ANALYSIS OF THE FIRE

The fire started in the second floor hallway, just inside the front Ponet door by the use of a flammable liquid. It appears that it burned unnoticed for some time. It is not clear how occupants first became aware of the fire. Once alerted, occupants started evacuating, using the hallways. Indications are that a flashover or back-draft occurred, resulting in 18 fatalities on the second floor and third floor.

The Ponet doors at the front stairwell were closed, as was the Ponet door on the fourth floor at the rear stairs. The Ponet doors from the second floor hallway to the rear stairs, and the fourth floor stairs to the exterior fire escape were open. This allowed the fire to travel from the front of the second floor to the rear stairs, and the fourth floor stairs to the exterior fire escape were open. This allowed the fire to travel from the front of the second floor to the rear, up the stairs to the third floor hallway, and up the stairs to the fourth floor, and out the rear of the building on the fourth floor.

The Fire Department received a delayed alarm to this incident. The flashover/backdraft occurred prior to the Fire Department's arrival. Upon our arrival there were indications of a small fire at the rear, not the true extent of the fire that had taken place, nor the large number of fatalities and injuries that had occurred.

ACTIONS TAKEN:

First arriving companies discovered the true situation upon entering the building at the rear. From the reports of bodies stacked in the stairwell, additional resources were requested. Companies were committed to extinguishing the residual fire, rescuing trapped occupants from windows, and a Medical Division was implemented to take care of the many injuries.

In the later stages of the incident, the fire that had transmitted to the ceiling of the first floor boiler room started to run the walls of the adjacent elevator shaft and up to the two apartments over the boiler room via an air shaft, was dug out and extinguished.

There have been 24 fatalities to date from this incident; 18 pronounced at the scene, and 6 within one week that died in hospitals. There were two Firefighter injuries.

Twenty Companies and eight Rescue Ambulances were used at this incident. The Medical Division triaged, treated, and transported 29 casualties in 45 minutes.

PROBLEMS ENCOUNTERED:

1. Initial visual indicators did not reflect the magnitude of the incident.

2. We were confronted with a large number of fatalities and casualties upon arrival.

3. There was a large number of occupants that required rescue from upper floors from windows.

LESSONS LEARNED:

1. First-in Battalion Chief instructed EMS-1 to assist "9's" in setting up Medical Division. Battalion 1 meant Task Force 9, and EMS assumed it to be R/A 9. This caused some momentary confusion until it was straightened out.

2. Command Officers should provide relief for members who were for any length of time in large gruesome situations like this.

CHIEF OFFICER'S OBSERVATIONS:

The Incident Command and Plans Chief's early decision to get the resources on scene to document and provide information and facts that the public, media, and public officials need in a large life situation like this proved successful.

The Medical Division function was performed well, resulting in the expeditious triaging, treating, and transporting of 27 injured civilians in 45+ minutes.

ANALYSIS OF INCIDENT COMMAND SYSTEM:

PROBLEMS ENCOUNTERED:
None.

ACTIONS TAKEN:
The Incident Command System was utilized at this incident.

LESSONS LEARNED:
None.

OBSERVATIONS BY CHIEF OFFICERS:
None.

FIRE PREVENTION HISTORY:
A. When was last Fire Prevention Inspection made?
...February 5, 1982 - Night Hotel Inspection
...September 16, 1981 - Routine Fire Prevention Inspection

B. Were any Fire Code violations found?
...No violations noted on Night Hotel Inspection.

...N.O.H.(Notice of Hazard) #91721 issued for drop ladders, fire doors, and torn carpet on routine Fire Prevention Inspection on September 16, 1981. All items completed by September 29, 1981.

C. Was a Notice Written?
...Yes.

D. At time of fire, was there an outstanding Notice?
...No.

E. Did any Fire Code violations contribute to the fire?
...No.

F. Give brief description of past fires and/or Fire Prevention activities that occurred in the past five years.
...1. Fires - None
...2. Fire Prevention Activities:
......a. Number of Notices written - 17
......b. Attitude of occupants in past Fire Prevention contacts - Unknown.

G. How could this fire been prevented?
...Due to possible incendiarism, it is not know at this time.

H. How did smoke detectors impact upon the final outcome of the fire/or life loss?
...1. Detectors may have caused occupants to go out into the hallways to evacuate where they were caught by the flashover/backdraft.

I. Did any building or Fire Prevention feature lessen or prevent extension of the fire?
...All of the front stairwell doors and the rear fourth floor doors were closed and prevented the extension of the fire in those areas.

J. Did a fire protection feature fail to function and contribute to the extension of the fire?
...Open Ponet doors at the rear stairwell on the second and third floor allowing the fire to travel from the second floor to the third floor.