AGVS & Lithium battery fire 11/10/2025

cedars-sinai.org

Incident review and lessons learned

Automated Guided Vehicle System

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• Moves carts throughout hospital
• Dirty linen
• Waste (regular & biohazard)
• Surgical supplies/trays
• Patient food

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• AGVS makes over 700 drops per day

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• Operates on an interstitial utility floor

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• Dropoff/pickups on occupied floors

Initial response: 11/10/2025

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• 1340: Security receives fire alarm and dispatches Code Red response
• Smoke detector, duct detector, pull station (stair 8)
• 1341: 911 called
• Security, plant operations, safety, emergency management, materials management all respond
• 1350 LAFD #458 arrives

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Removal to parking lot

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• AGVS unit
• LAFD #458 repositions to Beverly Blvd

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Removal to parking lot

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• AGVS unit
• LAFD #458 repositions to Beverly Blvd
• Hazmat arrives

Public Information

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Cedars-Sinai Statement

A lithium-ion battery that powers a motorized supply cart overheated and emitted smoke briefly in a non-patient corridor Monday. The incident, located in a supply space between patient floors, created an odor in some areas but did not harm patients, visitors or staff. There were no impacts to hospital operations and no evacuations were required. The cart was moved to an outside parking lot, where the battery is cooling.

We thank all those at Cedars-Sinai for their patience and understanding while we resolve this matter. We remain committed to the safety and wellbeing of our patients, our visitors and our employees.

Notifications

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• CalOES – ordered fire watch

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• CUPA (LAFD): LAFD also notified

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• Public Health HFID/Emergency Response: LAFD notified, CSMC follow-up
• Communicated that the fire was not in a direct patient care area.
• No patient evacuations. No disruption to services.

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• CDPH Licensing and Certification – unusual occurrence

Additional impacts

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Other impacts:

• Shutdown of entire AGVS system
• Carts need to be moved by hand
• Initially materials management and EVS staff
• Contract staff brought in
• Increased passenger elevator usage
• Full system inspection by AGVS and battery manufacturers
• Firewatch (also ordered by CalOES)
• Barrel moved slightly so that it was visible on security camera
• Cleaning – Environmental Services clean with coveralls, goggles, and N95s

Battery disposal

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• Disposal
• Battery and water removal by hazardous waste hauler
• 30 days to comply
• Water pH of 10, expected to increase to 11 as reaction continued
• Told battery would be unstable for disposal for at least two weeks

Lessons learned/improvement items

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Initial Response

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• Personnel tried to use ABC fire extinguishers, will not extinguish a lithium battery fire.

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• May have extinguished burning material on the AGVS cart.

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• Respiratory protection needed
• SCBAs are needed for PPE. Hydrogen fluoride, and other toxic gases, are expelled, especially in early stages of the fire.

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• Risk of rapid fire growth or explosion.
• LAFD recommendation personnel should focus on rapid notification and evacuation.

Lessons learned

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• Elevator
• Include fire dept elevator key in fire/law response kit
• Transport battery in unoccupied elevator
• LAFD should have put AGVS unit in elevator, used firefighter key (override smoke), pressed button, and exited elevator.
• Other firefighters should have been on lower floor to receive AGVS unit.
• Concern of battery continuing to off-gas in an enclosed space, potential for ignition/explosion
• AGVS was on cart pre-fire. Fortunate, otherwise hard to move (~1100lbs).

Lessons learned/improvement items

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Notifications

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• CUPA: Even though LAFD notified CUPA, LAFD CUPA still needed an official notification form filled out on their website. In future, notify CUPA as soon as possible.

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• CalOES: Notify ASAP.

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• CDPH Licensing and Certification – follow up site visit occurred the following week. Focus on impact to patients and services, of which there were none.

Lessons learned/improvement items

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Battery weight: Initial reports of 1100lbs, updated to 60lbs, actual 81.lbs

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• 26 AGVS units x 60lbs = 1,560lbs

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• CUPA requires reporting of batteries over 500lbs in a building
• These batteries normally roam through multiple buildings and floors
• AGVS system was shutdown, CUPA inspectors saw the robots together in a single location
• Lithium batteries were added to CERS reporting. Batteries had been listed as waste, but not the in-service quantities.
• Additional work ongoing to better understand quantities and types of batteries in use.

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• SDS was rapidly provided, which fire department appreciated

Lessons learned/improvement items

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• Security Cameras
• Adding additional security cameras to interstitial floor for earlier fire detection.
• Fortunate that two technicians were working on unit when fire started.

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• Vendor Coordination: Require off-site forensic analysis; prohibit on-campus analysis.
• RCA needed to determine risk of other units/batteries having similar failures.

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• Contingency Planning:
• Identify safe outdoor isolation areas for hazardous equipment
• Develop response plan for lithium-ion battery fires.

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• Waste Management: Address backlog in hazardous battery disposal; explore alternate vendors.

Cedars Sinai Medical Network 12/2/2025

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Photo credit: https://x.com/ScannerPacific

CSMC Nursery 12/27/25

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• RN dropped her phone; the battery case exploded and burst into flames.

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• Flames extinguished, two babies in the Nursery were safely evacuated.

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• LAFD, including hazmat responded. Ordered everyone out of the nursery due to fumes.

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• One RN suffered smoke inhalation and went to the ED.

Patient’s tablet 3/16/2026

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• Fire alarm activation 04:44am, 911 called
• Room was dark and smokey through glass window.
• Door opened and patient was assisted out of room into the hallway. No injuries.
• Another RN went into room, saw smoke but no flames coming from tablet and used extinguisher.
• Security and plant operations responded, placed tablet in bucket of water.
• Security took submerged tablet out of building and turned over to LAFD
• LAFD inspected and cleared room.
• Negative pressure isolation room. Reset HVAC to allow for room to be cleared.
• Terminal cleaning of room with goggles, N95, and isolation gown.
• 3 security to ED for dizziness, nausea and shortness of breath.

Next steps for preparedness

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• Follow standard fire plan
• Report the fire. Get fire department assistance ASAP.
• Evacuation of the fire room is a priority. Close doors. Contain the smoke.
• ABC fire extinguishers may continue to be used for standard combustibles
• Extinguishers will not stop the battery from burning

• Cool the battery with water – assess safety, PPE, and risk/benefits
• Submerge the battery if possible
• Recognize that battery may re-ignite

• Staff education to recognize early warning signs (swelling, odor, heat, popping sounds)

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• Investigating battery containment bags, blankets, wraps, etc.

https://files.asprtracie.hhs.gov/doc uments/aspr-tracie-ta---resources-on-lithium-ion-batteries-for-healthcare.pdf

Emergency Response plan

Pre-identify outdoor locations to move a damaged battery to. Consider:

• Access routes (for your personnel & fire department)
• Manual fire protection methods
• Water supply for long duration fires
• Smoke ventilation
• Security / fire watch, camera coverage?
• SDS sheets

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• Adapted from source: FM Global 7-112 Lithium Ion Battery Manufacturing and Storage

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Thank you

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