Skip to content


Remembering the Strand Theater Fire of 1941

No comments

The Strand Theater | Brockton, MA

March 10, 1941: The Strand Theater Fire turned from a routine fire into one of the worst tragedies in Brockton and Massachusetts history when the west section of the roof collapsed, killing 13 firefighters and injuring 20 firefighters.

Check out the comprehensive past post from CommandSafety.com from 2011

http://commandsafety.com/2011/03/the-strand-theatre-fire-brockton-ma-march-10-1941-13-firefighter-lodd/

The 1942 Luongo’s Restaurant Fire and Collapse in East Boston; Six Boston Firefighter Line of Duty Deaths

1 comment

The 1942 Luongo’s Restaurant Fire and Collapse in East Boston; Six Boston Firefighter Line of Duty Deaths

Boston Fire Department Box 6153 Five Alarm November 15,1942

 

Boston Fire Department Box 6153 Five Alarm November 15,1942

A multiple alarm fire and collapse 70 years ago resulting in six Boston Firefighter LODDs was overshadowed by the Coconut Grove Fire which occurred 13 days later. Here’ the story and legacy.  

 The 1942 Luongo’s Restaurant Fire and Collapse in East Boston; Six Boston Firefighter Line of Duty Deaths

During the early morning hours of Sunday November 15, 1942, a still alarm followed by box alarm 6153 was received for a fire at 4-6 Henry Street located in the Old Armory Building at Maverick Square in East Boston (MA). The address was for a report of fire in the Luongo’s Restaurant. A fire broke out in the rear of Luongo’s Restaurant on the first floor at about 2:26 a.m. The Boston Fire- District #1 report stated the fire originated in the rear kitchen ceiling.

November 16, 1942 New York Times:

The following is a description of the fire from the November 16, 1942 New York Times: “The fire, starting from a fireless cooker in the cafe on the ground floor at Henry Street and Maverick Square, suddenly swept through the building.

The firemen who were killed had just entered a restaurant on the second floor with a line of hose. As the flames ate through the cross timbers the wall collapsed with a roar, burying two men on the stairs and crushing the three others manning the hose.  That part of the wall which fell outward felled about forty firemen standing on the Henry Street side of the building beside the new $20,000 ladder truck, which was buried under the wreckage. At the same, a hot air explosion blew a half dozen firemen across Henry Street.”

The Building

The Luongo’s Restaurant was housed in what was called the Armory Building a five and one half story Type III Building of ordinary construction (Brick and joist) consisting of masonry bearing walls with approximate dimensions of 35 feet width x 60 feet depth x 65 foot height. The ensuing fire would spread to the exposure building at 10 Henry Street a three story 20 ft. X 40 ft. x 40 ft type III (brick and joist) structure.

Courtesy of the Boston Public Library, Leslie Jones Collection.

 

Fire and Collapse

Upon arrival of the first alarm companies, the fire initially was commanded by Fire Captain Amsler, Ladder Co. 2. District Chief Crowley rapidly assumed command upon his arrival and directed initial fire suppression activities of the companies to interior operations and quickly ordered a second alarm at 03:04hours.

Command was subsequently transferred to Deputy Chief Louis Stickel who ordered a third alarm struck due to fire extension twenty minutes later.

Suppression, ventilation and rescue operations were conducted with the fire under control when at 04:15 hours with without warning, it was reported the 3rd, 4th and 5th floors began to collapse with the brick masonry wall on the Henry Street side collapsing outward into the street. Ladder Company 8, a new 125 ft. aerial ladder, the largest in the United States at the time was buried in the timber and brick rubble and collapse pile. It was reported that as many of 43 firefighters in the street were injured as a result of the collapse.

 

Search, Rescue and Recovery Efforts

 

The arrival of Chief of Department Samuel Pope ordered fourth and fifth alarms. This brought Engine Companies 40, 9, 5, 11, 50, 8, 32, 6, 39, 3, 33, 12, 13, 38, 21, 35, 37, 20, 16, 10, 42, 51, 19; Ladder Companies 2, 31, 21, 8 and 3.

  • First Alarm: 02:27 hrs.
  • Second Alarm: 03:05 hrs.
  • Third Alarm: 03:24 hrs.
  • Fourth Alarm: 04:20 hrs.
  • Fifth Alarm: 04:35 hrs.

With both extensive interior and exterior collapse conditions with numerous trapped and injured firefighters, rescue efforts and medical assistance was being rendered by all fire service, military, hospital and civilian resources. Local Coast Guardsman were deployed to support the massive search and rescue efforts.

 

Rescue and Recovery

Six Boston Firefighters were killed in the line of duty as a result of the collapse, all of whom were conducting operations and working on the second floor with hose lines.

Supreme Sacrifice in the Line of Duty:

  • Hoseman John F. Foley, Engine Company 3
    • 57 years of age | 30 year veteran
  • Hoseman Edward F. Macomber, Engine Company 12
    • 47 years of age | 24 year veteran
  • Hoseman Peter F. McMorrow, Engine Company 50
    • 45 years of age | 19 year veteran
  • Hoseman Francis J. Degan, Engine Company 3
    • 24 years of age | 15 month veteran
  • Ladderman Daniel E. McGuire, Ladder Company 2
    • 44 years of age | 19 year veteran
  • Hoseman Malachi F. Reddington, Engine Company 33
    • 48 years of age | 19 year veteran

 Post Requiem

The Department’s 125 foot “jinx” aerial ladder, reported to be the largest in the nation at that time, was standing beside the falling wall on Henry Street. It was buried in the wreckage. The ladder was originally purchased by the City of Somerville. They found upon delivery that it was too big for their firehouse. Boston bought it. The truck had a series of problems. (additional Story on the 1941 American La France 125′ metal aerial By William Noonan,   HERE)  Apparatus Info – See Bostonfirehistory.org HERE

Boston Ladder 8 1941 ALF 125 ft. Aerail Ladder Shop#207. Photo Courtesy BostonFireHistory.org

There was some speculation that due to the long ladder and wide bed, the large ladder might have caused the wall collapse. This theory was later ruled out. In fact, some of the firefighters who were on the ladder at the time of the collapse, credit the ladder bed with saving their lives. When the granite and debris began falling, they lay down in the bed and the rubble slid down over them to the street.

Many felt that this was the end to the ladder. But, it was repaired and returned to service in South Boston as Ladder 19. Tragedy would continue to haunt this piece of apparatus. On December 3, 1947, Ladder 19 was out of service conducting tests on its brakes when it overturned and rolled. Provisional Firefighter Joseph B. Sullivan, on the job for less than six months, was killed. The Department took the truck out of service and scrapped

Individuals Remembered

As with many of these incidents, the men involved came from different backgrounds and circumstances that put them on that second floor that fateful night.

Edward Macomber was the father of eight children and considered to be one of the best firefighters in the department according to his superior officers. He was a member of the department for 28 years, and had been injured while on duty more than seven times.

Francis Degan, at age 24 was one of the youngest members of the Boston Fire Department at the time. He had been on the job only 19 months prior to November 15th. His officers thought that the young fireman was well on his way to becoming an officer. Young Degan took great pride in being a firefighter and realized his life’s ambition when he was appointed to the department to follow in the footsteps of his father, who was attached to Ladder Company 1.

John Foley, a hoseman on Engine Company 3, had been a member of the department for more than 30 years. He was planning to retire in a short time. In a tragic case of irony , Firefighter Foley should have been on a day off at the time of the fire, but had changed his schedule in order to get some time off later.

World War 1 veteran Pete McMorrow was a bachelor member of Engine Company 50 and was loved by many of the school children of Charlestown. He had served in the Navy in the first war and was telling his closest pals that he might just be going back to serve again. At age 46, he had carried the colors of the Boston Fireman’s Post #94, American Legion, through downtown Boston. While trapped in the debris for eleven hours, McMorrow’s fellow company members crawled into the space where he lay to tell him to hang on and they’d get him out soon. Throughout the early morning and into the next day the rescue efforts continued. However, when they were finally able to get to McMorrow, it was too late.

This fire and the subsequent six firefighter line of duty deaths were overshadowed by the Cocoanut Grove Fire which occurred only 13 days later on November 28, 1942.

Memorial, Dedication, and Reception

On Thursday November 15, 2012 the East Boston Neighborhood Health Center and the Boston Fire Department will be conducting a Memorial, Dedication, and Reception in Recognition of the 70th Anniversary of the Luongo Fire at Maverick Square, East Boston.

The event is scheduled from 12:00 pm to 2:00 pm at 20 Maverick Square, Boston, MA.

 

Video: Former Boston Fire Commissioner Paul Christian shares the story of the little-known Luongo fire as well as that of the 8-alarm Thanksgiving Day Fire of 1889. November has been a tragic month in Boston’s fire history. On November 15, 1942, a fire started in the back room of the Luongo Restaurant.

Collapse Scene from Maverick Square

 

Boston Fire Department 125 ft. Aerial Ladder on Henry Street Side

  

Rescue operations on Henry Street Side

 

Present sidewalk memorial marker

 

Memorial Dedication

 

Aerial Image of current property block in East Boston (MA). Bing Maps Image

  Historical Note: Three and a half story high, with granite faced and brick exterior walls, the interior wooden joisted building at the corner of Henry Street and Maverick Square in 1942 was one of the oldest buildings in East Boston. It was typical of mid 19th century Boston commercial construction. In accounts of the fire it is frequently referred to as “Old Armory Hall”. “Armory Hall” is the name by which it was known in the early years of the 20th century. That building however never was actually an armory as such. There once was an armory in East Boston. It was located at the corner of Maverick and Bremen Streets in a wooden building that preceded the still standing brick Overseers of the Public Welfare Building. The building in which the “Luongo Fire” occurred was built sometime before 1858. It was known originally as “Ritchie Hall” likely from the name of its owner.

 

Armory Hall Building is to the left of Photo – Circa 1910

 

 

Bromley Map Image Circa 1922

Sanborn Map Image Circa 1888

Leading Causes of Residential Fire Fatalities: Unintentional/Careless Actions, Smoking

No comments

USFA Releases Civilian Fire Fatalities in Residential Buildings (2008-2010) Report “Other unintentionally set, careless” actions and “smoking” are the leading causes
 

The Federal Emergency Management Agency’s (FEMA) United States Fire Administration (USFA) issued a special report today examining the characteristics of civilian fire fatalities in residential buildings. The report, Civilian Fire Fatalities in Residential Buildings (2008-2010) was developed by USFA’s National Fire Data Center and is based on 2008 to 2010 data from the National Fire Incident Reporting System (NFIRS).

According to the report:

  • Ninety-two percent of all civilian fatalities in residential building fires involve thermal burns and smoke inhalation.
  • The leading specific location where civilian fire fatalities occur in residential buildings is the bedroom (55 percent).
  • Fifty percent of civilian fire fatalities in residential buildings occur between the hours of 10 p.m. and 6 a.m. This period also accounts for 47 percent of fatal fires.
  • Thirty-six percent of fire victims in residential buildings were trying to escape at the time of their deaths; an additional 35 percent were sleeping.
  • “Other unintentionally set, careless” actions and “smoking” (each accounting for 16 percent) are the leading causes of fatal residential building fires.
  • Approximately 44 percent of civilian fatalities in residential building fires are between the ages of 40 and 69.
  • Thirteen percent of the fire fatalities in residential buildings were less than 10 years old.

Civilian Fire Fatalities in Residential Buildings (2008-2010) is part of the 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.

 REPORT DOWNLOAD: Civilian Fire Fatalities in Residential Buildings (2008-2010)
 

Time of Alarm

 

Human Factors Contrubuting to Fatalities

 
 

Age Factors

 

News and Features

Residential Fire Trends

ZoomClick charts below to enlarge.

Residential Building Cooking Fires Residential Building Electrial Malfunction Fires Residential Building Heating Fires Residential Building Smoking Fires

2008 State Fire Death Rates

National Fire Death Rate:
12.0 deaths per million population
State Fire Death Rate
District of Columbia 32.2
Oklahoma 26.4
Arkansas 24.1
West Virginia 23.7
Alabama 22.5
Mississippi 22.5
Tennessee 22.0
Louisiana 21.4
South Carolina 18.7
Alaska 17.5

View All States »

 

Fire Statistics

Browse Reports

      
Alcohol Lighters, Matches, and Candles
Civilian Casualties Mattresses and Bedding
Civilian Casualties – Children Outdoor
Civilian Casualties – Older Adults Rural and Urban
Civilian Casualties – People with Disabilities School and University
Cooking Smoke Alarms
Electrical and Appliances Smoking
Fire Departments Structure Fires
Firefighter Casualties Structure Fires (Nonresidential)
Heating Structure Fires (Residential)
Holiday and Seasonal Vehicles
Intentionally Set Fires Wildland

Fire in the United States

This report provides a statistical overview of fires in the United States and is designed to equip the fire service and others with information that motivates corrective action, sets priorities, targets specific fire programs, serves as a model for State and local analyses of fire data, and provides a baseline for evaluating programs.

PDF, 5MbFire in the United States Fifteenth Edition (2003-2007) (PDF, 5 Mb)

14th Edition (PDF, 4.1 Mb)
13th Edition (PDF, 1.3 Mb)

12th Edition (PDF, 2.3 Mb)
11th Edition (PDF, 1.7 Mb)

10th Edition (PDF, 2.0 Mb)
9th Edition (PDF, 3.7 Mb)

PDF, 1.3 MbProfile of Fire in the United States Fifteenth Edition (2003-2007) (PDF, 1.3 Mb)

 

San Francisco FD Berkeley Way Double LODD Report Issued: Routine Fire….

No comments

Charlie Side Fire View

 
 
 The Chief of the Department directed the Department Safety Officer to conduct a Safety Investigation of this incident. The primary purpose of the investigation was to identify and analyze the contributing factors that led to the incident as well as to create situational awareness to prevent future occurrences. The main objective of the Team’s investigation and subsequent report was to discover the key factor that led to the fatal outcome of two Firefighters. The SFFD report contains the findings and recommendations to help prevent Firefighter injuries or fatalities in the future.

 

In analyzing and recording these events, the Investigation Team acknowledges and respects that members confronted a challenging situation. On‐scene personnel reacted quickly to the changing conditions at this incident. We request that every person who reads this report show respect, appreciation and consideration for all personnel who responded to this incident.

As is a common industry practice, for this report Lieutenant Vincent Perez was referred to as Victim 1 and Firefighter Paramedic Anthony Valerio was referred to as Victim 2, with the exception of the Rescue Events Section.

 Excerpt from Chief of Department’s Letter

“On Thursday, June 2, 2011 at 10:45 a.m., the San Francisco Fire Department responded to Box 8155, at 133 Berkeley Way. What was seemingly a routine working fire in a single family residence quickly transformed into a fierce and unrelenting incident with ultimately tragic results.

When we answered the call to a career in the Fire Service and took our Oath of Allegiance, we were aware of the inherent danger of our occupation. Despite this awareness, we do not expect to encounter a line of duty death of a brother or sister, especially not in our very own Department. The profound loss of Lieutenant Vincent Perez and Firefighter/Paramedic Anthony Valerio has left an indelible impression in our hearts and will forever be remembered in the annals of SFFD history.

Even as we mourned our fallen brothers in the early days after the tragedy, our Department began the painful and difficult, but necessary, steps of a Line of Duty Death investigation. We were resolute in understanding what occurred during those fateful minutes and compelled to uncover any recommendations for improvement that may arise to future operations so that their passing will not have been in vain. For over six months, the Investigative Team worked tirelessly, scrutinizing every piece of evidence in order to produce a comprehensive report.”

SFFD

 

Joanne Hayes‐White

Chief of Department

 

 

 

Executive Summary and Report Excerpt

On June 2, 2011 at 10:45 hours, the San Francisco Fire Department was dispatched to a report of a fire in the building at 133 Berkeley Way in the City’s Diamond  Heights neighborhood. The first unit arriving on the scene, Engine 26, observed light smoke showing from the garage of the 4 story (2 above grade, 2 below grade) wood framed building, detached on the Bravo side.

 

Aerial from the Charlie Side

An aggressive interior fire attack was initiated through the front door, which is on a level between the ground level and second floor. After investigating the garage (ground level), Engine 24, the second Engine on the scene, led a small line through the garage to the interior door to back up the first Company. Battalion 9 was assigned Fire Attack by Battalion 6, who had assumed Command. Battalion 9 entered the fire building and, after conferring face to face with Engine 26 on the first floor (ground level), concluded that the fire was below them.

 

Alpha Side Operations

Battalion 9 exited the building and proceeded to the Bravo side to check for an entrance leading directly to the fire floor. Engine 11 led a large line wye to the driveway with the intention of leading a 1 ¾ inch line through the garage. They were redirected by Battalion 6 to make their lead down the Bravo side of the building to Sublevel 1 (one floor below grade) to assist Battalion 9. The Division Chief, upon arrival, assumed Command. He assigned Battalion 6 to Division 3 (ground floor).

Truck 15 was assigned Roof Division. Truck 11 split their crew, two members to the roof and three members to search and ventilate the top floor of the fire building. The Rescue Squad was ordered to conduct a search. Two members initially attempted to make entry through the garage but, due to extreme heat conditions, redeployed and entered through Sublevel 1 on the Bravo side.

The other two members of the Rescue Squad made entry through the front door, were pushed back by the heat and then made a successful second effort and conducted a search of the top floor.

 

In the course of fireground operations, members of several Companies came upon the stricken members on the first level and removed them from the building. All possible efforts were employed to revive the members and they were transported to San Francisco General Hospital (SFGH). One member (Victim 1) succumbed to his injuries that day and the second member (Victim 2) succumbed to his injuries two days later. Two other Firefighters were treated at SFGH for various injuries and released that day.

The Medical Examiner determined the cause of death for both members was due to complications from external and internal thermal injuries. Both victims suffered burns to 40% of their body surface. This fire was determined to be accidental by the SFFD Fire Investigative Unit. The fire originated on Sublevel 1, on the West side of the family room, near the large floor to ceiling windows. The ignition was a non‐specific electrical sequence in the electrical wiring or appliance (handheld vacuum cleaner) in this area.

There was a delay in reporting the fire due to the occupants’ attempting to extinguish it on their own. (SFFD Fire Investigation Report 11‐0500532)

The investigation identified that the failing of the window on Sublevel 1, located near the seat of the fire and directly across the stairwell leading to the ground floor, led to the extreme fire behavior which ultimately caused the death of two Firefighters. This fire was in a stage of deprived oxygen when the window failed, causing a rapid extreme high heat event to occur. The extreme heat followed the natural flow path up the interior stairs where Victims 1 and 2 were located.

The Safety Investigation Team found no conclusive evidence that the members were exposed to direct flame impingement during this rapid extreme heat event. However,

Victims 1 and 2 received varying degree of burns up to 40% of their body. The investigation concluded that this was caused by the rapid extreme heat conditions that radiated through their Personal Protective Equipment (PPE) to their bodies. These temperatures exceed the ability for human survival regardless of PPE.

The PPE was inspected and evaluated by NIOSH and the manufacturer. Both reviewing parties concluded that the PPE performed to its specifications and design. The manufacturer concluded that the PPE was exposed to temperatures in the range of 550‐ 700°F. These extreme temperatures were short in duration which caused limited damage to the outer shell of the PPE.

The Safety Investigation Team noticed severe heat damage to the portable radios remote speaker/microphones on Victims 1 and 2 and had the radios tested. The testing indicated that the remote speaker/microphones failed to operate correctly due to heat damage. The Safety Investigation Team was not able to determine, after testing, exactly when the remote speaker/microphones failed. The investigation has shown that multiple attempts were made to contact Engine 26 with no response.

The investigation also found that no radio transmissions of distress were received from Victims 1 or 2. Command and Control of any incident in the San Francisco Fire Department is acquired and maintained through the use of the Incident Command System (ICS).

The Incident Command System provides the tools for clear objectives, a single action plan, clear and acknowledged communications, and accountability for all members assigned to an incident. At this incident, some of the components of Incident Command System that were not followed include:

  • Single action plan
  • Fireground Accountability

From these findings, this report makes recommendations for several areas of the Department, including:

  • Training
  • Equipment
  • Policy Development
  • Policy Enforcement

The Safety Investigation Team gathered and analyzed many facts and conducted interviews of members directly involved in this incident. The Team identified several factors that occurred that contributed to the deaths at this incident.

These factors include:

  • Extreme heat conditions accelerated by the failure of a window on the fire floor.
  • Layout of building
  • Excessive live fuel load which contributed to the growth of the fire

Conclusion

This incident appeared from the onset to be a routine “room and contents” fire that the SFFD encounters on a regular basis. As the Companies were performing standard fireground operations, the incident rapidly deteriorated due to a hostile fire event. The failure of a window in the fire room allowed fresh oxygen to enter the room, providing a fire that was deprived of one of the key elements of combustion to rapidly intensify.

Due to the growth of the fire, the room flashed, causing extreme and rapid heat conditions which traveled up the interior stairs (the flow path) to the location which our members were operating. Our members were caught in this high heat, causing the injuries that ultimately claimed their lives.

Due to this fire event, other Companies attempting to conduct fireground support operations were prevented from making entry into the structure from street level (through garage) to back up Engine 26. These Companies were forced to regroup and find an alternate point of entry. In the process of doing so, crews made entry from the Bravo side directly into the fire room and extinguished the fire. This allowed members to make entry from above which led to the discovery and rescue of our members.

These events happened in a time frame of less than fourteen minutes.

 During the course of this investigation, the Safety Investigation Team recognized that no matter how experienced or properly prepared we are, we must always approach all incidents with the utmost awareness.

This incident showed that a simple failure of a piece of glass/window caused unforeseeable and fatal consequences.

We, as a Department, need to gain further knowledge and understanding of the following:

  • Having Situational Awareness prior to taking action, this would include the ongoing process when conditions change
  • How Risk Management must be used when making all decisions
  • Limitations of the PPE (turnouts, SCBA, and equipment)
  • Building construction, including layout and how fire/smoke will
  • move within the structure
  • Ventilation practices and how they affect fire conditions
  • Importance of Communications for all members operating on the scene
  • Companies must use strict discipline when assigned task/locations

Previous  CommandSafety Coverage from 2011, HERE, HERE  and HERE

Previous Coverage on CommandSafety.com below:

Other Links;

Reports were published in the San Francisco Chronical, HERE  and HERE.

SFFD Report PDF, HERE


 

SFFD Web Link, HERE

SFFD Mission

The mission of the Fire Department is to protect the lives and property of the people of San Francisco from fires, natural disasters, and hazardous materials incidents; to save lives by providing emergency medical services; to prevent fires through prevention and education programs; and to provide a work environment that values health, wellness and cultural diversity and is free of harassment and discrimination.

SFFD Color Seal

IN TRIBUTE TO
OUR FALLEN HEROES
 

 

Alpha Side

 

 STRUCTURE DESCRIPTION

Site overview: Steep downhill slope adjacent to Glen Canyon

Date of Construction: 1975

 

 Building overview:

  • Attached garage located in the front of the house. Main structure is 2 stories above grade and 2 stories below grade

 Type of Construction:

  • Four story, Type 5 wood framed, single family home, detached on three sides
  • Approximate square footage: 4,000 sq ft.
  • Four stories of living space
    • First Floor (Ground floor): garage, 3 bedrooms, 2 bathrooms
    • Second floor: dining room, living room, kitchen, bathroom and family room
    • Sublevel 1: large family room (origin of fire), mechanical room, bathroom, bedroom, balcony, side entrance on Bravo side
    • Sublevel 2: enclosed finished storage area, bathroom (no windows)

 Construction features:

  • Roof type: Flat roof, bitumen roofing membrane, normal dimensional lumber
  • Exterior: siding T1-11 plywood, 5/8”
  • Interior: drywall over normal insulated framing
    • Note: Fire origin room had decorative plywood veneer panels over drywall
  • Steel I beams wrapped in drywall were used as structural supports
    • Note: Fire origin room had a steel I beam that spanned horizontally from Bravo to Delta side
  • Rear of structure had extensive use of glass to capture views, including windows and sliding doors
  • Second floor and Sublevel 1 (fire origin) had large balconies
  • Flooring consisted of tile, carpet and sheet vinyl throughout the house
  • Dual glazed windows throughout, installed in 2003
  • Ground level had a two car garage with access to residence
    • Note: Two large vehicles occupying garage at time of fire
  • Main entrance was accessed by ascending a flight of stairs adjacent to the garage
    • Note: Main entrance stairs led to an interior landing which allowed access to top floor (5 stairs up) or grade level (7 stairs down)
  • Sublevel 1 had an access door from the exterior Bravo side along with access from interior stairs
  • Sublevel 2 had access door from exterior Bravo side. (no interior access)
    • Note: Access through the Bravo side was difficult due to unfinished terrain and poor housekeeping

 

 

 

 

 

Fire Fighter Fatality Investigation Reports

No comments

NIOSH has recently released the following Fire Fighter Fatality Investigation Reports:

Are they on your radar screen?

Recently Released Reports

Fire Fighter Fatality Investigation # F2011-04 Fire Apparatus Operator Suffers Fatal Heart Attack During Annual Fire Department Medical Evaluation – Missouri (added 10/4/11)

Fire Fighter Fatality Investigation # F2011-11 Fire Fighter Suffers On-Duty Sudden Cardiac Death – Missouri (added 9/28/11)

Fire Fighter Fatality Investigation # F2011-08 Fire Fighter Trainee Suffers Sudden Cardiac Death During Maze Training – Arkansas (added 9/14/11)

Fire Fighter Fatality Investigation # F2010-16 Volunteer Captain Runs Low on Air, Becomes Disoriented, and Dies While Attempting to Exit a Large Commercial Structure – Texas (added 9/1/11)

Fire Fighter Fatality Investigation # F2010-30 Seven Career Fire Fighters Injured at a Metal Recycling Facility Fire – California (added 8/17/11)

Fire Fighter Fatality Investigation # F2010-38 Two Career Fire Fighters Die and 19 Injured in Roof Collapse during Rubbish Fire at an Abandoned Commercial Structure – Illinois (added 8/4/11)

Fire Fighter Fatality Investigation # F2011-01 Fire Fighter Suffers Heart Attack While Fighting Grass Fire and Dies 2 Days Later – California (added 7/13/11)

Fire Fighter Fatality Investigation # F2010-18 A Career Lieutenant and a Career Fire Fighter Found Unresponsive at a Residential Structure Fire – Connecticut (added 7/8/11)

 

FIRE FIGHTER FATALITY INVESTIGATION AND PREVENTION PROGRAM

Cold-Storage and Warehouse Building Fire

Each year an average of 100 fire fighters die in the line of duty. To address this continuing national occupational fatality problem, NIOSH conducts independent investigations of fire fighter line of duty deaths. This web page provides access to NIOSH investigation reports and other fire fighter safety resources.

 

Fire Loss in the United States 2010 report from the NFPA

No comments

NFPA 2010 Report and Analysis

The NFPA recently released its report on Fire Loss in the United States During 2010. According to the report, public fire departments responded to 1,331,500 fires last year, a decrease of 1.3 percent from the year before.

U.S. fire departments responded to an estimated 1,331,500 fires. These fires resulted in 3,120 civilian fire fatalities, 17,720 civilian fire injuries and an estimated $11,593,000,000 in direct property loss. There was a civilian fire death every 169 minutes and a civilian fire injury every 30 minutes in 2010. Home fires caused 2,640, or 85%, of the civilian fire deaths. Fires accounted for five percent of the 28,205,000 total calls. Eight percent of the calls were false alarms; sixty-six percent of the calls were for aid such as EMS.

In 2010, public fire departments responded to 1,331,500 fires in the United States, according to estimates based on data NFPA received from fire departments responding to its 2010 National Fire Experience Survey. This represents a slight decrease of 1.3 percent from the previous year and is the lowest since NFPA started using its current survey methodology in 1977 – 78.

An estimated 482,000 structure fires were reported to fire departments in 2010, an increase of 0.3 percent, or virtually no change from the year before. For the period from 1977 to 2010, inclusive, the number of structure fires peaked in 1977 when 1,098,000 structure fires occurred. The number of structure fires then decreased steadily, particularly in the 1980s, to 688,000 by the end of 1989, for an overall decrease of 37.3 percent from 1977. Since 1989, structure fires again decreased steadily for an overall decrease of 24.7 percent to 517,500 by the end of 1998. They stayed in the 505,000 to 530,500 range from 1999 to 2008, before dropping to 480,500 in 2009, and increasing in 2010.

Of the 2010 structure fires, 384,000 were residential fires, accounting for 79.7 percent of all structure fires, an increase of 1.9 percent from the year before. Of these residential structure fires, 279,000 occurred in one- and two-family homes, accounting for 57.9 percent of structure fires. Another 90,500 occurred in apartments, accounting for 18.8 percent of all structure fires.

NFPA 2010 Overview

 

For nonresidential structure fires, some property types showed notable changes. In public assembly occupancies, such fires decreased 17.2 percent to 12,000. In stores and offices, they increased 9.1 percent to 18,000. And in special structure properties, they dropped 11.1 percent to 20,000.

2010 Report Overview

  • 1,331,500 fires were responded to by public fire departments, a decrease of 1.3 percent from the year before.
  • 482,000 fires occurred in structures, an increase of 0.3 percent from 2009.
  • 384,000 fires, or 80 percent of all structure fires, occurred in residential properties.
  • 215,500 fires occurred in vehicles, a decrease of 1.6 percent from the year before.
  • 634,000 fires occurred in outside properties, a decrease of 2.3 percent from 2009.

CIVILIAN FIRE DEATHS

  •  3,120 civilian fire deaths occurred in 2010, an increase of 3.7 percent from 2009.
  • About 85 percent of all fire deaths occurred in the home.
  • 2,640 civilian fire deaths occurred in the home, an increase of 2.9 percent from 2009.
  • 285 civilians died in highway vehicle fires.
  • 90 civilians died in nonresidential structure fires.

 CIVILIAN FIRE INJURIES

  •  17,720 civilian fire injuries occurred in 2010, an increase of 3.9 percent from the year before.
  • 13,800 of all civilian injuries occurred in residential properties, while 1,620 occurred in non-residential structure fires.

 PROPERTY DAMAGE

  •  An estimated $11.6 billion in property damage occurred as a result of fire in 2010, a decrease of 7.5 percent from 2009.
  • $9.7 billion of property damage occurred in structure fires.
  • $7.1 billion of property loss occurred in residential properties.

 INTENTIONALLY SET FIRES

  •  An estimated 27,500 intentionally set structure fires occurred in 2010, an increase of 3.8 percent from 2009.
  • Intentionally set fires in structures resulted in 200 civilian deaths, an increase of 17.7 percent from the year before.
  • Intentionally set structure fires also resulted in $585,000,000 in property loss, a decrease of 14.5 percent from 2009.
  • 14,000 intentionally set vehicle fires occurred, a decrease of 6.7 percent from the year before, and caused $89,000,000 in property damage, a decrease of 17.6 percent.

 

Estimate of Fires by Type in the United States (1977-2010) NFPA Statistics

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

No comments

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

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

No comments

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.

FireFighter Fatalities in 2009

No comments

The USFA recently issued the Report on Firefighter Fatalities in the Undited States for the year 2009. Ninety (90) on-duty firefighters from 33 states lost their lives as the result of incidents that occurred in 2009. Pennsylvania experienced the highest number of fatalities (8). In addition to Pennsylvania, only New York (7), North Carolina (6), Louisiana (5), and Texas (5), respectively, had 5 or more firefighter fatalities. This compares favorably to 2008′s firefighter losses where 9 states experienced 5 or more on-duty fatalities. The total number of fatalities in 2009 was one of the lowest totals in more than 30 years of record.

The unique and specific objective of Firefighter Fatalities in the United States is to identify all on-duty firefighter fatalities that occurred in the United States and its protectorates during the calendar year and to present in summary narrative form the circumstances surrounding each occurrence.

An overview of the 90 firefighters that died while on duty in 2009:

  • The total break down included 47 volunteer, 36 career, and 7 wildland agency firefighters.
  • There were 6 firefighter fatality incidents where 2 or more firefighters were killed, claiming a total of 13 firefighters’ lives.
  • 16 firefighters died in duties associated with wildland fires, compared to 26 such fatalities in 2008.
  • Activities related to emergency incidents resulted in the deaths of 57 firefighters.
  • 30 firefighters died while engaging in activities at the scene of a fire.
  • 15 firefighters died while responding to or returning from 13 emergency incidents in 2009. This compares to 24 responding/returning fatalities in 2008.
  • 10 firefighters died while they were engaged in training activities.
  • 14 firefighters died after the conclusion of their on-duty activity.
  • Heart attacks were the most frequent cause of death with 39 firefighter deaths.

Heart attacks were the most frequent cause of death with 39 firefighter deaths. For 33 years, USFA has tracked the number of firefighter fatalities and conducted an annual analysis. Through the collection of information on the causes of firefighter deaths, the USFA is able to focus on specific problems and direct efforts toward finding solutions to reduce the number of firefighter fatalities in the future. This information is also used by many organizations to measure the effectiveness of their current efforts directed toward firefighter health and safety.

Type of Duty Activities related to emergency incidents resulted in the deaths of 57 firefighters in 2009. (This includes all firefighters who died responding to an emergency or at an emergency scene, returning from an emergency incident, and during other emergency-related activities. Nonemergency activities accounted for 33 fatalities. Nonemergency duties include training, administrative activities, performing other functions that are not related to an emergency incident, and post incident fatalities where the firefighter does not experience the illness or injury during the emergency. Non-Emergency Type of Duty LODD accounted for 36.6% (33) versus Emergency Type of Duty which accounted for 63.3% (57) LODD.

In 2009, 49 firefighters died while responding to or working on the scene of an emergency. This number includes deaths resulting from injuries sustained on the incident scene or en route to the incident scene and firefighters who became ill on an incident scene and later died. It does not include firefighters who became ill or died after or while returning from an incident, e.g., a vehicle collision.

Thirty-nine firefighters were killed during firefighting duties; 3 firefighters were killed on emergency medical services (EMS) calls; 5 on motor vehicle accidents; 1 firefighter was killed in association with a weather incident; and 1 was killed during other emergency circumstances.

Of the 30 firefighters killed during fireground operations in 2009, 19 firefighters died while on the scene of a structure fire, 9 firefighters died while en route or at the scene of a wildland or outside fire, and 1 firefighter at the scene of a vehicle fire. One other firefighter fell ill while at the scene of an alarm in an apartment building and later died from a cerebrovascular accident (CVA) after being transported to the hospital.

Types of fireground activities in which firefighters were engaged at the time they sustained their fatal injuries or illnesses identified Fire Fighting duty accounting for 79.6% (39), with Motor Vehicle Accidents accounting for 10.2% (5). This total includes all firefighting duties, such as wildland fire-fighting and structural firefighting. There were 19 fatalities in 2009 where firefighters be-came ill or injured while on the scene of a structure fire.

The distribution of LODD deaths by fixed property use identified residential property use as the leading occupancy resulting in a LODD with 13 events, followed by commercial occupancy use resulting in six events. As in most years, residential occupancies accounted for the highest number of these fireground fatalities in 2009.

In 2009, there were nine firefighter fatalities where the type of emergency duty was not related to a fire. Four were from motor vehicle accidents, four from EMS incidents, and one fatality was related to an in-clement weather incident. In 2009, 14 firefighters died after the conclusion of their on-duty activity. Six deaths were due to heart at-tacks, five were due to CVA/strokes, and three were due to other causes (one aortic separation, one from asthma, and one unknown).

Firefighting is extremely strenuous physical work and is likely one of the most physically demanding activities that the human body performs. Stress or overexertion is a general category that includes all firefighter deaths that are cardiac or cerebrovascular in nature such as heart attacks, strokes, and other events such as extreme climatic thermal expo-sure. Classification of a firefighter fatality in this cause of fatal injury category does not necessarily indicate that a firefighter was in poor physical condition.

Fifty firefighters died in 2009 as a result of stress/ overexertion:

  • Thirty-nine firefighters died due to a heart attack.
  • Eight firefighters died due to CVAs.
  • One firefighter died from heat exhaustion.
  • One firefighter died from a pulmonary embolism.
  • One firefighter died from damage to a heart valve, an acute event caused by the extreme physical exertion. 

Lost or Disoriented Two firefighters died in 2009 when they became lost or disoriented inside of a manufactured home next to a camper where the fire had originated. The fire-fighters advanced an attack line into the home as other firefighters attacked the fire in the camper. Five to 10 minutes after their entry, the pump operator sounded an evacuation signal, concerned that he was running out of water. When the two firefighters did not emerge from the home, firefighters called out for them, at-tempted to contact them on the radio, and tugged on the attack line to no avail. The firefighters were eventually discovered in the front room of the home un-conscious. Both firefighters were pronounced dead at the scene.

Caught or Trapped  Three firefighters were killed in 2009 in two separate incidents when they were caught or trapped. This classification covers firefighters trapped in wildland and structural fires who were unable to escape due to rapid fire progression and the byproducts of smoke, heat, toxic gases, and flame. This classification also includes firefighters who drowned, and those who were trapped and crushed.

  • The cause of death for one firefighter was listed as asphyxiation due to probable carbon monoxide toxicity after he had re-entered a large grain silo to assist a fellow firefighter attempt an exit from the structure. Both firefighters subsequently lost conscious-ness. Firefighters on the exterior cut a hole in the metal wall of the bin and extricated the firefighters, saving one.
  • Two firefighters were caught and trapped after they advanced an attack line to the interior of the residence and fire conditions changed rapidly.

Collapse Two firefighters died in 2009 while they were searching a burning commercial structure and the main floor collapsed trapping the firefighters.

For a copy of the entire USFA Firefighter Fatalities in the United States in 2009 Report, HERE

USFA Statistics, HERE

Adobe PDF, 215 KbU.S. Firefighter Disorientation Study (PDF, 215 Kb)

Adobe PDF, 2.5 MbFire-Related Firefighter Injuries in 2004 (PDF, 2.5 Mb)

Adobe PDF, 3.0 MbFirefighter Fatality Retrospective Study 1990-2000 (PDF, 3.0 Mb)

Adobe PDF, 1.1 MbFire in the United States, Chapter 5: Firefighter Casualties (PDF, 1.1 Mb)

International Society of Fire Service Instructors; “Modern Construction Considerations for Company Officers.”

1 comment

The International Society of Fire Service Instructors is proud to announce the release of “Modern Construction Considerations for Company Officers.” The program is a train-the trainer package that combines the latest research on light weight building construction from National Institute of Standards & Technology (NIST), Underwriters Laboratories(UL), Michigan State University, The International Association of Fire Chiefs (IAFC), and the Chicago Fire Department into a single resource tailored for company-level instruction.

The program was made possible through a Prevention & Research Grant from the Assistance to Firefighters Grant Program and the Department of Homeland Security. The ISFSI partnered with Eastern Kentucky University’s Fire & Safety Engineering Technology Program to analyze line of duty deaths between 1997 and 2009 to study the impact that lightweight construction has had on firefighters and firefighting operations.

The DVD included in the program package contains all of the instructional resources necessary to provide quality training on this important topic. A wide variety of support materials are included to provide the user a deep understanding of the challenges with modern building construction techniques. Instructors can tailor the program to meet the needs of their audience, including a 2-hour brief up to a week-long program.

The program will be distributed to all members of the ISFSI as a free member benefit. The ISFSI has also partnered with the Safety & Health Section of the IAFC to provide a copy to each of its members. ISFSI President, Eddie Buchanan, was on hand at the Safety & Health Section Meeting at FRI to personally deliver Chief Billy Goldfeder his copy as chair of the section. All members should expect their copy to arrive in their mailboxes over the next week.

“I would like to extend a heartfelt thank you to the ISFSI members and staff who worked so hard to bring this product to firefighters across America and the globe. It is truly a lifesaving program and a fantastic use of grant funds. It is critical that this package get into the hands of every instructor and fire officer to ensure they are educated and prepared to handle the real risk that looms out there on the next call,” said President Buchanan.

Check out the International Society of Fire Service Instructor’s (ISFSI) web site HERE.

Not a member? Take the time to sign up and get connected.

Fatal Fires in Residential Buildings Report issued by the USFA

No comments

The Federal Emergency Management Agency’s (FEMA) United States Fire Administration (USFA)has  issued a special report examining the characteristics of fatal fires in residential buildings. The report, Fatal Fires in Residential Buildings, was developed by USFA’s National Fire Data Center and is further evidence of FEMA’s commitment to sharing information with fire departments and first responders around the country to help them keep their communities safe.

The report is part of the Topical Fire Report Series and is based on 2006 to 2008 data from the National Fire Incident Reporting System (NFIRS). According to the report, an estimated 1,800 fatal residential building fires occur annually in the United States, resulting in an estimated average of 2,635 deaths, 725 injuries, and $196 million in property loss. The leading cause of fatal residential fires is smoking (19 percent) and the leading areas of fire origin are bedrooms (27 percent) and common areas such as living and family rooms (23 percent). In addition, fatal residential fires, which tend to be larger, cause more damage, and have higher injury rates than nonfatal residential fires, occur most frequently in the late evening and early morning hours, peaking from midnight to 5 a.m. Finally, these types of fires are more prevalent in the cooler months, peaking in January (13 percent).

The topical reports are designed to 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.

Findings

■ An estimated 1,800 fatal residential building fires are reported to U.S. fire departments each year and cause an estimated 2,635 deaths, 725 injuries, and $196 million in property loss.

■ Fatal residential building fires tend to be larger, cause more damage, and have higher injury rates than nonfatal residential fires.

■ Smoking is the leading cause of fatal residential building fires (19 percent).

■ The leading areas of fire origin in fatal residential building fires are bedrooms (27 percent) and common areas such as living and family rooms (23 percent).

■ Fatal residential building fires are more prevalent in the cooler months, peaking in January (13 percent).

■ Fatal residential building fires occur most frequently in the late evening and early morning hours, peaking from midnight to 5 a.m. One-third (33 percent) of fatal residential fires occur during these 5 hours.

■ About two-thirds (66 percent) of fatal residential building fires are confined to the building of origin or extend beyond the building of origin.

The U.S. fire death rate has gone down dramatically over the past three decades since the creation of the U.S. Fire Administration (USFA), from over 30 deaths per million population to 11 deaths per million population. The United States, however, continues to have one of the highest fire death rates per capita among Western Nations.

 The original goal for USFA was to help lead a reduction in fire deaths by 50 percent in a generation. With annual fire deaths dropping from over 9,000 to less than 3,500 in that period of time, USFA’s goal has been achieved. Nevertheless, fire deaths are still high. Approximately 1,800 fatal residential building fires occurred annually in recent years (2006 to 2008). These fires resulted in an annual average of approximately 2,635 deaths, 725 injuries, and $196 million in property loss.

This report is one of a continuing series of topical reports issued by the USFA’s National Fire Data Center and addresses the characteristics of fatal residential building fires reported to the National Fire Incident Reporting System (NFIRS) from 2006 to 2008, the most recent data available at the time of the analysis. Because 79 percent of fire deaths occur in residential buildings, they are the focus of this report. The information in this report about fatal residential fires can be used not only to assess progress but also to understand the nature of the fatal fire problem and its implications for targeting of prevention programs. For the purpose of this report, the terms “residential fires” and “fatal residential fires” are synonymous with “residential building fires” and “fatal residential building fires,” respectively. “Fatal residential fires” is used throughout the body of this report; the findings, tables, charts, headings, and footnotes reflect the full category, “fatal residential building fires.”

The report, Fatal Fires in Residential Buildings,HERE 

FDNY Deutsche Bank Building LODD Fire Report issued by NIOSH

4 comments

The NIOSH Fire Fighter Fatality Investigation and Prevention Program has released the investigation report of the line of duty deaths of two career FDNY  firefighters during a 2007 seven-alarm high-rise fire in the former Deutsche Bank building undergoing deconstruction and asbestos abatement.

On August 18, 2007,  two FDNY firefighters; Fr. Joseph Graffagnino and Fr. Robert Beddia both assigned to Engine 24 and Ladder 5 in SoHo lost thier lives while operating at this incident. The seven alarm fire was being worked with a contingent of over 275 firefighters when the pair became trapped on the 14th floor of the building after being overcome by blinding concentrations of dense smoke after their air supply was depleted during the course of combat fire suppression operations. FDNY Fr. Robert Beddia a twenty-three year veteran and FDNY Fr. Joseph Graffagnino,  became trapped in the maze-like conditions of a high-rise building undergoing deconstruction. The building’s standpipe system had been disconnected during the deconstruction and the partitions constructed for asbestos abatement prohibited fire fighters from getting water to the seat of the fire. An hour into the incident, the fire department was able to supply water by running an external hoseline up the side of the structure. Soon after the victims began to operate their hoseline, they ran out of air. The victims suffered severe smoke inhalation and were transported to a metropolitan hospital in cardiac arrest where they succumbed to their injuries.

By the time the fire was extinguished, 115 fire fighters had suffered a variety of injuries.Key contributing factors to this incident include: delayed notification of the fire by building construction personnel, inoperable standpipe and sprinkler system, delay in establishing water supply, inaccurate information about standpipe, unique building conditions with both asbestos abatement and deconstruction occurring simultaneously, extreme fire behavior, uncontrolled fire rapidly progressing and extending below the fire floor, blocked stairwells preventing fire fighter access and egress, maze-like interior conditions from partitions and construction debris, heavy smoke conditions causing numerous fire fighters to become lost or disoriented, failure of fire fighters to always don SCBAs inside structure and to replenish air cylinders, communications overwhelmed with numerous Mayday and urgent radio transmissions, and lack of crew integrity.

NIOSH has concluded that, to minimize the risk of similar occurrences, fire departments should:

  • review and follow existing standard operating procedures on high-rise fire fighting to ensure that fire fighters are not operating in hazardous areas without the protection of a charged hoseline.
  • be prepared to use alternative water supplies when a building’s standpipe system is compromised or inoperable.
  • develop and enforce risk management plans, policies, and standard operating guidelines for risk management during complex high-rise operations.
  • ensure that crew integrity is maintained during high-rise fire suppression operations.
  • train fire fighters on actions to take if they become trapped or disoriented inside a burning high-rise structure.
  • ensure that fire fighters diligently wear their self-contained breathing apparatus (SCBA) when working in environments that are immediately dangerous to life and health (IDLH).
  • train fire fighters in air management techniques to ensure they receive the maximum benefit from their self-contained breathing apparatus (SCBA).
  • use exit locators (both visual and audible) or safety ropes to guide lost or disoriented fire fighters to the exit.
  • conduct pre-incident planning inspections of buildings within their jurisdictions to facilitate development of safe fireground strategies and tactics.
  • encourage building owners and occupants to report emergency situations as soon as possible and provide accurate information to the fire department.
  • consider additional fire fighter training using a high-rise fire simulator.

Manufacturers, equipment designers, and researchers should:

  • conduct research into refining existing and developing new technology to track the movement of fire fighters in high-rise structures.
  • continue to develop and refine durable, easy-to-use radio systems to enhance verbal and radio communications in conjunction with properly worn self-contained breathing apparatus (SCBA).
Municipalities should:

  • ensure that construction and/or demolition is done in accordance with NFPA 241: Standard for Safeguarding Construction, Alteration, and Demolition Operations.
  • develop a reporting system to inform the fire department of any ongoing, unique building construction activities (such as deconstruction or asbestos abatement) that would adversely affect a fire response.
  • establish a system for property owners to notify the fire department when fire protection/suppression systems are taken out of service.


The Complete NIOSH Report is available HERE

An excellent Training and Awareness PDF file of  the PPT program on Operational Safety and Awareness at Deonstruction and Demolition Sites Structural Anatomy Safety OPS at Demo Sites

Additional Links, HERE and HERE

New York Times Photos of Deutsche Bank Deconstruction Work, HERE

Other References and postings;

  • NY Daily News: Battle to save trapped firefighters
  • WABC: Fatal Deutsche Bank fire report released (2008)
  • FDNY Penalties After Deutsche Bank Fire
  • Lawyers: Evidence Withheld in Deutsche Bank Fire Trial
  • FDNY Disciplines Company Officers Following Tragic Deutsche Bank Fire
  • Attorney Claims Deutsche Bank Contractors Are “Scapegoats”
  • YouTube Preview Image YouTube Preview Image

    No More History Repeating Events-Remembrance

    No comments

    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.  Those events being the 1988 Hackensack (NJ) Ford Fire which resulted in five (5) LODD and the 2002 Gloucester City (NJ) Fire that resulted in three (3) LODD along with three children.

    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.  Our sister site TheCompanyOfficer.com   has a comprehensive overview of both events with report links and a must see video on the Gloucester City (NJ) 2002 LODD event. For Remembering Hackensack and Gloucester follow the link HERE

    Remembrance (1988)

    Hackensack (NJ) Fire Department
    • 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
      

    Remember (2002)

    Gloucester City (NJ) Fire
    • James Sylvester Fire Chief, Mount Ephraim Fire Department
    • John West Deputy Chief, Mount Ephraim Fire Department
    • Thomas G. Stewart III Paid Firefighter, Gloucester City Fire Department

    NIOSH Compilation of Line-of-Duty Injury and Death Investigation Reports and Publications CD

    No comments

    3-18-2010 5-26-09 PMIf you’re looking for a great resource check this out at NIOSH’s Fire Fighter Fatality Investigation Program and Prevention Program. HERE.

    NIOSH is offering a Compilation of Line-of-Duty Injury and Death Investigation Reports and Publications CD. This CD-ROM contains a compilation of all NIOSH fire fighter fatality and injury investigation reports completed through August 2009. Since 1998 NIOSH has investigated over 420 incidents involving fire fighter line-of-duty deaths and injuries. This CD-ROM also contains 21 NIOSH publications and 1 Safety Advisory covering a number of topics specific to fire fighter safety and health.

    CD ROMs of this publication can be downloaded directly from the web site and a copy created using CD authoring software.

    Fire Fighter Fatality Investigation and Prevention Program web site HERE