A Tale of Two Cities Case Studies of Success and Failure In Building Life Safety Planning

All buildings are required by law to conform to a building fire code. Appropriate signs need to be posted, portable fire fighting equipment must be mounted, exits need to be marked, fire drills conducted periodically, etc. Property managers are also realizing that building life safety cannot be limited solely to strict compliance to engineering standards; a program needs to be in place that ensures procedures are developed and people know what to do in the event of any emergency. The following two case studies illustrate how important a true all hazards safety program is for protecting life.

CASE 1 Cook County Admin Building – Chicago

At 5:02 pm October 17, 2003, a fire was discovered in a storage closet on the 12th floor of the Cook County Administration Building (“Brunswick Building”) in Chicago, Illinois. The discoverer did not know where any of the fire extinguishers were located and so no attempt was made to put the fire out. 9-1-1 was called and at 5:06pm the Building Engineer ordered the evacuation of the entire building. No information concerning location of the fire or appropriate evacuation routes was provided. By 5:16pm the Fire Department was on site and had proceeded up the southeast stairwell to the 12th floor. Occupants evacuating down the stairwell were instructed to go back up. The door was forced open and as thick black smoke entered the stairwell, firefighters advanced and began fighting the fire. Tragically, the stairwell doors to each floor above were self-locking and as evacuees proceeded upwards, they found they could not get out of the stairwell. Over the next several minutes 9-1-1 received numerous calls from building occupants trapped in the southeast stairwell. In all cases, occupants were instructed to stay where they were and that assistance would be sent to them. The Fire Department did receive this information, however no one was dispatched up the southeast stairwell to render assistance (there were also calls from the northwest stairwell and the Fire Department did respond to these). At 6:39pm the Fire Department reported the fire out and commenced a top to bottom search of the building. At 6:52pm a cluster of victims was found in the southeast stairwell in the vicinity of the 22nd floor. Six were dead and eight incapacitated. These victims had called 9-1-1 for assistance.

Subsequent analysis indicates there were major issues with the fitted systems in the building. Although the structure did meet code, it did not have a fitted sprinkler system. It did have a smoke tower, however subsequent tests revealed 45% of the dampers were defective or warped and it had never been tested (the recommendation was annually). The stairwells were equipped with self-locking doors (for security) but there was no override capability. This was allowed under the fire code. There were emergency phones located in the stairwell, but all were defective.

Procedurally, there were also major issues. Location of portable fire extinguishers was not well known. Occupants reported that evacuation drills had been conducted every six months, but many reported the plan was confusing and that they were unsure of procedures. The Building Engineer ordered full evacuation in direct contrast to established procedures of partial evacuation only (and then phased evacuation if required). No information was passed to building occupants (other than to evacuate) and no direction given in terms of appropriate evacuation routes. Facility management did not provide a brief to the Fire Department on arrival (there was no existing protocol for this) or volunteer any information about building systems (building documentation specifically recommended against attacking a fire from the vicinity of a smoke tower – exactly the strategy chosen by the Fire Department). When reports started coming in that people were trapped in the stairwells, no one had any training to deal with this or gave any thought to the self-locking mechanism of the stairwell doors. Although building management continues to claim they met code and had an established building life safety program, this tragedy could have been avoided had the safety program been effective.

(NOTE: This incident is still under investigation and there are several questions regarding the Fire Department’s response, however this article is only dealing with the building life safety issues.)

CASE 2 First Canadian Place – Toronto
First Canadian Place is a 72 story building in downtown Toronto with numerous tenants. On 14th August 2003, a massive blackout struck the northeastern region of North America plunging entire cities into darkness. Although First Canadian Place is fitted with a back up emergency diesel generator, this failed after five minutes of operation. Building management ordered the structure evacuated.

A major Canadian law firm is one of the tenants in this facility. In the aftermath of 9/11, this company had conducted an emergency needs assessment which had identified numerous concerns in building life safety protocols; most notably, the ability for employees to safely evacuate in a smoke filled environment. As a consequence of that, the firm undertook extensive updating of its life safety plan, procured individual evacuation kits and fire warden vests and provided its employees with building life safety training. When the lights went out, all other occupants of the building were faced with an evacuation of up to 72 stories in total darkness. However; the Law firm’s personnel took their evacuation kits and, using the flashlights and chemical light sticks, rigged temporary lighting in the stairwells. This was done under the direction and coordination of the firm’s floor wardens. Consequently, the rest of the building was also able to evacuate safely, simply by following the law firm personnel.

A comparison of these two case studies must be somewhat qualified. In Chicago, there was a fire, occupants did evacuate through toxic smoke and first responders were involved. In Toronto, the only danger was the requirement to evacuate in darkness. The atmosphere was not contaminated and there were no immediate life threatening factors. However, in Chicago, even though the building met code, there was no effective building life safety program. Equipment did not operate properly (maintenance is a key part of any safety program), building management had no idea how to lead and manage the event and tenants were not clear on the most basic of procedures. Had there been an effective program, there would almost certainly have been no fatalities. In Toronto, an “all hazards” application of life safety equipment enabled a large evacuation in a darkened building without panic or injury to evacuees. Implementation of a sound “all hazards” life safety program ensured the proper equipment was available, a sound floor warden program was in place and personnel had been trained. Had there been a smoke filled environment, there is every reason to believe the employees of the law firm would still have evacuated without injury.

Building fire codes are designed to ensure that structures are safe from fires for the occupants. However, an objective limited only to compliance to code is inappropriate. The objective must be protection of human life. (There is a sound commercial argument here to protect the company’s human capital, in addition to the obvious moral one.) An “all hazards” building life safety program, properly implemented and supported, is the single most important thing any organization can do to protect the lives and well being of its employees. The tragedy in Chicago illustrates what can happen in the absence of a life safety program. The example in Toronto shows its benefit.

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