move the battery to an open safe area. Thiswill reduce exposure of personnel and property to a

possible fire hazard. Electrolyte fumes and vapors areheavier than air and flammable. As such, they can movealong the ground to another ignition source to cause asecondary fire.

4. When possible, remove any fire hazards that may have con-tact with the battery. This includes flammable substancesand oxygen bottles. As our case report shows, theportable oxygen tank that caused the mechanical dam-age to the battery also suffered burns from being incontact with the battery. The oxygen tank in Figure 4was later deemed unsuitable for future use.

5. Do not attempt to smother the battery or use ice to cool downthe battery. Because this fire is caused by a chemical reac-tion, smothering the battery actually allows the heat to becontained within the battery to further accelerate the ther-mal runaway chemical reaction. Similarly, ice acts muchlike an igloo, thereby containing the heat within the bat-tery until it erupts into a thermal runaway fire. An excel-lent online FAA training video on laptop battery firesshows an Li-ion battery erupting into a fireball while cov-ered in ice.22

6. Avoid picking up a smoldering battery barehanded. Thesebatteries can become extremely hot. Touching thesebatteries can result in extreme thermal burns. In addi-tion, the temperature can rise so quickly that the bat-tery can actually become explosive, thereby resulting infurther thermal or shrapnel injuries.

7. Wear protective gloves, clothing, and eyewear when extin-guishing or handling. This is done to protect against skinor eye damage should the battery explode. The elec-trolyte within the battery is a skin and eye irritant.When the battery is being cooled and extinguishedwith water, burning pieces of flammable particles maybe ejected. If the battery does explode, immediatelyremove any contaminated clothing or eyewear and irri-gate all affected skin areas for at least 15 minutes. If aneye injury occurs, open the eyelids and irrigate for at

246 Air Medical Journal 31:5

Figure 6. Li-ion battery in a Pelican plastic protective case.

least 15 minutes. Then immediately seek emergencymedical attention.

8. For excessive smoke, immediately ventilate the area. As perour case report and the Dubai incident, Li-ion batterythermal runaways can generate a lot of smoke. In fact, itmay be one of the first signals that a thermal runaway isoccurring. If the device can be safely moved to an opensafe location, do so immediately.

9. If a fire erupts, immediately extinguish. Use lots of water,carbon dioxide, halon-type, or an ABC dry chemicalextinguisher. Pure lithium as a metal is explosivelyreactive with water. However, rechargeable Li-ion bat-teries are intercalated into graphite, lithium metaloxides, or lithium salts, making the lithium containedwithin these batteries inert to water. Avoid using afoam extinguisher, because this may act as a thermalinsulator, thereby increasing the chemical reaction and

subsequent heat. Finally, remember, that this is achemical reaction that can easily ignite again if leftunattended. Be prepared for another fire. After puttingout the fire, follow steps 1 through 7 as previouslyoutlined. Repeat these steps until the battery is cooland no longer a smoke or fire hazard.

10. In the event of a suspected Li-ion thermal runaway duringflight, immediately notify the pilot to seek an immediatelanding. An Li-ion thermal runaway fire during flightpresents some unique challenges as depicted in theDubai incident. Notifying the pilot immediately of asuspect lithium battery runaway will allow the pilot toinitiate aircraft evasive actions as quickly as possible.Do not proceed with the patient transport. Rather,immediately seek the closest suitable landing area andimmediately remove the thermal runaway battery fromthe aircraft. Notify the nearest fire department and lawenforcement to help assist with the possibility of alithium-ion battery fire and a possible patient transfer.The prudent action is to get the aircraft on the groundas soon as possible before an in-flight fire occurs.

Most air medical programs have defined in-flight emer-gency procedures that discuss what to do in the event of cabinsmoke or fire. Figure 7 depicts an example of pilot emergencyprocedures that should be performed in the event of cabinsmoke or fire within an Agusta AW109SP Grand helicopter.Be familiar with these pilot procedures so that you may assistthe pilot as requested. If possible, isolate the pilot from thepatient compartment. This will reduce that amount of smokereaching the pilot compartment. Available protective eyewearshould be used to reduce eye irritation occurring from thermalrunaway smoke. Immediately place either a protective face-mask (N-95) or an oxygen mask with low-flow oxygen (35L/min) over your nose and mouth to reduce the amount ofsmoke irritant being inhaled should the cabin fill with smoke.Be aware that some in-flight emergency procedures mayrequire the pilot to cut all oxygen flow to the cabin. If this isthe case, oxygen flow from the aircraft oxygen tanks may beterminated by the pilot. Have a backup plan formulated foroxygen delivery to the patient should the oxygen supply beterminated. Follow procedures 19 as outlined.

ConclusionsLithium batteries are an important component in portable

electronic medical equipment. However, if damaged, thesebatteries can be a significant smoke and fire hazard to medicaltransport crews. Practicing good preventive measures reducesthe likelihood of a hazardous lithium battery thermal run-away. In the event a lithium battery thermal runaway doesoccur, crewmembers must act quickly and efficiently toreduce the likelihood of a thermal explosion, smoke, or fire.

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247September-October 2012

Figure 7. Agusta AW109SP in-flight emergency procedure for in-

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248 Air Medical Journal 31:5

Lithium Battery Fires: Implications for Air Medical TransportCase ReportDiscussionHow Li-ion Batteries WorkLithium Battery FiresLithium Fire PreventionEmergency Procedures in the Event of a Lithium Battery Fire

ConclusionsReferences