TRAGEDY STRIKES COLORADO NURSING HOME

TRAGEDY STRIKES COLORADO NURSING HOME

Photos courtesy of Colorado Springs Fire Department.

On Monday, March 4, 1991, an early-morning fire at Crystal Springs Estate, an “intermediate care” boarding home, claimed the lives of nine residents. The painful lessons learned and reinforced from this tragic incident were numerous. What follows is a frank description of the incident and its problems. We hope that other departments will benefit from our experience.

THE FACILITY

Crystal Springs Estate provided meals, lodging, entertainment, and limited medical assistance to 25 residents ranging from 72 to 97 years of age. Many residents required walkers and wheelchairs to move about. At the time of the fire, 2.5 residents and one staff member were asleep in their rooms. One resident and the director of the facility were awake. Another resident had been admitted to a local hospital and was due to return the following day.

The fire building, built between 1959 and 1962, was a single-story, 11,500-square-foot, masonry structure with brick veneer and a wood joist roof. It was composed of four interconnected wings that enclosed a center courtyard. Outside access to the courtyard was possible from the northeast corner of the property without passing through the building.

The east wing contained eight resident rooms and a smoking room. There was a draft stop separating the north one-third of the attic space from the larger south portion; however, this draft stop had been breached by a fourby four-foot opening created byworkers sometime before the fire, used as a manway for access between the two sections. The existence of this considerable breach was confirmed by an electrician who had performed work on the building a week prior to the fire. A furnace flue, open from basement to attic, was situated at the inside corner junction between the east and south wings.

The southern one-third portion of the east wing roof was supported by the east wall of the south wing—the dining and kitchen area. Joist connections were at sockets (holes) cut into the wall. A single automatic-closing fire door separated the two wings.

There were no fire doors or fire walls separating the south and west wings. The west wing contained 10 resident rooms and the nurses’ station. The north wing contained nine resident rooms and the business office. There was a brick wall (which once had been an exterior wall) and a rated, automatic-closing fire door between the west and north wings; however, the fire door was positioned about four feet north of the brick wall, reducing the brick wall protection to nothing more than a draft stop in the attic.

The entire facility was equipped with rate-of-rise heat detectors in resident rooms, hallways, and attic spaces. Full stations, a few smoke detectors, and portable fire extinguishers were located in the hallways. These pull stations, smoke detectors, and heat detectors were connected in series on a two-wire loop and were designed to send an alarm signal to the central monitoring agency in Denver. In such a system, if a fire burns through one of the wires in the loop, the entire loop beyond that point becomes deactivated; furthermore, a two-wire system is not able to send a trouble indication should that occur. Neither facility’ management nor the monitoring agency could verify the condition of the alarm system prior to the fire.

As required by the State Health Department, 12 additional smoke detectors had been installed in the dining room and hallways a week before the fire. These were interconnected in a 110-volt system that received power through a separate circuit. Activation of any one of these would cause all 12 to sound an audible local alarm only.

THE DEPARTMENT

The Colorado Springs Fire Department is comprised of 324 uniformed personnel protecting 283,000 citizens in a 181-square-mile area. The department has 15 pumpers, four trucks, and rescue and support vehicles housed in 15 fire stations. In addition to its responses within city limits, the department is involved in wildland/urban interface in outlying areas.

ALARM

The director of the facility was working in the dining room when the local smoke alarm system in the building’s east wing activated. She heard at least one person in that area scream “fire.” She proceeded immediately to that area, whereupon she observed a considerable amount of fire coming out of the “smoking room” doorway. She then ran to the southeast corner of the dining room, near the exit, and operated an alarm pull station at 0034 hours. This closed two fire doors in the building and automatically sent an alarm to a central monitoring agency 70 miles away in Denver. She continued to run to the north wing, where she awoke an owner of the facility. Together they pounded on doors in the north and west wings to awaken the residents.

They reached the dining room, and it was well-involved in fire. The owner called the local 911 emergency center from the nurses’ station at that location, almost three minutes after the pull station was operated. This call came into the fire department dispatch center almost immediately after the call from the alarm company monitoring the system at Crystal Springs.

FIRST RESPONSE

The first-alarm assignment of two engines, a truck, and Battalion Chief Bill Sopp arrived at 0042 hours between four and five minutes after dispatch. Engine 1 approached the west (exposure #1) side of the fire building and reported it to be wellinvolved, with fire ventilating from the north windows of the south wing and the roof above the south end of the east wing. Engine 1 requested a second alarm. Members observed three or four residents, who apparently had escaped the building, gathered on the west side of the facility.

Chief Sopp arrived behind Engine 1 and assumed command. He made a quick drive around the perimeter of the building to accomplish size-up, then set up a command post at the southwest corner. Members of Engine 1 advanced a l’/Hnch hoseline charged with tank water into the building through the southwest (main) entrance while the driver/engineer connected to the nearby hydrant. Truck 1 arrived, staged at the front of the building, and was directed by Sopp to enter through the main entrance and perform primary search, beginning with the south portion of the west wing. Engine 8 made a forward lay of two 3-inch lines from a hydrant several hundred feet away and was directed to enter the alley at the exposure #3 side (northeast corner) and advance an attack line on the fire through the courtyard. At this time the flames were visible 15 to 20 feet above the south wing roof.

Sopp requested a safety officer, a liaison officer, a utility vehicle carrying extra air bottles, and a publicinformation officer in addition to the second alarm assignment. He also requested representatives from city water, gas, and electric utilities.

ATTACK AND SEARCH

Engine l’s crew forced entry and encountered high heat and heavy smoke. They slowly crawled east toward the south wing to attack the fire in the dining area. As they advanced, they informed command that they could hear fire crackling in the attic above them. Truck 1 pulled a l V-i-inch line from Engine 1 and followed behind the first attack team. Engine 8’s crew advanced a 1 3/4-inch line into the center courtyard and attacked visible fire in the eaves of the south building.

Second alarm companies began to arrive about four minutes after the initial attack was launched. Acting District Chief Jay Fink arrived and was directed by Sopp to establish a north division at the northeast corner of the property, affording command a 360degree view of the fireground perimeter, plus a view into the courtyard area.

Truck 8 was assigned primary search of the east wing. Its crew entered from the north entrance with a 1 ¾-inch line from Engine 8. The hallway was heavily charged with smoke and there were numerous pockets of fire. The floor was covered with glowing embers and room doors were charred on the hallway side. The crew from Truck 8 extinguished fire and searched rooms as they went. One by one, they removed four victims from the east wing, all DOA.

Engine 8 informed command that it had knocked down visible fire in the south wing from its exterior position and was moving to the east wing. Members entered through a courtyard window and rescued a resident in the room just north of the smoking room. Meanwhile, members of Engine 1 exited the building because they were running out of air, leaving Truck 1 to attack the fire and search as they went. As the crew advanced through the south wing fire door, the door fell off its hinges, demonstrating the fire conditions that existed in this area prior to department arrival. Truck l’s crew located a body, covered with soot, in the first room east of the dining area. Members, now running out of air, exited the building shortly after this discovery’, leaving the body behind.

Sopp decided to commit incoming units to search, removal, and triage operations. Two ambulances and the on-duty paramedic lieutenant arrived. Sopp assigned the lieutenant as triage officer and requested additional medical support. He assigned incoming Engine 4 the task of gaining entry into exposure #4—a church—and establishing a triage area and a shelter for survivors. Engine 2 was assigned the task of assisting the triage officer with victim removal and triage. A morgue area was established behind the church, at an exterior recess.

Engine 1 had replenished its air supply and moved to the west wing to begin search and rescue. This action was not communicated to the command post. Chief Sopp believed the crew still to be attacking the fire in the south wing. Engine 1 removed three victims from the west wingtwo DOAs and one survivor. Engine 8 prepared for a second entry into the building, and the IC directed the crew to the west wing, where they removed two victims—one who survived and the other who later died in the hospital. Engine 2 was involved in efforts to assist residents out of the north wing. Trucks 1 and 8 continued their searches of the south and east wings.

As more victims were located, command was asked for more assistance from various locations around the scene. Sopp requested three more pumpers: One was used as an advanced life support unit; another was assigned to assist with operations in the east wing; the third with operations in the north and west wings. Sopp appointed an aide from a thirdalarm engine company to track crew assignments, progress, and rehab needs. He assigned the aide to keep an accounting of Crystal Springs residents, including casualty information, and to utilize a cellular telephone for contacting support services without tying up fireground radio traffic.

Sopp did not as yet have an accurate number of injured residents. He requested two more ambulances and advised dispatch to notify area hospitals of the potential for numerous fire, smoke, and burn victims and to determine how many patients each hospital could handle. Approximately 20 minutes after first units arrived, the triage officer informed the command post that he had accounted for five DOAs, had sent six evacuees to the church shelter, and had transported three victims to hospitals. He requested that the coroner respond to the scene.

SECOND ATTACK

With all available resources engaged in search and removal operations, fire began to show again from the south and east wings. Lines again were placed into action by Engine 8 and Truck 1. Chief Fink advised that unless the roof on the east side was vented, they would lose the building. Chief Sopp directed Fink to ensure that the building was all clear on the east side and then assign his available companies to ventilation and fire attack.

Truck 1 reported an “All clear on the structure, primary search” at 0124 hours, approximately 42 minutes into the incident. Command also verified that there was still one DOA in the east wing. After replenishing their air supply, members of Truck 1 removed that body. The triage unit reported that its on-scene body count was seven and that it was identifying the fatalities. Members had obtained a list of Crystal Springs residents and reported that 24 residents and two workers were in the building at the time of the fire. All were accounted for except one resident, whose whereabouts at this time were unknown; all units had communicated completion of their primary searches.

Incident command requested dispatch to initiate a callback of off-duty personnel at approximately 0130. Crews reported to their stations and were transported by department bus to the fireground.

On the fireground, crews waged interior attacks on the east wing and the west wing, which by now also was showing signs of growing fire. These efforts proved unsuccessful. Chief Sopp gave the order to clear the building at 0144 hours. Roll call was taken to ensure that all firefighters were out of the structure, and then a defensive attack was initiated with monitors.

It soon became apparent that the municipal water supply system in that area was inadequate for the required defensive fire flow. Despite the efforts of city water department crews, this situation could not be rectified.

Meanwhile, the communications center was receiving numerous calls from occupants of neighboring buildings about smoke in their structures. Communications dispatched on several alarms, all which proved to be smoke from the Crystal Springs fire. Crews evacuated nearby residents from their homes and brought them to a safe shelter.

To make matters worse, fire was threatening to involve the church even though a deluge gun was positioned and repositioned (for shifts in the wind) to protect that exposure. On the east side of the fire building, Engine 8’s monitor, placed into operation to combat the fire that was now coming through the roof, was ineffective because it couldn’t be depressed sufficiently to hit the main body of fire in that area and because power lines were in the way. The monitor was shut down and a “baby” deluge (with two 2’/2-inch inlets) was placed into operation at the northeast corner of the east wing, with another set up at the entrance to the courtyard. Given the water supply situation, Engine 8 was unable to supply both deluge sets. The courtyard gun was shut down and two 1 ¾-inch lines that had been used in the interior attack were operated from the courtyard. Command now had a deluge gun on the south/west wings and a “baby” deluge gun and two handlines on the east wing. Still the water system was unable to supply adequately the 1,300-gpm fireflow needed for this defensive attack. The fire continued.

It became apparent to Chief Fink that the north wing might be saved. Communications with crews that had operated in the west and north wings indicated that the attic between them was firestopped and that a fire door was intact in the hallway. Sopp and Fink considered the proposal to protect the north wing at the firestopping to be both possible and safe. Taking caution not to mix offense and defense in the area, crews from two engine companies were sent into the west wing from the courtyard and knocked down the fire that burned around the firestopping in the attic. Then they exited, reentered the north wing, and completed the extinguishment of the fire around the door and the firestopping in the attic from that side.

It became apparent from conversations with residents that one occupant might still be in the structure. With fire finally extinguished in the south wing, members of Truck 1 reentered the structure and located the body of a woman who occupied the first room east of the main entrance. Tragically, during primary search, firefighters had passed over her room.

The fire was declared under control at 0458 hours. Crew relief continued through the morning. Overhaul continued until 1350 hours that day.

Eight residents were dead at the scene. Eight residents were evaluated and transported to hospitals; one died there. The owner and director of the facility, who were occupants at the time of the fire, refused treatment and were released to family members. Two men who lived in the neighborhood had rescued several occupants from the north wing during the initial operations; they were treated at the hospital for smoke inhalation and fatigue.

Twenty-five firefighters were evaluated at the on-site rehab. Three were transported by ambulance to Memorial Hospital and another was delivered to that hospital via his pumper while en route back to quarters. Two received injuries from falls. Four ambulance crew members were treated for smoke inhalation sustained from working outside the building and released.

INVESTIGATION

An investigation was undertaken immediately following the fire.

The fire destroyed the entire east wing, the kitchen and dining facilities, and the south two-thirds of the west wing. The north wing was spared fire damage.

The fire originated near a consumer-grade, 120-volt ceiling exhaust fan in the smoking room of the east wing and extended west into the dining room. The smoking room ceiling failed and east wing joists pulled out of the south wing exterior wall sockets, through and on which they were mounted, presenting an accessible channel for fire. From there fire spread through the void between the cinder block and brick veneer of the dining room’s east wall. This vertical channel terminated at the underside of the dining room’s exposed tongueand-groove wood roof decking (which was supported by exposed heavy timbers). Fire quickly flashed over the entire ceiling area of the dining room; the wood had been treated with at least eight coats of varnish, and cooking oil/grease deposits had accumulated on the wextd over time. Without fire walls, firestops, and fire doors, the fire further extended into the west wing, burning north until stopped at the brick wall subdividing the attic space.

The fire extended to the north section of the east wing through the large breach in what had been a draft stop. A furnace flue, continuous from basement to attic, provided the fire with a sustained flow of fresh air into the attic spaces.

The first of two areas of severe burning was noted where the ceiling fan had been. The fan was on the samecircuit as the overhead lighting. Its bearing/bushing element showed evidence of extreme wear, worn into an oblong shape. Witnesses said it was very noisy. An electrician inspected the circuit to the overhead lighting and exhaust fan and found them to be serviced by the only 15-amp circuit breaker in the electrical panel. The breaker showed evidence of extreme internal heat. Investigations indicate that the breaker failed in the closed position with its internal elements fused together. The electrician reported that it may have been operating very near its capacity for a long time. Adjacent breakers showed no signs of heat and appeared to remain functional.

The double twoby four-inch top plate on the north wall of the smoking room showed evidence of extreme heat and near total destruction above the location where the ventilating fan was found. Distinct burn patterns also were found on the wall beneath this area.

A second area of severe burning was located approximately eight feet west of the exhaust fan, at the enclosure to the furnace flue extending from the basement. This flue was immediately next to the extreme east end of the dining room. The top platesurrounding this flue revealed extreme burning on the north side where a support strap connects to a ceiling joist. This originally was thought to be the origin of fire. It was during excavation of the smoking room that the ceiling fan and its nearby structural members were discovered.

It is unknown why the heat detectors in the attic area of the east wing did not warn of the fire in that area. The condition of the system before the fire has not been established.

Fire burned in the attic above the residents undetected for a considerable period of time—perhaps as long as 90 minutes. Only when the ceiling in the. smoking room collapsed did fire products reach the recently installed smoke detector system and activate a local alarm.

POSTFIRE

The Colorado Springs Critical Incident Stress Debriefing Team held a debriefing on Tuesday night, the night after the fire, for all employees involved in the Crystal Springs Estate incident. Thirty-six firefighters attended the debriefing on a voluntary basis. On Wednesday night the C1SD team debriefed 16 members of the ambulance companies and the following night held a meeting to defuse its own members.

Three fire department critiques were held: the first for A-shift officers, the second for upper-level department managers, and the third for all personnel involved with the fire.

On March 28, the first meeting of the Health Care Facility Safety Review Group convened. It is composed of representatives from the Fire Board of Appeals, the Regional Building Department Board of Review, the Regional Building Committee, the Housing and Building Association, and administrators from three health care facilities. The committee plans to formulate code change recommendations to the city council to improve fire detection and protection systems in health care facilities.

The Colorado State Fire Chief’s Association moved quickly to renew its appeal to the state executive and legislative government branches to take a more active role in fire safety. The association drafted a position paper for distribution to the governor and all members of the general assembly, making five recommendations on fire safetyand fire protection. Only time will tell what impact the death of the nine residents of Crystal Springs Estate will have on the overall fire safety of Colorado residents.

LESSONS LEARNED AND REINFORCED

• To prevent such tragedies from occurring, fire protection measures and fire prevention activities must be increased. The need for full residential automatic sprinkler protection in concert with reliable detection systems, particularly in high-risk occupancies such as Crystal Springs Estate, is apparent. Fire protection requirements must address attic/void spaces—the best escape plan in the world is useless when fire burns undetected and unchecked in voids for considerable periods of time. Fire departments must devote more time and resources to upgrading fire and building codes for life safety and to more comprehensive inspection activities in cooperation with other municipal and private agencies.
• Builders and contractors must be educated on how important building modifications can be to the development of a fire. They must know, for instance, that breaches in firestopping can have serious life-and-death consequences.
• A two-wire circuit should not be an acceptable means of wiring a detection/alarm system.
• For fires in occupancies that have the potential for many casualties— high-risk occupancies—call additional resources to the scene at once.
• Alarms received from more than one source indicate a potentially serious fire problem. Departments should analyze whether or not a larger firstalarm response assignment is dictated, particularly for known high-risk occupancies.
• In larger buildings or in those with a large life hazard, assign search and rescue by zone or geographiclocation.
• All search and rescue teams should be backed up by protective lines.
• Rescued victims should be protected from exposure to hazardous
• conditions during their evacuations. Always take the safest route of escape when removing victims —for instance, if possible, pass them out windows instead of carrying them down a smoke-filled hallway.
• A fire that has entered an attic space requires rapid ventilation of the attic. Prompt ventilation of the atticspace reduces fire spread and relieves smoke and heat buildup, thereby improving visibility, survivability, and the capability to perform a more ef-
• fective, safer search.
• Ongoing fireground communications are absolutely essential. Incident decision making for large and complex incidents would be improved with time-on-scene references provided to command by the emergency communications center.

When a company completes an assignment, it should report its availability to the incident commander. If a company cannot complete an assignment or is diverted from its assignment for any reason, it should report its status to the incident commander.

The incident commander must be notified immediately of any change in fire conditions and/or the need to change tactics. Command will make specific objective assignments to arriving companies. No free-lancing should ever be undertaken on the fireground.

If companies are split into two teams, ensure that both teams are equipped with portable radios.

• At large-scale incidents, always keep additional companies in staging, from where members can respond to unanticipated incident developments without delay.
• The assignment of a trained safety officer who performs only a safety function greatly increases the safety of an operation. This individual can offer more objective views of operations for postincident critiques.
• The assignment of an aide for the incident commander should be automatic for incidents of two or more alarms. An aide is invaluable for manning the telephone and tracking company assignments, status, locations, and needs. This helps keep the incident commander from becoming overwhelmed.
• In a major incident, call support agency representatives to the scene immediately.
• Medical evaluation and rehabilitation of all personnel are critical during the incident. Medical evaluation must occur before members are released to return to quarters. This must be established as policy and not be voluntary for each member.
• The sight of many sheet-covered bodies can take a severe psychological toll on all people involved in a tragic incident. Make certain that DO As are moved to a location remote from operation, rehabilitation areas, or victim shelter locations. Handle bodies as you would a living victim — with respect and compassion.
• Critical incident stress debriefing is of vital importance to members
• following traumatic incidents. All members should be educated in how to recognize signs of stress in themselves and fellow firefighters.
• Large fires dictate a heavy fire flow. A 2‘/2-inch attack line may be preferable under such conditions.
• Cooperate with city management and utilities to improve fire defenses in your jurisdiction. Firefighting efforts were severely hampered by municipal water supply deficiencies. Ironically, work to upgrade water supply in that area had been sched-
• uled prior to the Crystal Springs Estate fire. One week after the fire, hydrants and supply lines were replaced.
• Particularly in municipalities that do not encounter large and complex incidents every day, training and preplanning are the keys to effective response. Preplanning high-risk occupancies should include such factors as water supply, hydrant locations, main sizes, anticipated fire load, and anticipated fire flows, as well as life hazards and building construction.