FT. WORTH NUSRING HOME FIRE:
FIRE PROTECTION LESSONS
During the early morning hours of June 21, 1992, the Ft. Worth (TX) Fire Department was dispatched on a smoke investigation call to the Colonial Manor Nursing Home at 400 South Beach Street on the city’s east side. Firefighters had answered many calls to this address in the past without having a working incident. This time would be different: The events of the next hour were to provide numerous lessons for fire departments and prove once again that, even in sprinklered health-care facilities, firefighters should be prepared to combat a working fire at any time.
THE FACILITY
The Colonial Manor Nursing Home was constructed in the early 1960s. During the mid 1970s, the facility was expanded to its present 181-bed capacity. The majority of the facility consists of wood-frame construction with a brick veneer exterior and a peaked wood-truss roof. ‘Hie kitchen area, a 12by 70-foot addition on the building’s west side, had a flat, builtup roof on a plywood decking. Interior walls and ceilings in most areas consisted of gypsum wallboard (sheetrock) attached to the wood studs/joists.
The facility’s existing wet-pipe automatic sprinkler system was expanded in the 1970s to cover the additional areas. The system appeared to meet the requirements of NFPA 13 except for one area in the kitchen (which will be discussed later in detail). Sprinklers were provided in the attic space of the peaked truss roof as required by NFFA 13-
The building’s fire alarm system consisted of corridor smoke detectors along with manual pull stations at the exits. Horn/strobe devices were installed in the corridors. Relays were provided for the automatic shutdown of HVAC systems and closure of corridor doors held open by magnetic devices. The sprinkler system was monitored by electronic waterflow and supervisory devices. These two devices were installed on the same fire alarm zone.
Since the state of Texas required existing health-care occupancies to conform to Chapter 13 of the NFFA 101 Life Safety Code-1985 edition, smoke barriers were provided. These barriers generally consisted of gypsum wallboard on wood studs and extended into the attic space. However, the smoke barriers in the attic had substantial penetrations that compromised their ability to stop the spread of smoke and fire. Self-closing wood doors (held open by magnetic devices) were provided in corridors penetrating these barriers. These doors contained ordinary glass view panels, lacked gasketing around the edges of the door, had no latching hardware, and were not listed by a testing laboratory.
INITIAL RESPONSE
A call to the Ft. Worth Alarm Office at 4:47 a.m. on the morning of June 21 reported smoke in the kitchen area of the Colonial Manor Nursing Home. A first-alarm assignment, consisting of three engines, a truck company, and Battalion 4, was dispatched. Shortly thereafter, an alarm company reported that an automatic alarm had been received from the nursing home.
Engine and Truck 14 arrived at the front (east) entrance of the nursing home within one minute. Their entry into the facility was delayed momentarily because the front door was locked and there was no employee waiting to meet the fire department. Members were let in by an ambulatory resident. They went to the rear of the facility, where the kitchen was located, while the alarm system’s horns/strobes operated in the hallway.
In the hallway just outside the kitchen, firefighters observed a haze of smoke, and hot water was leaking from the hallway ceiling. The kitchen was locked. While a nursing home employee searched for a key, fire personnel used a ladder to check the attic above the hallway by means of a small access door in the ceiling. This investigation found a fair amount of smoke in the attic along with some type of water spray.
Several minutes had elapsed while employees tried to find a key to the kitchen door. About this time, smoke conditions, which had been a light haze, suddenly began to worsen. Firefighters donned breathing apparatus and forced open the kitchen door, revealing a smoke-filled kitchen but no visible signs of fire. The ceiling was opened up approximately four feet inside the kitchen from the hallway door, exposing fire conditions in the attic. Using this access point, firefighters used a small handline to extinguish all visible fire in the attic. Firefighters now felt they had extinguished the fire, confining it to the attic area above the kitchen.
Members waited for the smoke to start clearing to begin overhaul —but just the opposite was occurring. The smoke continued to increase. An officer ordered that a larger handline be stretched.
ADDITIONAL ALARMS
Battalion 4 arrived and established a command post at the rear of the nursing home on Essex Street. Upon learning of the request for a larger handline, he transmitted a second alarm at 5:01 a.m., bringing an additional three engines, one truck company, one battalion chief, one squad, the duty deputy chief, and the command vehicle to the scene. The duty deputy chief, along with the command vehicle, reported to Essex Street, and command was transferred from Battalion 4.
Limited smoke production during the early stages of the fire dictated the initial strategy of a quick knockdown with limited search and evacuation. One company conducted a primary search of patient areas immediately adjacent to the kitchen. Despite an employee’s statement that all patients had been removed from the back portion of the nursing home, firefighters found several patients still in their rooms in Zone 14—which by this time was starting to fill with smoke. These occupants were brought to an area of the facility removed from fire.
Truck company personnel vented the roof with a single-hole cut just east of the compressors serving the walk-in cooler/freezer on the lower end of the sloped roof. Some smoke and fire vented out, but the kitchen was still obscured in smoke.
Kitchen conditions continued to intensify. Several additional ceiling areas were pulled, and handlines extinguished visible fire. With each knockdown, firefighters falsely believed the fire to be under control. However, it was obvious from the exterior that this was not the case, and command requested a third alarm at 5:19 a.m., followed by a fourth alarm at 5:49 a.m. These two alarms brought an additional four engines, one truck company, and two battalion chiefs.
Deteriorating conditions at the back of the nursing home and the spread of smoke throughout the majority of the facility made it necessary to move all patients to the outside of the building. They were moved to the front parking lot on the east side of the building with the assistance of employees and fire department personnel. City buses were called to transport nursing home occupants to shelters.
Eventually, the fire burned through the roof decking near the compressor motor situated directly above the walk-in cooler/freezer. Because interior companies could not reach the seat of the fire despite having placed six handlines into operation, a handline was taken to the roof and used to extinguish the fire from above. After some additional truck work on the roof, all additional pockets of fire were extinguished. The fire was declared under control at 6:42 a.m. Damage was estimated at 5200,000 to the structure and 550,000 to contents. Two staff members and one firefighter received minor injuries.
FIRE DEVELOPMENT
When the facility was expanded in the 1970s, two walk-in cooler/ freezers were placed in the new kitchen. These units extended vertically to a height approximately one foot below the bottom of the joists that supported the kitchen’s flat wood roof deck. The area above the cooler/ freezers was enclosed by gypsum wallboard, thus creating a nonsprinklered, combustible, concealed space approximately nine by eight inches with a depth of approximately two feet.
The rest of the ceiling in the kitchen was composed of gypsum wallboard attached directly to the bottom of the 2X8 joists. This provided combustible concealed spaces in each joist channel. There was no draftstopping at the point where each joist channel above the kitchen came in contact with the trusses of the main building’s peaked roof. None of these combustible concealed spaces were sprinklered as required by NFPA 13-
The Ft. Worth Fire Department concluded that the fire started from an electrical short in one of the compressor motors for the walk-in cooler/ freezer. This motor was located on the roof directly above the cooler/ freezer. The short ignited the wood surfaces in the combustible concealed space between the cooler/ freezer and the roof decking.
Since there was no draftstopping in the joist channels, the fire attempted to spread east into the peaked attic of the main building. Since this area was equipped with automatic sprinklers, five heads operated and prevented the fire from spreading. One additional head operated at ceiling level in the kitchen.
The initial ventilation hole cut in the roof was located in the immediate vicinity of one of the operating sprinklers in the peaked portion of the main attic. Due to the closeness of the operating sprinkler to the ventilation hole, the removal of the products of combustion was hampered by the downward force of air caused by the discharging water. Therefore, crews operating inside the kitchen continued to be hampered by smoke obscuration.
During the entire incident there was no major fire extension beyond the concealed space above the cooler/ freezer. Since this area had been enclosed by gypsum wallboard, firefighters working in the kitchen were never able to observe the fire. Only when the fire broke through the roof did it become apparent that a concealed space must have been present.
DISCUSSION
Two factors played a major role in making this fire larger than it should have been. The key factor was the lack of automatic sprinklers in the concealed combustible areas of the kitchen. This allowed the fire to grow to a size that produced enough smoke to filter throughout the majority of the facility. Although the automatic sprinklers in the peaked portion of the main building stopped the spread of fire into the remainder of the nursing home, sprinkler spacing violations in this area could have hampered the system from effectively controlling the fire. Fortunately, these violations were not concentrated in areas where the fire attempted to enter the main attic.
Smoke spread was another area of concern at this fire. Due to the unprotected openings in the smoke barriers caused by nonlisted smoke doors and penetrations in the attic, the idea of compartmentation was negated and smoke traveled through the majority of the structure. The concept of “defend in place,” where patients in zones outside of the fire zone can feel safe and protected, was not possible in this incident. All patients had to be evacuated from the building due to the smoke spread and the uncertainty of whether the fire would spread beyond the kitchen.
This incident proved that it’s conceivable to have a working fire in a sprinklered facility. Although it first appeared as though the sprinkler system had totally failed in its function of controlling the fire, the follow-up investigation quickly proved otherwise. Mad the sprinklers not been present in the peaked portion of the main attic, firefighters would have found a totally different scene when they pulled up to the front of the nursing home.
Without the sprinklers, the fire most likely would have fully involved the attic of Zone 4 upon fire department arrival. Although the smoke barrier would have slowed down the horizontal spread of the fire to some degree, the fire eventually would have traveled through the penetrations to involve zones 5, 12, and 14 prior to the fire department’s ability to set up operations.
Fortunately, the automatic sprinkler system was present in the peaked portion of the main attic and activated prior to the arrival of fire department units on the scene. Their continued operation during the early stages of the fire allowed the nursing home to be fully evacuated without any injuries to the patients.
LESSONS LEARNED AND REINFORCED
- Smoke barriers are critical in a health-care facility. Too often, their integrity is compromised by improper installation and/or subsequent breaches. Annual inspections of
- health-care facilities by fire inspectors (required by many states, including Texas) must include a check of these assemblies. These inspections require a ladder, flashlight, and time to check walls above and below installed ceilings. Automatic sprinklers must be examined to ensure proper spacing if modifications have been made to smoke barrier locations.
- A key to a nursing home facility should be provided in a lock box near the entrance so that valuable time is not lost waiting for someone to open the door. If possible, a master key to all doors should be provided.
A skeleton nursing home staff is typical of “after-hours” fires in these facilities. The inevitable “search for keys” will necessitate that firefighters use the fire department’s universal “keys”—the halligan tool and flathead axe. Nursing home staff often will be preoccupied with moving and calming patients.
Although the Colonial Manor was not a psychiatric facility, it is important to remember that keys, including those for patient room doors and windows, are essential. Anticipate difficult and numerous forcible entries if the keys are not found tethered around the nurse’s neck (where they should be) in these types of facilities.
- Even if an employee states that an area already has been evacuated by facility staff members, conduct a primary search of the area and verify the statement. During times of minimum staffing due to budget constraints, additional alarms may be necessary to accomplish this task.
- Do not always count on using the “defend in place” method of patient evacuation. All of the building’s fire protection features must properly work together for this method to be used. Whenever the “defend in place” method is not possible, provisions for moving the patients to a safe location must be made. When the weather is inclement, time becomes a critical consideration in transferring resi dents quickly and orderly.
- Plan reviews of buildings with wood-frame construction do not always reveal combustible concealed spaces. Full elevation views of the building are necessary to obtain a full “picture” of the structure. Questionable areas can be reviewed for the need for sprinklers in the concealed space. Unfortunately, plans do not always reveal all concealed spaces— thorough inspections are essential.
- Proper sprinkler inspection at the time of installation is critical. All ceiling areas should be examined prior to covering the ceiling, to ensure proper installation of piping and to confirm that no combustible concealed spaces are present. In addition to the final sprinkler inspection, the Ft. Worth Fire Department now conducts a rough-in inspection prior to the covering of the ceilings.
- During reconstruction of the fire area, fire inspectors must visit the site to inform contractors of the reasons for the fire and how to properly reconstruct the area. In some jurisdictions, contractors are only required to reconstruct the area back to its original condition (that is, plans are not submitted to the building and fire departments). Therefore, if the building was constructed improperly to begin with, there’s a good chance it would be reconstructed that way.
- If at first roof ventilation efforts do not succeed, additional openings may be necessary to locate the seat of the fire. Small observation holes may be used to locate the fire. Once the location of the fire is known, the truck company officer can determine if additional ventilation holes will provide desirable results without pushing the fire into other areas of the attic.
- Wet-pipe sprinkler systems in attics can become a freeze-up problem in winter, especially if gypsum board is used as a ceiling (where heat transfer from the room below is very limited). In the case of the Colonial Manor, the heating system is ducted into the attic to maintain adequate temperatures.
