Cylinder design

The threaded connections on the Kawasaki air breathing apparatus and oxygen breathing apparatus cylinders were the same and there were no other engineering controls to prevent an oxygen cylinder from being connected to the air compressor.

The company will place caution labels on all future OBA oxygen cylinders. These labels will draw attention to the fact that the re-filling and inspection of the cylinders must be carried out ashore; and that the cylinders should only ever be re-filled with oxygen. The company has taken actions to raise awareness but has not introduced any controls to prevent the inadvertent connection of an oxygen cylinder to an air system.