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Standpipe Systems and Operational Insights

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The Fire Deparment Connection

 

There are some discussions emanating and emerging regarding the Medical Center Fire in Asheville, NC that claimed the life of a highly regarded Captain and injured numerous firefighters. Emerging reports are discussing water supply, standpipe operability and integrity and deployment delays affecting fire behavior, growth, intensive and operational risks during the time in which water was attempting to be delivered to hand lines extended on the fire floor of the Medical Center.

See coverage HERE on CommandSafety.com and HERE at the Asheville Citizens-Times.com today. Direct link HERE

The following links have been compiled that provide a variety of insights and perspectives on operations conducted with standpipe systems.

Two 1.5-inch attack lines off a gated wye (poor standpipe valve positioning - the second line probably would kink when charged). Technically, a 2.5-inch to 2.5-inch gated wye with reducers is better if a high-volume (2.5-inch) line is suddenly needed. Copyright © 2011 Massey Enterprises, Inc.

Delayed Standpipe Operations Investigated in Asheville Medical Building Fire

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Photo: C.J. Naum, 2010

 

Apparent delays with establishing a sustained water supply via the building standpipe system are being published in the Asheville Citizens-Times.com today. Direct link HERE

Published reports are indicating possible problems with water delivery to the standpipe system designed to supply water from a street hydrant system to the fifth floor of a burning medical office building likely delayed firefighters as they battled the deadly blaze, according to Fire Department radio transmissions.
Nearly 25 minutes passed from the time the first trucks left their stations about 12:30 p.m. Thursday until a company reported they were finally putting water on the blaze at 445 Biltmore Center from a ladder truck.

Typical Standpipe Stairwell Valve Connection

Firefighters repeatedly made references to a lack of water, even as they reached the fourth floor and made their way toward flames one floor above according to same publication. They are referencing transcripts from fireground radio transmissions. HERE.

  • Asheville NC Fatal FF Mayday Audio 7/28/11; The audio has been edited and most of the Mayday audio from the FF has been edited out

The lack of timely application of water as a suppression agent to disrupt the progressing fire growth and magnitude could contribute towards increased fire severity based upon the fire load package and heat release rate and likely contribute towards untenable interior conditions in the absence of a vent path and confinement of the escalating products of combustion due to fire growth.

  • Refer to the CommandSafety.com posting HERE with a typical floor layout plan and interior photos
  • Reports indicating delays and challenges in gaining access into various rooms and locations are also being reported whcih should be expected based upon typical medical office layouts and configurations.

Vent path considerations, when addressing interior suppression operations, ventilation profiles and avenues and fire and heat propagation all have considerations and applications when working a seated fire within a compartment fire in a commercial occupancy

Refer to the following links for some further insights on the aforementioned elements and factors;

 

 

Fire Location on the Number Five Floor. Medical Office Building Copyright 2011 Microscoft Pictometry Birdseye View Pictometry Intl. Corp

 

 

  •  PDFs On Standpipe Systems: HERE and HERE
  • San Diego Fire & LIfe Safety Services LINK HERE
  • FDNY Standpipe Operations, HERE
  • STANDPIPE SYSTEM OPERATIONS: ENGINE COMPANY BASICS BY ANDREW A. FREDERICKS, FDNY (1996),

 

Medical Office Building Multiple Alarm Fire Leds to Fire Captain LODD

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Medical Office Building A multiple 4-alarm fire took command of a medical office suite located in a five story non-sprinklered Medical Center Office Building in the City of Asheville, North Carolina on Thursday July 28, 2011.

The mid-day fire was reported on the fifth floor at 445 Biltmore Center medical offices and was found extending from exterior perimeter windows as arriving companies went to work.

According to published reports, companies encountered heavy smoke and heat conditions. As initial suppression operations were being conducted, coordinated search and rescue operations were assigned and being conducted.  AFD Capt. Jeff Bowen was among the first alarm assignment of firefighters to reach the building’s fire floor as unabated fire development and growth caused the perimeter windows to fail causing fire extension to the exterior and the induction of fresh air onto the fire floor. The intensity of the flame front and extension was evident as photographed out fifth-floor windows.

Fire Showing During primary search and rescue operations, approximately 45 minutes into the operations Captain Bowen transmitted a mayday for reasons undetermined at the present time. Heavy smoke and pronounced heat conditions filled that top floor, where he and fellow firefighter Jay Bettencourt were conducting search efforts.  Command quickly directed efforts to manage the mayday with companies deployed to support the RIT and mayday. There were reported sixty fire fighters assigned the suppression and rescue operations for the multiple alarms. About 200 patients and staff were in the building at the time of the fire.

Captain Jeff Bowen, Asheville FDPreliminary information suggests that Captain Bowen went into cardiac arrest after succumbing to intense smoke and heat, the city said in a statement released on Friday. Firefighter Bettencourt was transported to the Joseph M. Still Burn Center at Doctors Hospital in Augusta, Ga., for treatment. He was listed in critical condition Thursday night. Nine other firefighters were taken to the hospital in connection with the blaze. Six remained hospitalized late Thursday. Three were treated and released, according to Mission spokeswoman Merrell Gregory and published reports. Captain Bowen was a thirteen year fire service veteran and was a husband and father of three children. He was 37 years of age.

The Building comprising the occupancy at 445 Biltmore Center medical offices was occupied by the Cancer Care of WNC which had its laboratory and information and technology offices on the fifth floor.

The building was constructed in 1982 and was not required by codes to have a sprinkler system at the time of occupancy. Since that time, state code provisions have changed that mandate sprinkler system protection. There were no requirements for retrofitting according to published reports.

The five story building with non-combustible construction classification consisted of approximate 120,000 square feet of space with approximately 20,000 SF per floor level.  

Links

 

The Hyatt Regency Skywalk Collapse 1981; The Begining of Urban Heavy Rescue

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The Hyatt Regency Walkway Collapse July 1981

On July 17, 1981 a suspended walkway collapsed in The Hyatt Regency Hotel  in Kansas City, Missouri, killing 114 people and injuring 216 others during a tea dance. At the time, it was the deadliest structural collapse in U.S. history. This event and a subsequent series of other major incidents in the early and mid 1980′s began the formulative efforts towards defining the emerging field of Urban Heavy Rescue (UHR) that would transition into Urban Search  and Rescue (USAR) in the late 1980′s and early 1990′s. 

Another significant incident occurring in 1981 included the Harbor Cay Condominium Collapse (Cocoa Beach, Florida, 1981). This building was under construction at the time of collapse. Heavy floor and wall construction consisted of precast reinforced concrete slabs and cast-in-place concrete components. All five floors and the roof of the condominium collapsed in a pancake configuration, trapping a large number of construction workers. Eleven were killed and 23 injured. The incident involved more than 60 hours of continuous rescue operations and resources from 5 county fire districts; 16 municipal fire departments; and a response of Civil Defense, military, and private sector technical specialists.

Today marks the thirty year anniverary of the Kansas City event and the lessons learned that continue to be applied towards collapse rescue, urban search and rescue and techncial rescue operations, protocals, techniques, methodologies and preparedness.

On July 17, 1981, approximately 1,600 people gathered in the atrium to participate in and watch a dance competition. Dozens stood on the walkways. At 7:05 PM, the second-level walkway held approximately 40 people with more on the third and an additional 16 to 20 on the fourth level who watched the activities of crowd in the lobby below. The fourth floor bridge was suspended directly over the second floor bridge, with the third floor walkway offset several feet from the others.

Construction difficulties resulted in a subtle but flawed design change that doubled the load on the connection between the fourth floor walkway support beams and the tie rods carrying the weight of both walkways. This new design was barely adequate to support the dead load weight of the structure itself, much less the added weight of the spectators.

The connection failed and the fourth floor walkway collapsed onto the second floor and both walkways then fell to the lobby floor below, resulting in 111 immediate deaths and 216 injuries. Three additional victims died after being evacuated to hospitals making the total number of deaths 114 people.

Direct Link to the 1982 NIST Report, HERE

The hotel had only been in operation for approximately one year at the time of the walkways collapse, and the ensuing investigation of the accident revealed some unsettling facts:

  • During January and February, 1979, the design of the hanger rod connections was changed in a series of events and disputed communications between the fabricator (Havens Steel Company) and the engineering design team (G.C.E. International, Inc., a professional engineering firm). The fabricator changed the design from a one-rod to a two-rod system to simplify the assembly task, doubling the load on the connector, which ultimately resulted in the walkways collapse.
  • The fabricator, in sworn testimony before the administrative judicial hearings after the accident, claimed that his company (Havens) telephoned the engineering firm (G.C.E.) for change approval. G.C.E. denied ever receiving such a call from Havens.
  • On October 14, 1979 (more than one year before the walkways collapsed), while the hotel was still under construction, more than 2700 square feet of the atrium roof collapsed because one of the roof connections at the north end of the atrium failed.
  • In testimony, G.C.E. stated that on three separate occasions they requested on-site project representation during the construction phase; however, these requests were not acted on by the owner (Crown Center Redevelopment Corporation), due to additional costs of providing on-site inspection.
  • Even as originally designed, the walkways were barely capable of holding up the expected load, and would have failed to meet the requirements of the Kansas City Building Code.

 The Kansas City Star has a dedicated memorial website established with images, video and information; HERE 

A look back at the Hyatt Regency Skywalk Disaster, HERE

Kansas City (MO) Fire Department, HERE

Photos from Hyatt Regency Skywalk collapse aftermath, HERE

The high number of dead and injured, the location of the collapse, the size of the collapsed material, and the ineffectiveness of the typical emergency service tools created severe rescue limitations.

The incident required a large number of medical personnel working alongside the rescuers.

Twenty-nine live victims were removed from under the debris during the rescue operations. Heavy rigging and construction specialists and heavy equipment were needed to remove the debris during the rescue operations. large scale rescue operation soon unfolded. Heroes of the evening ranged from a husband who pulled his wife’s trapped foot from the wreckage, to a surgeon who performed an emergency amputation to save a trapped and bleeding victim, to construction crew workers who toiled throughout the night clearing the debris.

A local crane company arrived at the scene to remove sections of collapsed walkway. Dispatchers called in emergency vehicles from throughout the city. Outlying cities such as Belton and Lee’s Summit offered help within minutes of the dispatch calls. Victims were rushed to four nearby hospitals. Donors poured into the Greater Kansas City Community Blood Center. Local talk-show host Walt Bodine broadcast throughout the night. As late as midnight, excavators were trying to reach over a dozen people still trapped under the debris. At 5 a.m., workers uncovered the final 31 bodies from the last slab of concrete to be removed.

The rescue operation lasted well into the next morning and was carried out by a veritable army of emergency personnel, including 34 fire trucks, and paramedics and doctors from five area hospitals. Dr. Joseph Waeckerle directed the rescue effort setting up a makeshift morgue in the ruined lobby and turning the hotel’s taxi ring into a triage center, helping to organize the wounded by highest need for medical care. Those who could walk were instructed to leave the hotel to simplify the rescue effort, the fatally injured were told they were going to die and given morphine.

Workmen from a local construction company were also hired by the city fire department, bringing with them cranes, bulldozers, jackhammers and concrete-cutting power saws.

The biggest challenge to the rescue operation came when falling debris severed the hotel’s water pipes, flooding the lobby and putting trapped survivors at great risk of drowning. As the pipes were connected to water tanks, as opposed to a public source, the flow could not be shut off.

Eventually, Kansas City’s fire chief realized that the hotel’s front doors were trapping the water in the lobby. On his orders, a bulldozer was sent in to rip out the doors, which allowed the water to pour out of the lobby and thus eliminated the danger to survivors.

 

Diagram of the Atrium before the Collapse from the Kansascitystar.com

 

After the Collapse. Diagram from the Kansascitystar.com

Investigators photograph the hanger rods while standing in an aluminum platform designed to change burned out lights in the 5th floor ceiling. Note that the channel beam sections have completely slipped around the supporting nuts leaving the rods, washers, and nuts completely undamaged. The large white material above the rod is fireproofing material. It was later found that the rods were also defective, in that the material used was of a lower strength material than specified. However, this deficiency played no part in the collapse.

Photo of one of the walkway cross-beams, lying on the floor of the lobby. This is one of the 4th floor beams, as evidenced by having two bolt holes drilled through the beam. The 2nd floor beams had a single rod hole.

The Hyatt Regency Hotel walkway collapse did not occur as a result of innovative design, construction or material use, but rather as a product of numerous management errors. It was these fatal management errors that resulted in the flawed construction detail to be used in the support system of the walkways of the Hotel Atrium (Moncarz, Fellow, and Taylor 2000). Various events and disputed communications between G.C.E. engineers and Havens Steel Company resulted in the design change from a single to a double hanger rod box beam connection on the fourth floor walkways (Texas A&M University 2009).
The original design detail of continuous threading of the nut through two stories of the building appeared to be impractical to the contractor and as such he changed the design drawings (Shop Drawing 30 and Erection Drawing E-3) and replaced the original single hanger rod design with a two rod system. In the two rod system, one rod goes from the lower to the upper bridge and the other goes from the upper bridge to the roof truss (Moncarz, Fellow, and Taylor 2000).
This change in the hanger rod more or less doubled the load to be transferred on the 4th floor box beam-hanger rod connection (Marshall 1982). The design load for the fourth floor walkway was 20.3 kips (90 kN) when under the new design system the connection should have had a design load of double that, 40.7 kips (181 kN) (Texas A&M University 2009). The original hanger rod design would have been able to hold the load at the time of the collapse (Marshall 1982).
Within a year, the box beams resting on the supporting rod nuts and washers were deformed, so that the box beam resting on the nuts and washers on the rods could no longer hold up the load, thus the box beams detached from the ceiling rods and the fourth and second floor walkways of the Hotel. Had this change in the hanger rod design not been made, the maximum capacity of the design connection would have been far short of Kansas City building code requirements which require a minimum value of 33.9 kips (151 kN).
The value for the original connection would have been approximately 20.5 kips (91 kN) meaning that the original connection capacity would have been only 60% of what was expected by building codes (Texas A&M University 2009). Apart from the design change, poor management and decisions on the part of the construction firm and engineering firm, and the failure of the connection to meet building codes, other factors resulted in the collapse of the hotel. Quality of workmanship, improper welding and connections, inadequate building material, failure on the part of the hotel to hire building inspectors as well as failure of the building inspectors to allow the building to be occupied despite its hazards were also factors in the collapse (Kieckhafer, Moses, and Warta 2010).
One year into construction on the Hyatt skywalks, G.C.E. Engineers submitted a series of drawings detailing the connections points suspending the walkways to the fabricator, Havens Steel Company.
Originally proposing that a single hanger rod should support the walkways, G.C.E. approved of the fabricator’s suggestion to redesign this connection using two smaller rods. However, a miscommunication occurred between the two groups when neither G.C.E. nor the fabricator made calculations on the strength of the beam, each claiming that they themselves were not responsible. A second opportunity to test the connection points presented itself during the construction phase when the atrium ceiling collapsed: calculations were then made at these crucial points, but not on the skywalk connections. G.C.E. was later held responsible for allowing the design to pass inspection although it was far below Kansas City building codes. Had these points been tested, G.C.E. would have discovered that the critical connections points at these box beams supported only one third of the load capacity required (Nelson 2006).

Close-up of third floor hanger rod and cross-beam, showing yielding of the material. The flanges have been bent significantly, and the webs are bowed out against the fireproofing sheet rock. It should be remembered that the 3rd floor walkway cross beams were subjected to only half the loading of that induced in the 4th floor beams. The distortion shown below was caused by only very light loading, mostly due to the dead load of the structure.

Original Design versus As-Built

LINKS

Check out the following books about the Hyatt Regency disaster held by the Kansas City Public Library:

Continue researching the Hyatt Regency disaster using material held by the Missouri Valley Special Collections:

Additional references:

 

pdf icon Investigation of the Kansas City Hyatt Regency Walkways Collapse. Building Science Series (Final). (57803 K)
Marshall, R. D.; Pfrang, E. O.; Leyendecker, E. V.; Woodward, K. A.; Reed, R. P.; Kasen, M. B.; Shives, T. R.

NBS BSS 143; May 1982. An investigation into the collapse of two suspended walkways within the atrium area of the Hyatt Regency Hotel in Kansas City, Mo., is presented in this report. The investigation included on-site inspections, laboratory tests and analytical studies. Three suspended walkways spanned the atrium at the second, third, and fourth floor levels. The second floor walkway was suspended from the forth floor walkway which was directly above it. In turn, this fourth floor walkway was suspended from the atrium roof framing by a set of six hanger rods. The third floor walkway was offset from the other two and was independently suspended from the roof framing by another set of hanger rods. In the collapse, the second and fourth floor walkways fell to the atrium floor with the fourth floor walkway coming to rest on top of the lower walkway.

  

Chronology Of The Hyatt Regency Walkways Collapse

  • Early 1976: Crown Center Redevelopment Corporation (owner) commences project to design and build a Hyatt Regency Hotel in Kansas City, Missouri.
  • July 1976: Gillum-Colaco, Inc. (G.C.E. International, Inc., 1983), a Texas corporation, selected as the consulting structural engineer for the Hyatt project.
  • July 1976- Hyatt project in schematic design development.
  • Summer 1977: G.C.E. assisted owner and architect (PBNDML Architects, Planners, Inc.) with developing various plans for hotel project, and decided on basic design.
  • Late 1977- Bid set of structural drawings and specifications
  • Early 1978: Project prepared, using standard Kansas City, Missouri, Building Codes.
  • April 4, 1978: Actual contract entered into by G.C.E. and the architect, PBNDML Architects, Planners, Inc. G.C.E. agreed to provide “all structural engineering services for a 750-room hotel project located at 2345 McGee Street, Kansas City, Missouri.”
  • Spring 1978: Construction on hotel begins.
  • August 28, 1978: Specifications on project issued for construction, based on the American Institute of Steel Construction (AISC) standards used by fabricators.
  • December 1978: Eldridge Construction Company, general contractor on the Hyatt project, enters into subcontract with Havens Steel Company. Havens agrees to fabricate and erect the atrium steel for the Hyatt project.
  • January 1979: Events and communications between G.C.E. and Havens.
  • February 1979: Havens makes design change from a single to a double hanger rod box beam connection for use at the fourth floor walkways. Telephone calls disputed; however, because of alleged communications between engineer and fabricator, Shop Drawing 30 and Erection Drawing E3 are changed.
  • February 1979: G.C.E. receives 42 shop drawings (including Shop Drawing 30 and Erection Drawing E-3) on February 16, and returns them to Havens stamped with engineering review stamp approval on February 26.
  • October 14, 1979: Part of the atrium roof collapses while the hotel is under construction. Inspection team called in, whose contract dealt primarily with the investigation of the cause of the roof collapse and created no obligation to check any engineering or design work beyond the scope of their investigation and contract.
  • October 16, 1979: Owner retains an independent engineering firm, Seiden-Page, to investigate the cause of the atrium roof collapse.
  • October 20, 1979: Gillum writes owner, stating he is undertaking both an atrium collapse investigation as well as a thorough design check of all the members comprising the atrium roof.
  • October- Reports and meetings from engineer to clients
  • November 1979: owner/architect assures clients of overall safety of the entire atrium.
  • July 1980: Construction of hotel complete, and the Kansas City Hyatt Regency Hotel opens for business.
  • July 17, 1981: Connections supporting the rods from the ceiling that held up the 2nd and 4th floor walkways across the atrium of the Hyatt Regency Hotel collapse, killing 114 and injuring in excess of 200 others.
  • February 3, 1984: Missouri Board of Architects, Professional Engineers and Land Surveyors files complaint against Daniel M. Duncan, Jack D. Gillum and G.C.E. International Inc., charging gross negligence, incompetence, misconduct and unprofessional conduct in the practice of engineering in connection with their performance of engineering services in the design and construction of the Hyatt Regency Hotel in Kansas City, Missouri.
  • November, 1984: Duncan, Gillum, and G.C.E. International, Inc. found guilty of gross negligence, misconduct and unprofessional conduct in the practice of engineering. Subsequently, Duncan and Gillum lost their licenses to practice engineering in the State of Missouri, and G.C.E. had its certificate of authority as an engineering firm revoked. American Society of Civil Engineering (ASCE) adopts report that states structural engineers have full responsibility for design projects. Duncan and Gillum now practicing engineers in states other than Missouri.
  • Investigators, including David Tonneman (a respected engineering critic), concluded that the basic problem was a lack of proper communication between Jack D. Gillum and Associates, Christopher Willoughby (a University of Michigan engineering student at the time), and Havens Steel.
  • In particular, the drawings prepared by Jack D. Gillum and Associates were only preliminary sketches but were interpreted by Havens as finalized drawings.
  • Jack D. Gillum and Associates failed to review the initial design thoroughly, and accepted Havens’ proposed plan without performing basic calculations that would have revealed its serious intrinsic flaws — in particular, the doubling of the load on the fourth-floor beams.
  • The engineers employed by Jack D. Gillum and Associates who had approved the final drawings were convicted by the Missouri Board of Architects, Professional Engineers, and Land Surveyors of gross negligence, misconduct and unprofessional conduct in the practice of engineering; they all lost their engineering licenses in the states of Missouri and Texas and their membership with ASCE.
  • While Jack D. Gillum and Associates itself was discharged of criminal negligence, it lost its license to be an engineering firm
  •   

The Following is a direct reference to ENGINEERING ETHICS The Kansas City Hyatt Regency Walkways Collapse  pubished by theDepartment of Philosophy and Department of Mechanical Engineering  Texas A&M University  through NSF Grant Number DIR-9012252 Direct Link: http://ethics.tamu.edu/ethics/hyatt/hyatt1.htm

Structural Failure During the Atrium Tea Dance

In 1976, Crown Center Redevelopment Corporation initiated a project for designing and building a Hyatt Regency Hotel in Kansas City Missouri. In July of 1976, Gillum-Colaco, Inc., a Texas corporation, was selected as the consulting structural engineer for the project. A schematic design development phase for the project was undertaken from July 1976 through the summer of 1977. During that time, Jack D. Gillum (the supervisor of the professional engineering activities of Gillum-Colaco, Inc.) and Daniel M. Duncan (working under the direct supervision of Gillum, the engineer responsible for the actual structural engineering work on the Hyatt project) assisted Crown Center Redevelopment Corporation (the owner) and PBNDML Architects, Planners, Inc. (the architect on the project) in developing plans for the hotel project and deciding on its basic design. A bid set of structural drawings and specifications for the project were prepared in late 1977 and early 1978, and construction began on the hotel in the spring of 1978. The specifications on the project were issued for construction on August 28, 1978.

On April 4, 1978, the actual written contract was entered into by Gillum-Colaco, Inc. and PBNDML Architects, Planners, Inc. The contract was standard in nature, and Gillum-Colaco, Inc. agreed to provide all the structural engineering services for the Hyatt Regency project. The firm Gillum-Colaco, Inc. did not actually perform the structural engineering services on the project; instead, they subcontracted the responsibility for performing all of the structural engineering services for the Hyatt Regency Hotel project to their subsidiary firm, Jack D. Gillum & Associates, Ltd. (hereinafter referenced as G.C.E.).7 According to the specifications for the project, no work could start until the shop drawings for the work had been approved by the structural engineer.

Three teams, with particular roles to play in the construction system employed in building the Hyatt Regency Hotel, were contracted for the project: PBNDML and G.C.E. made up the “design team,” and were authorized to control the entire project on behalf of the owner; Eldridge Construction Co., as the “construction team,” was responsible for general contracting; and the “inspection team,” made up of two inspecting agencies (H&R Inspection and General Testing), a quality control official, a construction manager, and an investigating engineer (Seiden and Page).

On December 19, 1978, Eldridge Construction Company, as general contractor, entered into a subcontract with Havens Steel Company, who agreed to fabricate and erect the atrium steel for the Hyatt project.

G.C.E. was responsible for preparing structural engineering drawings for the Hyatt project: three walkways spanning the atrium area of the hotel. Wide flange beams with 16-inch depths (W16x26) were used along either side of the walkway and hung from a box beam (made from two MC8x8.5 rectangular channels, welded toe-to-toe). A clip angle welded to the top of the box beam connected these beams by bolts to the W section. This joint carried virtually no moment, and therefore was modeled as a hinge. One end of the walkway was welded to a fixed plate and would be a fixed support, but for simplicity, it could be modeled as a hinge. This only makes a difference on the hanger rod nearest this support (it would carry less load than the others and would not govern design). The other end of the walkway support was a sliding bearing modeled by a roller. The original design for the hanger rod connection to the fourth floor walkway was a continuous rod through both walkway box beams (Figure 1 below).

Events and disputed communications between G.C.E. engineers and Havens resulted in a design change from a single to a double hanger rod box beam connection for use at the fourth floor walkways. The fabricator requested this change to avoid threading the entire rod. They made the change, and the contract’s Shop Drawing 30 and Erection Drawing E-3 were changed (Figure 2 shows the hanger rod as built).

On February 16, 1979, G.C.E. received 42 shop drawings (including the revised Shop Drawing 30 and Erection Drawing E-3). On February 26, 1979, G.C.E. returned the drawings to Havens, stamped with Gillum’s engineering review seal, authorizing construction. The fabricator (Havens) built the walkways in compliance with the directions contained in the structural drawings, as interpreted by the shop drawings, with regard to these hangers. In addition, Havens followed the American Institute of Steel Construction (AISC) guidelines and standards for the actual design of steel-to-steel connections by steel fabricators.

As a precedent for the Hyatt case, the Guide to Investigation of Structural Failure‘s Section 4.5, “Failure Causes Classified by Connection Type,” states that:

Overall collapses resulting from connection failures have occurred only in structures with few or no redundancies. Where low strength connections have been repeated, the failure of one has lead to failure of neighboring connections and a progressive collapse has occurred. The primary causes of connection failures are:

  1. Improper design due to lack of consideration of all forces acting on a connection, especially those associated with volume changes.
  2. Improper design utilizing abrupt section changes resulting in stress concentrations.
  3. Insufficient provisions for rotation and movement.
  4. Improper preparation of mating surfaces and installation of connections.
  5. Degradation of materials in a connection.
  6. Lack of consideration of large residual stresses resulting from manufacture or fabrication.

On October 14, 1979, part of the atrium roof collapsed while the hotel was under construction. As a result, the owner called in the inspection team. The inspection team’s contract dealt primarily with the investigation of the cause of the roof collapse and created no obligation to check any engineering or design work beyond the scope of their investigation and contract. In addition to the inspection team, the owner retained, on October 16, 1979, an independent engineering firm, Seiden-Page, to investigate the cause of the atrium roof collapse. On October 20, 1979, G.C.E.’s Gillum wrote the owner, stating that he was undertaking both an atrium collapse investigation as well as a thorough design check of all the members comprising the atrium roof. G.C.E. promised to check all steel connections in the structures, not just those found in the roof.

From October-November, 1979, various reports were sent from G.C.E. to the owner and architect, assuring the overall safety of the entire atrium. In addition to the reports, meetings were held between the owner, architect and G.C.E.

In July of 1980, the construction was complete, and the Kansas City Hyatt Regency Hotel was opened for business.

Just one year later, on July 17, 1981, the box beams resting on the supporting rod nuts and washers were deformed, so that the box beam resting on the nuts and washers on the rods could no longer hold up the load. The box beams (and walkways) separated from the ceiling rods and the fourth and second floor walkways across the atrium of the Hyatt Regency Hotel collapsed, killing 114 and injuring in excess of 200 others.

One investigation report gave the following summary:

The Hyatt Regency consists of three main sections: a 40-story tower section, a function block, and a connecting atrium. The atrium is a large open area, approximately 117 ft (36 m) by 145 ft (44 m) in plan and 50 ft (15 m) high. Three suspended walkways spanned the atrium at the second, third and fourth floor levels [see Figure 3 on following page]. These walkways connected the tower section and the function block. The third floor walkway was independently suspended from the atrium roof trusses while the second floor walkway was suspended from the fourth floor walkway, which in turn was suspended from the roof framing.

In the collapse, the second and fourth floor walkways fell to the atrium first floor with the fourth floor walkway coming to rest on top of the second. Most of those killed or injured were either on the atrium first floor level or on the second floor walkway. The third floor walkway was not involved in the collapse.

Following the accident investigations, on February 3, 1984, the Missouri Board of Architects, Professional Engineers and Land Surveyors filed a complaint against Daniel M. Duncan, Jack D. Gillum, and G.C.E. International, Inc., charging gross negligence, incompetence, misconduct and unprofessional conduct in the practice of engineering in connection with their performance of engineering services in the design and construction of the Hyatt Regency Hotel. The NBS report noted that:

The hanger rod detail actually used in the construction of the second and fourth floor walkways is a departure from the detail shown on the contract drawings. In the original arrangement each hanger rod was to be continuous from the second floor walkway to the hanger rod bracket attached to the atrium roof framing. The design load to be transferred to each hanger rod at the second floor walkway would have been 20.3 kips (90 kN). An essentially identical load would have been transferred to each hanger rod at the fourth floor walkway. Thus the design load acting on the upper portion of a continuous hanger rod would have been twice that acting on the lower portion, but the required design load for the box beam hanger rod connections would have been the same for both walkways (20.3 kips (90 kN)).11

The hanger rod configuration actually used consisted of two hanger rods: the fourth floor to ceiling hanger rod segment as originally detailed on the second to fourth floor segment which was offset 4 in. (102 mm) inward along the axis of the box beam. With this modification the design load to be transferred by each second floor box beam-hanger rod connection was unchanged, as were the loads in the upper and lower hanger rod segments. However, the load to be transferred from the fourth floor box beam to the upper hanger rod under this arrangement was essentially doubled, thus compounding an already critical condition. The design load for a fourth floor box beam-hanger rod connection would be 40.7 kips (181 kN) for this configuration. …

Had this change in hanger rod detail not been made, the ultimate capacity of the box beam-hanger rod connection still would have been far short of that expected of a connection designed in accordance with the Kansas City Building Code, which is based on the AISC Specification. In terms of ultimate load capacity of the connection, the minimum value should have been 1.67 times 20.3, or 33.9 kips (151 kN). Based on test results the mean ultimate capacity of a single-rod connection is approximately 20.5 kips (91 kN), depending on the weld area. Thus the ultimate capacity actually available using the original connection detail would have been approximately 60% of that expected of a connection designed in accordance with AISC Specifications.12

During the 26-week administrative law trial that ensued, G.C.E. representatives denied ever receiving the call about the design change. Yet, Gillum affixed his seal of approval to the revised engineering design drawings.

Results of the hearing concluded that G.C.E., in preparation of their structural detail drawings, “depicting the box beam hanger rod connection for the Hyatt atrium walkways, failed to conform to acceptable engineering practice. [This is based] upon evidence of a number of mistakes, errors, omissions and inadequacies contained on this section detail itself and of [G.C.E.'s] alleged failure to conform to the accepted custom and practice of engineering for proper communication of the engineer’s design intent.”13 Evidence showed that neither due care during the design phase, nor appropriate investigations following the atrium roof collapse were undertaken by G.C.E. In addition, G.C.E. was found responsible for the change from a one-rod to a two-rod system. Further, it was found that even if Havens failed to review the shop drawings or to specifically note the box beam hanger rod connections, the engineers were still responsible for the final check. Evidence showed that G.C.E. engineers did not “spot check” the connection or the atrium roof collapse, and that they placed too much reliance on Havens.

Due to evidence supplied at the Hearings, a number of principals involved lost their engineering licenses, a number of firms went bankrupt, and many expensive legal suits were settled out of court. In November, 1984, Duncan, Gillum, and G.C.E. International, Inc. were found guilty of gross negligence, misconduct and unprofessional conduct in the practice of engineering. Subsequently, Duncan and Gillum lost their licenses to practice engineering in the State of Missouri (and later, Texas), and G.C.E. had its certificate of authority as an engineering firm revoked.

As a result of the Hyatt Regency Walkways Collapse, the American Society of Civil Engineering (ASCE) adopted a report that states structural engineers have full responsibility for design projects.

Both Duncan and Gillum are now practicing engineers in states other than Missouri and Texas.

The responsibility for and obligation to design steel-to-steel connections in construction lies at the heart of the Hyatt Regency Hotel project controversy. To understand the issues of negligence and the engineer’s design responsibility, we must examine some key elements associated with professional obligations to protect the public. This will be discussed in class from three perspectives: the implicit social contract between engineers and society; the issue of public risk and informed consent; and negligence and codes of ethics of professional societies.

Annotated Bibliography

Davis, Michael, “Thinking Like An Engineer: The Place of a Code of Ethics in the Practice of a Profession,” Philosophy & Public Affairs, Vol. 20, No. 2, Spring 1991, pp. 150-167. (see also, “Explaining Wrongdoing,” Journal of Social Philosophy, Vol. 20, Numbers 1&2, Spring/Fall 1989, pp. 74-90.

In these lucid essays, Davis argues that “a code of professional ethics is central to advising individual engineers how to conduct themselves, to judging their conduct, and ultimately to understanding engineering as a profession.” Using the now infamous Challenger disaster as his model, Davis discusses both the evolution of engineering ethics as well as why engineers should obey their professional codes of ethics, from both a pragmatic and ethically-responsible point of view. Essential reading for any graduating engineering student.

Engineering News Report.

Throughout the hearings, Engineering News Report, published by the National Society of Professional Engineers (NSPE), kept vigilant watch over the case. Of particular interest are their following articles:

  • “Hyatt Walkway Design Switched,” July 30, 1981.
  • “Hyatt Hearing Traces Design Change,” July 26, 1984.
  • “Difference of Opinion: Hyatt Structural Engineer Gillum Disputes NBS Collapse Report,” September 6, 1984.
  • “Weld Aided Collapse, Witness Says,” September 13, 1984.
  • “Judge Bars Hyatt Tests,” September 20, 1984.
  • “Hyatt Engineers Found Guilty of Negligence,” November 21, 1985.
  • “Hyatt Ruling Rocks Engineers,” November 28, 1985.
  • “Construction Rescuers Sue,” August 7, 1986.

Glickman, Theodore S., and Michael Gough (eds.), Readings in Risk, Washington, D.C.: Resources for the Future, 1990.

This is an excellent collection of essays on managing technology-induced risk. As a starting-off point, of particular worth to the engineers are the essays: “Probing the Question of Technology-Induced Risk” and “Choosing and Managing Technology-Induced Risk,” by M. Granger Morgan; “Defining Risk,” by Baruch Fischhoff, Stephen R. Watson, and Chris Hope; “Risk Analysis: Understanding ‘How Safe is Safe Enough?’,” by Stephen L. Derby and Ralph L. Keeney; “Social Benefit Versus Technological Risk,” by Chauncey Starr; and “The Application of Probabilistic Risk Assessment Techniques to Energy Technologies,” by Norman C. Rasmussen.

Gibble, Kenneth (ed.), Management Lessons from Engineering Failures, Proceedings of a symposium sponsored by the Engineering Management Division of the American Society of Civil Engineers in conjunction with the ASCE Convention in Boston, October 28, 1986, New York: American Society of Civil Engineers, 1986.

This short work examines a variety of engineering failures, including those involving individual planning, and project failures. In particular see Irvin M. Fogel’s essay, “Avoiding ‘Failures’ Caused by Lack of Management,” and Gerald W. Farquhar’s “Lessons to be Learned in the Management of Change Orders in Shop Drawings,” both excellent illustrations for use with the Hyatt case.

Hall, John C., “Acts and Omissions,” The Philosophical Quarterly, Vol. 39, No. 157, October 1989, pp. 399-408.

This article is a discussion of the legal and ethical ramifications of professional choices and activities, both active and passive.

“Hyatt Notebook: Parts I and II,” Kansas City, October 1984 and November 1984.

These are two articles written by a Kansas City television reporter for the local magazine, Kansas City, detailing highlights from the 26-week Hyatt Regency Walkways Collapse hearings.

Janney, Jack R. (ed.), Guide to Investigation of Structural Failures, prepared for the American Society of Civil Engineers’ Research Council on Performance of Structures, sponsored by the Federal Highway Administration, U.S. Department of Transportation, Contract No. DOTFH118843, 1979.

This short volume gives an excellent overview of structural failure investigation procedures, and discusses failure causes by project type, structural type, and material, connection and foundation type. In addition, discussions on field operations, project management, and data analysis and reports are offered. Of particular interest to those studying the Hyatt case are sections 4.5-4.7, “Failure Causes Classified by Connection Type,” and “Steel to Steel Connections.”

Martin, Mike W. and Roland Schinzinger, Ethics in Engineering (2nd ed.), New York: McGraw-Hill Book Company, 1989.

An excellent text-book treatment of ethical issues in engineering. Of particular interest to this case is Part Two, “The Experimental Nature of Engineering,” and Part Three, “Engineers, Management and Organizations.”

McK Norrie, Kenneth, “Reasonable: The Keystone of Negligence,” Journal of Medical Ethics, Vol. 13, No. 2, June 1987, pp. 92-94.

This article is a brief discussion of legal liability for professional actions. “The more knowledge, skill and experience a person has, the higher standard the law subjects that person to” (p. 92).

PDF version: Missouri Board for Architects, Professional Engineers and Land Surveyors vs. Daniel M. Duncan, Jack D. Gillum and G.C.E. International, Inc., before the Administrative Hearing Commission, State of Missouri, Case No. AR840239, Statement of the Case, Findings of Fact, Conclusions of Law and Decision rendered by Judge James B. Deutsch, November 14, 1985, 442 pp. Note this is a BIG file – 20 Mb!

Word version: Missouri Board for Architects, Professional Engineers and Land Surveyors vs. Daniel M. Duncan, Jack D. Gillum and G.C.E. International, Inc., before the Administrative Hearing Commission, State of Missouri, Case No. AR840239, Statement of the Case, Findings of Fact, Conclusions of Law and Decision rendered by Judge James B. Deutsch, November 14, 1985, 442 pp. This has been changed to Word format, without any checking. Many errors are found when the scanner attempted to transcribe the pdf file to Word, but no one has found the time to correct the conversion

This volume contains the findings, conclusions of law and the final decision of the Hyatt Regency Walkways Collapse case, as rendered by Judge James B. Deutsch. The volume contains both the findings of the case and an excellent general discussion of responsibilities of the professional engineer.

Pfrang, Edward O. and Richard Marshall, “Collapse of the Kansas City Hyatt Regency Walkways,” Civil Engineering-ASCE, July 1982, pp. 65-68.

Official findings of the failure investigation conducted by the National Bureau of Standards, U.S. Department of Commerce. Among its conclusions was this: “Even if the now-notorious design shift in the hanger rod details had not been made, the entire design of all three walkways, including the one which did not collapse, was a significant violation of the Kansas City Building Code.”

 

Lobby Area

 

June 1981

 

Post Collapse

 

MCI Triage Operations

 

Cross Section Architectural Diagram of Walkways

Schematic View of the Walkways

Cross Section Construction Detail of the Walkway

Large Loss Building Fires Report

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Photo Dave Bullock http://eecue.com/

 

The Federal Emergency Management Agency’s (FEMA) United States Fire Administration (USFA) have recently issued a special report examining the characteristics and causes of Large Loss Building Fires (PDF, 834 Kb). 

The report, developed by USFA’s National Fire Data Center, is based on 2007 to 2009 data from the National Fire Incident Reporting System (NFIRS).

  • From 2007 to 2009, an estimated 900 large loss building fires were reported by U.S. fire departments annually. 
  • These fires caused an estimated 35 deaths, 100 injuries, and $2.8 billion dollars in property damage. 
  • In this report, large loss building fires are defined as fires that resulted in a total dollar loss of $1 million or more.

According to the report:

  • Forty-eight percent of large loss fires occur in residential buildings.
  • Exposures are the leading cause of large loss building fires at 22 percent, followed by electrical malfunctions (12 percent), other unintentional, careless actions (11 percent), and intentional (9 percent).
  • A peak in large loss building fires is seen between the hours of 1 a.m. and 4 a.m.
  • Attics are the primary origin of all large loss building fires, along with cooking areas or kitchens.

Large Loss Building Fires (PDF, 834 Kb) is part of the USFA’s  Topical Fire Report Series. 

Topical reports explore facets of the U.S. fire problem as depicted through data collected in NFIRS.  Each topical report briefly addresses the nature of the specific fire or fire-related topic, highlights important findings from the data, and may suggest other resources to consider for further information.

Also included are recent examples of fire incidents that demonstrate some of the issues addressed in the report or that put the report topic in context.

Examples

The following are some recent examples of large loss fires reported by the media:

  • October 2010: A fire in a Franklin, TN, home resulted in $2.5 million worth of damage. The cause of the fire is still unknown, but the fire began in a patio fireplace. The family of four present in the house at the time of the fire was able to escape safely. Four firefighters were injured while fighting the fire; two of them were treated at the scene and two were sent to the hospital for minor injuries.
  • June 2010: A Palo Alto, CA, two-alarm house fire caused between $1 and $2 million worth of damage. The family of four living in the house was awoken by their son when he heard the smoke alarm. The fire is believed to have been started by an unattended candle or cigarette the son left in a second-story room. The fire was brought under control in about 45 minutes and no deaths or injuries were reported.
  • June 2010: A fire that started in a Carmel, IN, shopping mall is believed to have been caused by lightning. Investigators have determined that the fire started in a restaurant located at the north end of the mall. There were no deaths or injuries as a result of the fire, but investigators estimate that the fire caused over $5 million worth of damage.
  • May 2009: A fire that started in a Gallery Furniture storage warehouse located in Houston, TX, resulted in at least $15 million worth of damage. Investigators have determined that the fire was caused by arson. Thirty to 40 employees were present when the fire broke out. The fire was determined to have been started in an area only accessible to employees. There were no injuries or deaths as a result of the fire.

 

Contributing Factors

Additional reports of interests include;


View more videos at: http://www.nbcdfw.com.

National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program

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Video Clip recorded live by Fire Department Network News TV (FDNNTV) at the 50th IAFF Fire Fighter Convention in San Diego, CA on August 23, 2010.

The National Institute for Occupational Safety and Health, also known as NIOSH, is a federal agency that is part of the Centers for Disease Control. NIOSH has a mission of generating new knowledge in the occupational safety and health field and to transfer that knowledge into practice for the advancement of workers, including firefighters and emergency responders.

In 1998, the International Association of Fire Fighters (IAFF) requested that Congress fund NIOSH to start a firefighter safety initiative called the NIOSH Fire Fighter Fatality Investigation and Prevention Program.  “We investigate fatalities to learn from the mistakes the others made and to try to prevent future fatalities and injuries from occurring in similar events,” stated Project Officer Tim Merinar with the NIOSH Fire Fighter Fatality Investigation and Prevention Program. According to NIOSH, the Fire Fighter Fatality Investigation Program has made over 1,000 recommendations arising from over 300 investigations since its inception in 1998.

Merinar claimed that some do not fully understand who NIOSH is and what their goals are, often being confused with OSHA. However, the National Institute for Occupational Safety and Health is not an enforcement agency, they are a research and education agency. Merinar added, “We’re not looking to find fault or place blame on the fire departments or the individual firefighters in the incidents.”

As soon as possible after an incident, a NIOSH investigator will meet with the fire department. “Oftentimes, we have to explain who we are, why we’re there, what we’re trying to accomplish,” added Merinar. NIOSH investigates as many firefighter fatalities as possible involving structure fires, deaths from cardiovascular disease, as well as deaths during non-fireground incidents.

NIOSH offers many different publications to firefighters, including their newest one about risk management at structure fires. This literature is distributed to the fire service free of charge. Another publication offered to firefighters deals with floor joists and the risk of falling through fire-damaged floors. “They work very well for the construction industry, but when they’re exposed to fire they also fail very rapidly. Which leads to early building collapses,” explained Merinar. “Many firefighters have been injured and killed in these collapses.”

NIOSH FFFIPP

Trends such as this uncovered during their investigations and spread to the fire service, could help prevent future deaths. Another trend found several years ago by NIOSH involved PASS devices not sounding on firefighters who died. According to Merinar, NIOSH worked with the National Fire Protection Association to have the standard changed to make the PASS devices more reliable and more effective for firefighters. Currently, they are working with the NFPA on the thermal degradation characteristics of face piece lenses.

Fire Fighter Fatality Investigation and Prevention Program

For more information on the NIOSH Fire Fighter Fatality Investigation and Prevention Program, incident reports or fire fighter publications, visit www.cdc.gov/niosh/fire/.

Cold-Storage and Warehouse Building Fire

Topic Index:

Reports and Publications
  Safety Advisories
  Fatality Reports
  Pending Investigations
  Safety Quizzes
  Publications
Program Information
  Program Description
  What to Expect During a NIOSH Investigation
  Public Comment Docket
  Future Directions
  Inspector General’s Program Review
  IAFC’s Program Review
  Fire Fighter Fatality Investigation and Prevention Program Evaluation
  Strategic Plan – 2009

 

NIOSH Request for Comment on the Fire Fighter Fatality Investigation and Prevention Program The NIOSH Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) is seeking stakeholder input to ensure that the FFFIPP program is meeting the needs and expectations of the fire service, and to identify ways in which the program can be improved to increase its impact on the safety and health of fire fighters across the United States. Additional information can be found in the FFFIPP Progress Report and Proposed Future Directions document.

Stakeholder Comment on the National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program (FFFIPP)-2011
The National Institute for Occupational Safety and Health (NIOSH) is seeking stakeholder input on the progress and future directions of the Fire Fighter Fatality Investigation and Prevention Program (FFFIPP). Since its initiation in 1998, NIOSH has sought public input to help plan and direct the goals and objectives of the FFFIPP. NIOSH received public comments on the FFFIPP in 1998, March 2006, and November 2008. NIOSH is again seeking input on the progress and future directions of the FFFIPP to ensure that the program is meeting the needs and expectations of the U.S. fire service and to identify ways in which the program can improve its impact on the safety and health of fire fighters across the United States. NIOSH will compile and consider all comments received and use them in making decisions on how to proceed with the FFFIPP.

There are several resources that may be useful to individuals and groups who would like to comment on the FFFIPP:

  • The NIOSH Fire Fighter Fatality Investigation and Prevention Program Progress (FFFIPP) Report and Proposed Future Directions – 2011. This document includes specific topics for stakeholder input.
  • The Strategic Plan for the NIOSH Fire Fighter Fatality Investigation and Prevention Program that was finalized in 2009 after public input.
  • The FFFIPP web site that includes an overview of the FFFIPP, fatality investigation reports and other publications.

Related Dockets
NIOSH Docket number 063NIOSH Docket number 063-A
——————————————————————————–

Public Comment Period
Written comments on the document will be accepted through July 29, 2011 in accordance with the instructions below. All material submitted to NIOSH should reference Docket Number NIOSH-063-B. All electronic comments should be formatted as Microsoft Word documents and make reference to docket number NIOSH-063-B.

Comments will be accepted until 5:00 p.m. EDT on July 29, 2011

To submit comments, please use one of these options:

  • Send NIOSH comments using this online form
  • Send comments by email.
  • Fax comments to the NIOSH Docket Office: 513-533-8285
  • Send by Mail to:
    NIOSH Mailstop: C-34
    Robert A. Taft Lab.
    4676 Columbia Parkway
    Cincinnati, Ohio 45226
    All information received in response to this notice will be available for public examination and copying at the …
    NIOSH Docket Office
    4676 Columbia Parkway, Room 111
    Cincinnati, Ohio 45226.

A complete electronic docket containing all comments submitted will be available on the NIOSH docket home page, and comments will be available in writing by request. NIOSH includes all comments received without change in the docket, including any personal information provided.

Contact persons for technical information

  • Paul Moore
    Chief, Fatality Investigations Team
    NIOSH/CDC
    1095 Willowdale Road
    Mailstop H-1808
    Morgantown, WV 26505
    304/285-6016

Recent NIOSH Fire Fighter Safety Publications

Preventing Deaths and Injuries of Fire Fighters Operating Modified Excess/Surplus Vehicles
DHHS (NIOSH) Publication No. 2011-125
Fire fighters may be at risk for crash-related injuries while operating excess and other surplus vehicles that have been modified for fire service use. Fire departments with limited resources often craft fire apparatus out of excess/surplus military and other vehicles as an affordable alternative to purchasing new or used apparatus. NIOSH urges fire departments to take precautions and actions to minimize the hazards and risks to fire fighters when using modified excess/surplus vehicles.

Evaluation of Chemical and Particle Exposures During Vehicle Fire Suppression Training (2010)this document in PDF (56 pages, 4.85 MB)
Health Hazard Evaluation Report, HETA 2008-0241-3113
In September 2008 and July 2009, NIOSH researchers collected area and personal breathing zone air samples during a Health Hazard Evaluation (HHE) to evaluate firefighters’ exposures to airborne chemicals during vehicle fire suppression training. Several hazardous chemicals were found on the area samples, including respiratory toxicants and potential carcinogens. Of the chemicals measured in the personal breathing zones, levels of formaldehyde, carbon monoxide, and isocyanates were near or above short term exposure limits or ceiling limits. In addition, the number of particles and mass of the particles in the air increased during knockdown and remained elevated throughout the fire overhaul. Based on this evaluation, the levels of gases and particles released during vehicle fires have the potential to cause acute health effects to firefighters who do not wear self-contained breathing apparatus.

NIOSH Alert: Preventing Deaths and Injuries of Fire Fighters using Risk Management Principles at Structure Fires
DHHS (NIOSH) Publication No. 2010-153
Fire fighters are often killed or injured when fighting fires in abandoned, vacant, and unoccupied structures. These structures pose additional and sometimes unique risks due to the potential for fire fighters to encounter unexpected and unsafe building conditions such as dilapidation, decay, damage from previous fires and vandals, and other factors such as uncertain occupancy status. Risk management principles must be applied at all structure fires to ensure the appropriate strategy and tactics are used based on the fireground conditions encountered.

Preventing Exposures to Bloodborne Pathogens among Paramedics
DHHS (NIOSH) Publication No. 2010-139
Patient care puts paramedics at risk of exposure to blood. These exposures carry the risk of infection from bloodborne pathogens such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), which causes AIDS. A national survey of 2,664 paramedics contributed new information about their risk of exposure to blood and identified opportunities to control exposures and prevent infections.

Preventing Deaths and Injuries of Fire Fighters Working Above Fire-Damaged Floors
DHHS (NIOSH) Publication No. 2009-114
Fire fighters are at risk of falling through fire-damaged floors.

Fire Fighter Fatality Investigation and Prevention Program: Leading Recommendations for Preventing Fire Fighter Fatalities, 1998–2005
DHHS (NIOSH) Publication No. 2009-100
This document is a synthesis of the 1,286 individual recommendations from the 335 FFFIPP investigations conducted from 1998 to 2005.

Fire Fighter Fatality Investigation and Prevention Program Evaluation
NIOSH report of findings from its national survey of U.S. fire departments.

Preventing Fire Fighter Fatalities Due to Heart Attacks and Other Sudden Cardiovascular Events
DHHS (NIOSH) Publication No. 2007-133
Fire fighters are at risk of dying on the job from preventable cardiovascular conditions.

FDA AND NIOSH Public Health Notification: Oxygen Regulator Fires Resulting from Incorrect Use of CGA 870 Seals External Web Site Policy
This document provides information on the danger of fires at the interface of oxygen regulators and cylinder valves because of incorrect use of CGA 870 seals, and identifies measures to prevent such fires.

NIOSH Alert: Preventing Injuries and Deaths of Fire Fighters due to Truss System Failures
DHHS (NIOSH) Publication No. 2005-132
Fire fighters may be injured and killed when fire-damaged roof and floor truss systems collapse, sometimes without warning.

NIOSH Workplace Solutions—Preventing Deaths and Injuries to Fire Fighters During Live-Fire Training in Acquired Structures
DHHS (NIOSH) Publication No. 2005-102
Fire fighters are subjected to many hazards when participating in live-fire training. Training facilities with approved burn buildings should be used for live-fire training whenever possible. However, when acquired structures are used for live-fire training, NIOSH strongly recommends that fire departments follow the national consensus guidelines in NFPA 1403, standard on live-fire training evolutions [NFPA 2002a] to reduce the risk of injury and death. These guidelines are summarized in the recommendations in this document.

Radio Communication

The past few decades have seen major advancements in the communication industry. These advancements have improved radio frequency spectrum efficiency, but also have added complexity to the expansion of existing systems and the design of new systems. The U.S. Fire Administration in conjunction with the International Association of Fire Fighters has released the report Voice Radio Communications Guide for the Fire Service External Web Site Policy this document in PDF 3.85 MB (77 pages) This report is designed to help fire service leaders and members understand new communication and radio system issues in order to remain informed players in the process.

Current Status, Knowledge Gaps, and Research Needs Pertaining to Firefighter Radio Communication Systems
The National Institute for Occupational Safety and Health (NIOSH) commissioned this study to identify and address specific deficiencies in firefighter radio communications and to identify technologies that may address these deficiencies. Specifically to be addressed were current and emerging technologies that improve, or hold promise to improve, firefighter radio communications and provide firefighter location in structures.

The National Institute of Standards and Technology, Building and Fire Research Laboratory publication “Testing of Portable Radios in a Fire Fighting EnvironmentExternal Web Site Policy this document in PDF 265 KB (24 pages)
focuses on the thermal environment that radios would be expected to withstand while being used in structural fire fighting operations. Current NFPA standards for radios are reviewed and recommendations for establishing performance standards are presented. The need for providing additional protection from the thermal environment is documented.

Remembering Hackensack and Gloucester

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Hackensack (NJ) Ford Fire July 1, 1988

As we approach the July 4th holiday period, two significant LODD incidents previously occurred during this time frame that hold a number of lessons learned related to command management, operations, building construction principles and building performance, fire behavior and the ever present dangers of the job.

Take the opportunity to learn more about these events, and expand your insights and knowledge base.

Take a moment to reflect upon the supreme sacrifice made by these heroic firefighters and the messages that lay within the pages of the incident case studies, reports and summaries.

There’s a lot of practical safety and operational information on these events along with a tremendous volume of information in the various text books on strategy and tactics, incident command and building construction.

Learn from the past so we don’t repeat it. Remember- NO MORE HISTORY REPEATING EVENTS!

The Hackensack Ford Fire & Collapse occurred nearly ten years AFTER another tragic LODD event involving a bowstring truss roof collapse; the August 2nd, 1978 FDNY Waldbaum’s Fire, Brooklyn, New York that took the lives of six FDNY firefighters.

Street Smarts for Safety and Survival…………Stay safe.
Additional Relevant Safety considerations, HERE and HERE

Twenty-Three Year Anniversary Hackensack Ford Fire and Truss roof collapse, Hackensack Fire Department. July 1st, 1988

Pause to remember our brothers who made the ultimate sacrifice twenty-three years ago, on July 1st, 1988 and the lessons learned from this event.

On July 1, 1988 Hackensack’s Captain RICHARD L. WILLIAMS, Lieutenant RICHARD REINHAGEN, Firefighter WILLIAM KREJSA, firefighter LEONARD RADUMSKI, and Firefighter STEPHEN ENNIS lost their lives at Hackensack Ford when a bowstring arch truss collapsed entrapping them in the area below. The five firefighters were in the structure, a bowstring truss building, when the roof suddenly collapsed a 60-foot square section of the building’s wood bowstring truss roof collapsed, and an intense fire immediately engulfed the area. Williams, Kresja and Radumski were killed instantly, and four other firefighters escaped. Reinhagen and Ennis survived the initial collapse and found refuge in a tool room where they spent the next 13 minutes calling for help.. . despite heroic rescue attempts, succumbed to carbon monoxide poisoning. Approximately 90 minutes after the collapse, firefighters located the bodies of their fallen comrades.

Three (3) building factors contributed to the collapse of this bowstring trussed roof:

• Alterations that consisted of a heavy ceiling of cementitious material on wire lathe;
• Auto parts storage in the attic; and
• The Fire burned for a significant length of time and was well advanced prior to detection.
• This roof collapsed 35 Minutes after the initial units arrived.

Remember:
• CAPT. RICHARD L. WILLIAMS, Engine Co. No. 304
• LIEUT. RICHARD REINHAGEN, Engine Co. No. 302
• F/F WILLIAM KREJSA, Engine Co. No. 301
• F/F LEONARD RADUMSKI, Engine Co. No. 302
• F/F STEPHEN ENNIS, Rescue Co. No. 308

NFPA SUMMARY
Hackensack, New Jersey Fire Fighter Fatalities July 1, 1988

Five fire fighters from the Hackensack, New Jersey Fire Department were killed while they were engaged in interior fire suppression efforts at an automobile dealership when portions of the building’s wood bowstring truss roof suddenly collapsed. The incident occurred on Friday, July 1, 1988, at approximately 3:00 p.m., when the fire department began to receive the first of a series of telephone calls reporting “flames and smoke” coming from the roof of the Hackensack Ford Dealership.

Two engines, a ladder company, and a battalion chief responded to the first alarm assignment. The first arriving fire fighters observed a “heavy smoke condition” at the roof area of the building. Engine company crews investigated the source of the smoke inside the building while the truck company crew assessed conditions on the roof. For the next 20 minutes, the focus of the suppression effort was concentrated on these initial tactics.

During this time, however, little headway appeared to have been made by the initial suppression efforts, and the magnitude of the fire continued to grow. The overall fire ground tactics were shifted to a more “defensive” posture (exterior operation) and the battalion chief gave the order to “back your lines out.” However, before suppression crews could exit form the interior, a sudden partial collapse of the truss roof occurred, trapping six fire fighters. An intense fire immediately engulfed the area of the collapse. One trapped fire fighter was able to escape through an opening in the debris. The other five died as a result of the collapse. This incident and several others before and since, provide important lessons to the fire service regarding the fire ground hazards of wood truss roof assemblies.

This NFPA Summary may be reproduced in whole or in part for fire safety educational purposes as long as the meaning of the summary is not altered, credit is given to NFPA and the copyright of the NFPA is protected.

Following is an excerpt from the New York Times article:
Demers contended that Chief Williams, primarily because of the volume of fire on the rooftop, should have ordered nine firefighters out of the garage within 7 minutes of his arrival. The order to pull out was given at 3:34 p.m., about 30 minutes after his arrival, the report said.

  • “This radio message was not acknowledged by any companies,” the report said.

The roof collapsed at 3:36 p.m. Three firefighters were hit by burning debris and killed, four escaped, and two, Lieut. Richard R. Reinhagen and Stephen Ennis, took refuge in the tool room.

  • At 3:39 p.m., Lieutenant Reinhagen began to radio his location and appeal for help, the report said.

In one of the major communications flaws cited by Mr. Demers at the fire scene, all departmental communications were transmitted on a single channel, or frequency. Consequently, Lieutenant Reinhagen’s appeals for help were intermingled with orders for deploying men and hoses and instructions to arriving companies.

  • “You have to hurry, we’re running out of air,” Lieutenant Reinhagen said at 3:42 p.m.

Headquarters then radioed to Chief Williams: “Expedite on that, they’re running out of air.” The transcript did not show any response from Chief Williams.Over the next 6 minutes, through 3:48 p.m., Lieutenant Reinhagen made 10 more calls. None was answered. For three of the minutes, bells indicating depletion of his air tanks’ supply were ringing repeatedly. At one point, a civilian who overheard the ringing on a radio scanner called fire headquarters to tell officials of the noise.

At 3:49 p.m., the Lieutenant radioed: “Chief, this is Lieutenant Reinhagen. I’m still stuck back in the right rear of the building in the closet. We are out of air in a closet. We’re out of air.”
“What’s your location?” Chief Williams said. The response was inaudible and the Chief began ordering water from a truck.

At 3:50 p.m., the Lieutenant got the Chief directly and repeated that they were “stuck in a closet” and “out of air.”

  • “Stuck in a closet?” Chief Williams asked.

Twelve seconds later, the Chief Williams asked: “Where you at?”

  • “Right there in the closet,” came the response.
  • Fourteen seconds later, Lieutenant Reinhagen radioed again: “Help. The right rear. Out of air. Anybody out there? Stuck in the closet, right rear. No air. Help.”

The Lieutenant was asked if he was on the first or second floor. “First floor, underneath the collapsed ceiling,” the Lieutenant said at 3:52 p.m. It was his last transmission. Firemen eventually punched a hole through an exterior wall about 10 feet from the tool room, but saw only a mass of flame, Mr. Demers said. The burning timbers were leaning against the tool room, he said, but neither fireman was burned.

Learn from the past so we don’t repeat it. Remember- NO MORE HISTORY REPEATING EVENTS!

Some Open Questions;

  • What impact did the Hackensack Ford Fire & Collapse have upon you in your career?
  • Were you aware of this event and its lessons learned prior to this posting?
  • What do you feel you need to learn related to Building Construction, Fire Behavior or Strategy and Tactics related to various occupancies and construction types?
  • What is you knowledge base on Truss Construction related to Timber Bow String or Engineered Structural Systems?

Additional References:
NFPA REPORT, HERE

Dave STATter’s 2008 Coverage, HERE

Fire Rescue Magazine Article, A Failure in Command; HERE

Lessons Learned from Tim Sendelbach, Editor-in-Chief, FireRescue magazine, HERE

Other Resource Links:
http://www.wusa9.com/news/columnist/blogs/2008/06/hackensack-ford-20-years-later.html
http://query.nytimes.com/gst/fullpage.html?res=940DE3D6143FF931A357
http://www3.gendisasters.com/new-jersey/6534/hackensack-nj-fire-aut
http://www.nfpa.org/itemDetail.asp?categoryID=442&itemID=18676&;…;…

Memorial Park, Hackensack, NJ (http://www.cyberonic.net/~mikef6/p0000120.htm)

Three Firefighters and Three Sisters Killed in Gloucester City, New Jersey Building Collapse during Fire Attack, Rescue Operation, July 4th, 2002

Gloucester City (NJ) Collapse 2002

On July 4th, 2002 at 0136 hrs.,The Gloucester City Fire Department was dispatched to 200 North Broadway for a reported house fire. Responding units were advised that occupants may be trapped. First arriving units were on location in less than three minutes.

They found heavy fire on all exposures of a three-story multi-family dwelling and initiated a search for entrapped occupants. (Various reports from bystanders were at times conflicting regarding the number and location of victims). While providing an aggressive interior attack and rescue operation, an occupant was rescued from the dwelling. Due to the severity of their injuries they were unable to give direction regarding the whereabouts of any other occupants.

While all hands were operating by continuing an aggressive interior attack and rescue, a partial collapse of the structure occurred. An emergency evacuation signal was sounded and while that was commencing a further and much more substantial collapse occurred trapping eight firefighters inside the burning debris.

Additional specialized collapse rescue resources were requested, firefighter accountability was initiated and rescue efforts were intensified. Five of the eight trapped firefighters were rescued. Three of the eight gave the ultimate sacrifice in service to their fellow man. Unfortunately these three children did not survive. A total of nine victims were transported to area hospitals, one civilian and eight firefighters.

Remember:
• James Sylvester
Fire Chief, Mount Ephraim Fire Department
Sylvester, 31, a 17 year veteran, was survived by his wife, who was pregnant with the couple’s first child
• John West
Deputy Chief, Mount Ephraim Fire Department
West, 40, a 23-year veteran, was survived by his wife and three children
• Thomas G. Stewart III
Paid Firefighter, Gloucester City Fire Department
Stewart, 30, a 13 year veteran, was survived by his fiancée and their son. Stewart publicly proposed to his girlfriend, hours before the fire while they watched the city’s fireworks from high atop a fire truck ladder at Gloucester City High School.

NIOSH REPORT: Structural Collapse at Residential Fire Claims Lives of Two Volunteer Fire Chiefs and One Career Fire Fighter – New Jersey, HERE

Philadelphia Inquirer Posting, HERE

Everyone Goes Home Newsletter Article by Chris Collier, HERE

New Jersey Division of Fire Safety LODD Report, HERE

SUMMARY
On July 4, 2002, a 30-year-old male volunteer fire chief, a 40-year-old male volunteer deputy fire chief, and a 30-year-old male career fire fighter died when a residential structure collapsed, trapping them, along with four fire fighters and an officer who survived. At 0136 hours, a combination fire department and a mutual-aid volunteer fire department were dispatched to a structure fire. Local law enforcement radioed Central Dispatch reporting a fully involved structure with three children trapped on the second floor. The first officer on the scene assumed incident command and reported to Central Dispatch that the incident site was a three-story structure with fire showing and that people could be seen at the windows. Note: The female resident (survivor) was the person seen in the window.

The three children that were reported as being trapped did not survive and were later found in the debris. Additional units were requested, including a mutual-aid ladder company from a career department. Crews were on the scene searching for occupants and fighting the fire for approximately 27 minutes when the building collapsed.

NIOSH investigators concluded that, to minimize the risk of similar incidents, fire departments should;
• Ensure that the department’s structural fire fighting standard operating guidelines (SOGs) are followed and refresher training is provided
• Ensure that the Incident Commander (IC) formulates and establishes a strategic plan for offensive and defensive operations
• Ensure that the incident commander (IC) continuously evaluates the risk versus gain during operations at an incident
• Ensure that a separate Incident Safety Officer, independent from the Incident Commander, is appointed
• Ensure that fire fighters conducting interior operations (e.g., search and rescue, initial attack, etc.) provide progress reports to the IC
• Ensure that accountability for all personnel at the fire scene is maintained
• Ensure that a Rapid Intervention Team (RIT) is established and in position
• Ensure that the officer in charge of an incident recognize factors (e.g., structural defects, large body of fire in an old structure, etc.) when analyzing potential building collapse
• Ensure, when feasible, that fire fighters should respond together, in one emergency vehicle, as a crew
Additionally, municipalities should consider
• Establishing and maintaining regional mutual-aid radio channels to coordinate and communicate activities involving units from multiple jurisdictions

In order to minimize the risk of similar incidents, the New Jersey Division of Fire Safety identified key issues that must be addressed and remedies that should be implemented within all departments.

1. FACTOR: There appears to be a disconnect between career and volunteer personnel in the Gloucester City Fire Department (GCFD). Many personnel expressed the concern that the GCFD operated as separate fire departments rather than as one.

REMEDY: It is essential that all firefighters put individual differences aside in order to work together successfully as a team to achieve their common goal of saving lives and property.

2. FACTOR: The GCFD, faces a common dilemma associated with combination fire departments: staffing levels may be unpredictable depending on how many volunteers are available to respond to any one incident. This unpredictability can result in insufficient staff to perform required tasks until additional staff arrives.

REMEDY: Elected or appointed municipal officials need to make a commitment to the adequate staffing of the fire department and staffing levels must allow for compliance with the two-in / two-out provisions of the Public Employees Occupational Safety and Health (PEOSH) Standard 29CFR1910.134. The New Jersey Division of Fire Safety can provide assistance to the municipalities and provide examples of how this can be accomplished

3. FACTOR: Due to the limited number of firefighting personnel who arrived at this incident, all initial efforts were focused on the rescue of occupants. This postponed fire suppression operations until additional resources arrived. Because rescue and fire suppression operations were performed sequentially rather than simultaneously, the fire may have spread more quickly resulting in the early failure of the structure.

REMEDY: Sufficient personnel are critical to ensure that all necessary operations can be performed at the appropriate time. Furthermore, a continual size-up assessment must be maintained so that the Incident Commander (IC) can be kept aware of the conditions as the incident progresses. This continual size-up will allow the IC to modify the strategy and / or tactics as deemed necessary.

4. FACTOR: Although the GCFD was equipped with a thermal imaging camera (TIC), firefighters failed to utilize it for the initial search for victims. The TIC was also not used properly to analyze the scope of the incident and determine what tactics to employ.

REMEDY: Fire departments that possess TIC units should use them regularly during routine operations such as training, scene size up, search and rescue and structural fire fighting.

5. FACTOR: From the onset of operations, the Incident Management System (IMS) was not properly expanded as the incident progressed. Given the scale of this incident, the span of control quickly became too large for the IC to effectively manage and additional functions were not delegated to subordinates. Critical tasks such as safety and accountability were not effectively implemented.

REMEDY: N.J.A.C. 5:75 mandates that all fire departments utilize an IMS. It is a modular system, which allows the IC to apply only those elements that are necessary at a particular incident, and allows elements to be activated or deactivated as incidents escalate or decline. Fire departments are required to adopt written plans, or Standard Operating Guidelines (SOG’s) based on the IMS, to address different types of incidents. The NJ Division of Fire Safety distributed suggested SOGs upon adoption of this regulation and they continue to be available to all fire departments.

6. FACTOR: The GCFD did not assign a dedicated safety officer (SO) to observe operations and terminate potentially unsafe actions.

REMEDY: IMS regulations under N.J.A.C. 5:75 mandate the use of safety officers (SO’s) at all incidents. An SO is required to observe operations on the fire scene, identify next steps and order the correction of safety hazards to personnel. Given the scope of this incident, the IC should have assigned at least one SO.

7. FACTOR: The GCFD did not designate accountability officers to monitor each area of entry into the structure. Nor was a Personal Accountability Report (PAR) or roll sheet utilized to track personnel and monitor their functions. Therefore, the concept of accountability of personnel location, function, and time failed.

REMEDY: Although not enforceable at the time of this incident, the regulations for the NJ Personal Accountability System (NJPAS) under N.J.A.C 5:75 now require that fire departments utilize an accountability system. This system includes the designation of accountability officers and the use of PAR’s / roll calls, all within the framework of the IMS that is required to be utilized at all incidents. The NJ Division of Fire Safety is in the process of finalizing suggested SOGs and will distribute them to all fire departments when complete.

8. FACTOR: Although firefighters Sylvester and Stewart were equipped with Personal Alert Safety System (PASS) devices, they did not activate them prior to entering the structure. It should be further noted that their PASS devices were not automated; they had to be manually activated by the user. Firefighter West was not equipped with a PASS device.

REMEDY: PASS devices must be provided, used, and maintained in accordance with PEOSH regulations under N.J.A.C. 12:100-10 et seq. Although many departments still rely on PASS devices that must be activated manually, – devices that are acceptable by PEOSH regulations – they are not ideal because the firefighter must remember to activate the PASS device. For this reason, fire departments should strongly consider upgrading their SCBA to those employing automatic activating PASS devices.

9. FACTOR: The GCFD did not specifically designate the required personnel for the rescue of distressed firefighters through the establishment of Rapid Intervention Teams (RIT) or Firefighter Assist and Search Teams (FAST). Consequently, when the building collapsed, there was not a properly equipped team in place for immediate rescue operations.

REMEDY: IMS regulations under N.J.A.C. 5:75 require that fire departments utilize RIT or FAST to rescue distressed firefighters when operating in a hazardous atmosphere. The IC should request a RIT or FAST as soon as possible after dispatch to allow the team to arrive quickly.

10. FACTOR: Not all fire departments operating on the fire ground were communicating on the same radio frequency, which resulted in communication failures. Although, the Camden Fire Department (CFD) did have the capability to communicate on the GCFD “Fire 5” frequency they chose not to.

REMEDY: IMS regulations under N.J.A.C. 5:75 require that a communication system allow for inter-agency communication during mutual aid responses by providing a direct communication link between companies. Fire departments should work with other departments that are used routinely for mutual aid to ensure radio interoperability.

11. FACTOR: An emergency evacuation signal was sounded upon reports of a firefighter missing inside the structure before the impending collapse, however, the signal was never sounded at any other time prior to the collapse, nor was it sounded immediately after the collapse.

REMEDY: In the event an emergency evacuation becomes necessary and an emergency signal is required, N.J.A.C. 5:75 requires that fire departments utilize an emergency evacuation signal that is easily recognizable and distinguishable from all other fireground noises. The signal must be utilized when conditions on the fireground indicate an imminent and extreme risk to firefighters. At this time NJ DFS is finalizing a proposal that would establish a statewide emergency evacuation signal.

12. FACTOR: During this incident, fireground conditions were not properly analyzed, which led to the failure to recognize an impending building collapse.

REMEDY: Firefighters and officers need to learn the warning signs and causes of building collapses. Often following a collapse, as was the case with this incident, personnel on the scene report that the structure collapsed “without warning”. However, this is usually not the case; the reality is that the IC and firefighters simply failed to identify the indicators that were present prior to the collapse.

13. FACTOR: After removal of all victims, the remaining structure was demolished and the incident scene was cleared of all debris within 48 hours of law enforcement concluding their origin and cause investigation. This prevented a thorough assessment of the remaining structure in order to identify the cause and contributing factors of the collapse.

REMEDY: A protocol should be adopted to ensure that fire scenes are secured in a manner that not only allows for public safety, but also prevents immediate demolition. This will provide agencies with an opportunity to conduct any investigations that may be necessary.

14. FACTOR It was difficult to gauge the amount of training for all GCFD personnel due to insufficient record keeping. Although it was determined that the GCFD firefighters and officers met the minimum regulatory training requirements, many members did not possess a great deal of supplemental training with regard to structural firefighting. Additionally, the volunteer firefighters and officers often did not attend the scheduled departmental drills and rarely trained with the career personnel despite having frequent opportunities to participate.

REMEDY: Standards such as NFPA 1500 recommend that fire departments establish a regular training and education program that is commensurate with the duties and functions that firefighters are expected to perform. Additionally, proper record keeping is essential to certify that all personnel have received both required and supplemental training or education.

15. FACTOR: Qualifications of volunteer officers were difficult to judge and there were serious concerns voiced by the career members of the department regarding the suitability of some of the volunteer officers. This resulted in a lack of confidence by several career personnel in the volunteer officers and reluctance to take direction from them.

REMEDY: In addition to the NJ DFS requirement that all fire service supervisors obtain incident management certification; municipal officials need to establish uniform minimum qualifications for fire officers in order to ensure the effective provision of fire suppression services to the public. The NJ DFS recently adopted voluntary fire officer standards and will be developing a training curriculum to meet those standards.

16. FACTOR: It was not possible to determine if a smoke detector inspection was conducted in the building after a change in occupancy in October of 2001 as required by the NJ Uniform Fire Code. The city’s housing department, who has the responsibility for these inspections, was unable to provide documentation of such an inspection to either the Division of Fire Safety or to the Camden County Prosecutor’s Office. It was not clear whether smoke detectors were activated during this fire incident.

REMEDY: It is recommended that the responsibility for smoke detector inspections be transferred to the fire department to ensure complete and documented inspections.


Discovery Channel Special on the Gloucester City Incident. A must see for all Company and Command Officers…

Addtional Link on Bowstring Truss Safety Considerations;