KEY
FINDINGS AND RECOMMENDATIONS FOR IMPROVEMENT
NIST Investigation of The Station Nightclub Fire
Key
Findings
Description
of The Station Nightclub and the Feb. 20, 2003, Fire
The Station
nightclub in West Warwick, R.I., was a single-story wood frame building
with a footprint of about 412 square meters (4,484 square feet).
The main entrance on the north side, with double doors, led to a
short hallway with a single interior door. In addition to the main
entrance, there were doors leading directly to the outside adjacent
to the platform (commonly, but less precisely, referred to as the
stage) on the west end of the building and at the side of the main
bar at the east end of the building. The kitchen also had an exit
door. There were windows along the north side of the building on
both sides of the main entrance.
The fire began
when pyrotechnics used during the performance of a band ignited
polyurethane foam lining portions of the walls and ceiling of the
platform area, and spread quickly along the ceiling area over the
dance floor. Smoke was visible in the main entrance doorway in a
little more than one minute after ignition, and flames were observed
breaking through a portion of the roof in less than five minutes.
Crowding at the main entrance to the building hampered egress from
the nightclub. One hundred people lost their lives in the fire.
Key
Findings of the NIST Investigation Regarding Building Contents:
A non-fire
retarded foam sample purchased by NIST ignited within 10 seconds
when exposed to a pyrotechnic device; under similar conditions,
a fire retarded foam sample did not ignite.
A computer
simulation of the nightclub fire shows that flames spread rapidly
over foam finish material and ignited the wood paneling adjacent
to foam.
The fire transitioned
to a more traditional, oxygen-limited fire once the building’s
wooden frame ignited.
Key
Findings of the NIST Investigation Regarding Fire Protection Systems
During a fire
test of the NIST mockup of The Station platform area and dance floor,
a sprinkler system installed in accordance with the National Fire
Protection Association (NFPA) 13 standard was able to control a
fire initiated in non-fire retarded polyurethane foam panels used
by NIST for the test.
Sprinklers
were not installed in The Station, nor would they have been required
for such existing structures under 2003 editions of the model codes.
A heat detection/fire
alarm system was installed in the building and was activated (sound
and strobe) by the fire 41 seconds after the fire started.
Key
Findings of the NIST Investigation Regarding Emergency Egress
The nightclub
patrons first recognized danger 24 seconds after the ignition of
the foam by the pyrotechnics. The bulk of the crowd began to evacuate
around the time that the band stopped playing (30 seconds after
ignition).
About two-thirds
of the occupants attempted to leave through the main entrance; many
were unsuccessful.
Prior to 90
seconds into the fire, a crowd crush occurred at the main entrance
that almost entirely disrupted the flow of the evacuation through
the front exit.
The event that
precipitated the crowd crush likely was related to the arrangement
of the single interior door with merging streams of traffic and
the pressure to escape the rapidly deteriorating conditions in the
main area of the nightclub.
Measurements
in a fire test conducted on a mockup of a portion of The Station
nightclub platform and dance floor produced—within 90 seconds—temperatures,
heat fluxes and combustion gases well in excess of accepted survivability
limits.
A computer
simulation of the full nightclub fire suggests that conditions around
the dance floor, sunroom and dart room would have led to severe
incapacitation or death within about 90 seconds after ignition of
the foam for anyone remaining standing in those areas – and
not much longer even for those close to the nightclub floor.
Key
Findings of the NIST Investigation Regarding Emergency Response
The first
9-1-1 call reporting the fire was before 11:09 p.m., less than 40
seconds after the ignition of the foam around the platform. Off-duty
West Warwick, R.I., police officers on the scene also reported the
fire about one minute after its start. Four engine companies, a
tower-ladder truck, a rescue unit and a battalion chief were dispatched.
The first fire
engine, staffed with a firefighter and a fire officer, was confirmed
on the scene about 4 minutes after the first 9-1-1 call was received—well
within the limit of the NFPA standard for fire department response.
However, NFPA standards recommend a minimum staffing level of four
firefighters on both engine and truck companies. NIST is unable
to say how the outcome of The Station nightclub fire might have
been altered if this staffing level standard had been met.
Recommendations
from the NIST Investigation of The Station Nightclub Fire
(All recommended changes to model codes should be adopted by state
and local agencies)
Recommendation
1
Model codes should require
sprinkler systems for all new and existing nightclubs regardless
of size.
Recommendation
2
In regard to building
contents and finish materials, model codes should:
(a) specifically forbid
(with no exceptions) from all new and existing nightclubs certain
classes of materials that are known to easily ignite and rapidly
propagate flames (this includes non-fire retarded flexible polyurethane
foam);
(b) provide greater guidance
for when large-scale tests are required to demonstrate that materials
pose no undue hazard for the use intended, and establish pass/fail
criteria using best measurement and prediction practices; and
(c) strengthen provisions
in NFPA 1126 regarding use of pyrotechnics by banning the use of
pyrotechnic devices from buildings smaller than 930 square meters
(10,000 square feet), and by requiring that all materials in nightclubs
in which pyrotechnic devices are permitted meet low flame spread
and heat release rate criteria, with a minimum clearance greater
than twice the designed projection of the pyrotechnic device from
the nearest fixed surface or moveable contents.
Recommendation
3
The factor of safety
on the time to egress should be increased in the model codes by:
(a) computing the number
of required exits and permitted occupant loads assuming at least
one exit will be inaccessible in an emergency;
(b) increasing the capacity
of the main entrance to accommodate the evacuation, at a minimum,
of two-thirds of the maximum permitted occupant level during an
emergency;
(c) eliminating
trade-offs between sprinkler installation and factors that impact
the time to evacuate buildings;
(d) requiring staff training
and evacuation plans for buildings that cannot be evacuated in less
than 90 seconds;
(e) providing improved
means—such as exit signs near the floor and floor lighting—for
occupants to locate emergency routes once standard exit signs become
obscured by smoke;
(f) using recognized
best practices to estimate safe evacuation time relevant to building
size and occupant capacity; and
(g) requiring
explicit evacuation directions be provided to occupants prior to
the start of any public event inside a nightclub.
Recommendation
4
New life-safety provisions
should apply to existing as well as new nightclubs, and the practice
of grandfathering older structures should be eliminated. Exemptions
from the new provisions should be on a case-by-case basis and justified
by a comprehensive fire safety analysis using best practices.
Recommendation
5
Model codes and standards
should require redundancy in passive and active fire protection
systems to ensure adequate performance of the structure when one
or more of the protective systems is compromised by uncertain behaviors
of the building owner or occupants (for example, disabling sprinklers
for maintenance).
Recommendation
6
When an analysis of proposed
changes to model codes is performed, proper account should be taken
of the soundness of and safety factor provided by the existing provisions
in light of the history of similar building failures.
Recommendation
7
The number
of portable fire extinguishers required by model codes should be
increased, with their number and placement based upon a minimum
time for access and application in a fully occupied building. Staff
should be properly trained in their use.
Recommendation
8
Model codes
should provide specific guidance on how to implement an effective
fire inspection program, including the training necessary to implement
it.
Recommendation
9
Career and
volunteer fire departments should comply with the minimum apparatus
staffing guidelines as detailed in the relevant NFPA standards;
Public safety
agencies at all levels should give greater attention to the difficulty
of communication systems interoperability;
Emergency
services organizations should develop/maintain robust, interoperable
communications to support major incident operations; and
Major incident/mass
casualty operations should be conducted utilizing appropriate Incident/Unified
Command structures, policies and practices such as those established
by the NFPA.
Recommendation
10
Research should
be conducted to better understand human behavior in emergency situations
and to predict impact of building design on safe egress in emergencies.
Recommendation
11
Research should
be conducted to better understand fire spread and suppression in
order to provide the tools needed by the design profession to address
the recommendations of this report.
Recommendation
12
Research should be conducted
to refine computer-aided decision tools for determining costs/benefits
of alternative code changes and fire safety technologies, and to
develop computer models to assist communities in allocating resources.
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