Group Home Fire Claims Seven Lives
FIRE REPORT
Factors surrounding fatalities in these occupancies repeat themselves once again.
Cincinnati, OH, firefighters battled an early morning fatal fire in a converted group home last December. The structure was used to house mentally retarded adults. Six of the residents lost their lives and a seventh died two months later from injuries sustained during the fire.
The building was a three-story, single-family residence of ordinary brick and joist construction built in 1905. It had been converted to a group home housing 10 men of varying degrees of mental retardation, ranging in age from 25 to 50. The front entrance opened into a central foyer and hallway with rooms on either side. An open stairway at the rear of this hall led to the second floor where bedrooms and offices were located. There were also bedrooms at the top of the third-floor stairs. The door to an enclosed solarium off the rear west side bedroom was found padlocked. Since the door was not used as a fire exit, this lock did not violate fire codes. A fire escape on the east side of the structure extended from ground level to the third floor.
At the time of the fire, the building complied with all existing city and state codes and the standards of the State Board of Mental Retardation. The alarm system was a combination smoke detector/pull-station alarm. It was operable when the fire started, although investigation revealed that at some point, the wires had been burned through. Fire extinguishers were in place on every floor. An evacuation plan was posted and fire drills were held on a quarterly basis. The building had passed inspection by the Cincinnati Fire Department on August 8, 1983.
The fire
At 7:19 a.m. on Monday, December 5, a motorist stopped at a fire station to report flames and smoke issuing from a house approximately 1 1/2 miles away. At about the same time, someone transmitted a street alarm box nearer the fire location. A neighbor also telephoned an alarm to fire communications. The initial response consisted of two engine companies, a ladder truck, and District Chief Maurice Nie. While enroute to the incident, Lieutenant T. Rave on first-arriving unit Engine 9 called in a Code Two (working fire) because of the heavy smoke condition in the area.
Remembering the location from previous EMS runs, Engine 9 was aware that the building was a group home for mentally retarded adults.
Conditions confronting the first-in companies on arrival were heavy flame involvement of the first floor of an obviously occupied building; fire issuing from various self-vented windows; and heavy smoke conditions on the second and third floors.
Rave sized up the situation and immediately requested assistance. A rescue company and an additional engine were dispatched.
When bystanders indicated that there were still people inside, a second alarm was transmitted, bringing an additional engine, truck, heavy rescue unit, and District Chief John Meyers to the scene. Fire Chief Norman Wells also responded on this additional alarm. Three minutes after the second alarm was sounded, Chief Nie called for an additional truck company for manpower to aid in rescue operations.
Operational tactics
On arrival, Engine 9 laid 10 lengths of 2 1/2-inch supply line from a hydrant to the fire location. The rapidly spreading fire had vented itself through both front windows, a side window and the front door. Making an aggressive interior attack, Engine 9 advanced a 1 3/4 inch pre-connected line with a Task Force tip through the front door. The main objective was to extinguish what fire they could and to gain control of the interior stairway to the second floor. “They went right in through the smoke and flames,” said a neighbor at the scene.
Engine 32’s three-man crew hooked up to a hydrant connection with their 4 1/2-inch supply line approximately 150 feet from the fire. They then laid three lengths of a 2 1/2-inch line with a 1 1/2inch wye on the end. From that wye, they stretched a l line around the east side of the building to the rear of the structure. Flames were boiling from a second floor window and extending to the eaves. Firefighters quickly knocked that fire down before proceeding through the back door into the rear of the center hallway and up the stairway to the second floor.
Truck 12, a 100-foot aerial, had positioned their apparatus in a narrow driveway on the east side of the building. Chief Nie ordered Engine 39 to take a line to Truck 12’s location to protect them from the flame exposure from the side window. They later advanced this line up the fire escape to attack the blaze on the second and third floors.
Engine 23, assigned on the second alarm, laid a 2 1/2-inch supply line from a third hydrant and a 2 1/2-inch relay line to Engine 32 for additional water. They then stretched a 1 3/4 -inch handline with a Task Force tip up an 18-foot straight ladder to the second floor. This line was later advanced up to the third floor.
While engine companies fought the blaze from the interior, ladder companies performed the necessary ventilation coordinated with search and rescue operations. Truck 12 raised three portable straight ladders to the second floor windows on the east side and rear of the building. Two firefighters climbed the fire escape to the third floor where they broke out the windows in order to vent, enter, and search for victims.
Truck 9 arrived and positioned its aerial ladder to the peak of the roof and began to ventilate above the fire. These firefighters continued until the roof became hot and spongy, forcing them to retreat. Truck 9 personnel also raised a straight ladder to the west side of the building. Starting at the front, they took out all the windows on the second floor, finally placing the ladder at the back bedroom window. Lieutenant M. Childs ascended that ladder to enter and aid in search operations.
Truck 4 maneuvered their apparatus to the front of the building and extended their aerial ladder to a dormer on the third floor. They stretched a 1 3/4 -inch line up the ladder to fight the fire in the kneewalls and the attic and also for protection during necessary search operations.
Within 20 minutes, all of the victims had been found and removed. Chief Wells assigned paramedics, already on the scene, to set up a triage area. Not yet knowing the extent of the injuries, he also requested the city’s three ambulances to respond to the scene.
Reconstruction/critique
One of the survivors, a staff member at the home, had been working there since the previous January and was on duty alone from midnight to eight a.m. He admitted to having no prior experience with group homes or retarded persons. Upon becoming aware of the fire, he yelled to the men that they needed to get out. He gathered as many men as possible into a front bedroom, coaxing them to jump out the window. He did manage to lower one resident to safety but the others panicked and, confused, ran out of the room.
The open bedroom door allowed heavy smoke and heat to enter the room, so he jumped, landing on the concrete porch and fracturing both heels. Later at the hospital, he described his rescue attempts to reporters: “The men panicked. I looked up the stairs to the third floor and could see some of them up there. I yelled for them to come down but they just panicked and didn’t want to come down.”
Firefighters found three residents in the front bedroom; one was dead but the other two were resuscitated by paramedics and transported to the hospital in critical condition. One victim, severely burned, was discovered on the landing between the first and second floor. It is assumed that in his panic he ran straight into the fire.
Men from Truck 12 entered the third floor from the roof and proceeded down the stairs to the second floor. They encountered resistance when they tried to open the door at the base of the third-floor stairs. It was blocked by the body of another victim. The rear right bedroom contained three victims, one just inside the door, one in front of the padlocked door leading to the enclosed solarium, and one standing in the closet. After the fire was extinguished and the firefighters were overhauling, another resident was found, clothed and unharmed, wandering around inside the building. There is speculation that he exited the building before firefighters arrived but the facts are not yet known.
Investigation
According to the Fire Investigation Bureau, the fire started on the first floor in a room used as a sitting and recreation area on the front right-hand side of the building. Officially, the cause of the fire is listed as careless use of smoking materials. The fire involved a large section of the first floor with an open staircase to the second floor completely burned. A fire door between the first and second floor was open and destroyed by the fire. Smoke and flames were spread throughout the house by the furnace duct system as evidenced by the burned fan motor and furnace filters. As in most older homes, the return air ducts were in enclosed spaces between joists.
Several factors contributed to the multiple fatalities. The occupancy is on a busy street located near a university. Flames had been spotted at 7 a.m. when rush hour traffic is beginning, but due to a neighbor’s assumption that someone else had reported it, no alarm was transmitted until 7:19 a.m. That 19minute delay made the difference between life and death for six men. Although pertinent changes in the fire code can prevent similar tragedies from occurring, educating the public about the importance of prompt reporting of fires is just as crucial.
It’s also possible that one attendant was not really capable of evacuating 10 mentally disabled persons. The National Bureau of Standards is currently developing criteria called the Fire Safety Evaluation System for Group Residences for the Developmentally Disabled. Using a measure of the difficulty that can be encountered in evacuating a specific group home plus the measure of fire protection available, will give a factor showing which homes need more fire protection. These figures would also aid management of group homes in determining the number of staff persons required for effective emergency evacuation.
An interesting side note is that all of the residents worked at the Jackson Adult Center. Each weekday, they were supposed to be awake, dressed, have their beds made and breakfast eaten by 7:30 a.m. Vet, only one of the residents was dressed. The others, including the six fatalities, were either in pajamas or naked. And there was no indication that anyone heard the fire alarm sounding.
At presstime, the State Fire Marshal’s Office, the Hamilton County Prosecutor’s Office and the State Board of Mental Retardation were still investigating this fire.
Future problems
All of the residents of this group home had originally been housed at Orient Developmental Center in Orient, OH. This facility was under a court order to close down by early 1984 and return the inhabitants to their home counties. This, coupled with the growing advocacy of home-like environments for mentally disabled, elderly, prison parolees, problem children and adolescents has created a new fire safety hazard.
In the last few years, several fires have occurred at so-called group homes across the nation, resulting in multiple fatalities. Some met state and local codes; others did not. Questions are being raised as to whether current codes are stringent enough to protect those individuals with physical or mental handicaps.
Chief Wells feels that requiring sprinkler systems would go a long way towards preventing loss of life. He states, “I think it’s an absolute necessity when you’re dealing with resident homes where the people already have some type of problems that may not allow them to respond in a normal manner to a fire situation. And 1 feel certain that had there been an operable sprinkler system in that building, the fire would have never gotten out of that first floor room.”
As a result of this fire, Chief Wells is organizing a statewide campaign to change the building codes for such residences. Also, a committee has been formed in Columbus to study whether or not changes are necessary. As the group home or boarding home concept becomes more popular, an increasing number of fires involving multiple fatalities are occurring which warrants the attention of fire department personnel across the nation.
Chief Wells has contacted the fire chiefs and building directors in Ohio’s 10 major cities. Together, they plan to lobby in Columbus for a change in state code to require that group homes have operable sprinkler systems. Dayton and Akron are both drafting city ordinances to this effect, but Chief Wells feels that a statewide code would be more effective. “It should be a statewide regulation so that it doesn’t impose a burden on any one locality.”
In an article for the National Fire Protection Association, Dave Holton, chief investigator for the U.S. House of Representatives Select Committee on Aging agrees that changes in codes need to be made. “Local, state and federal fire and health authorities have been ill-prepared to deal with this complex and growing industry. In some instances, inappropriate codes are being applied; in others, basic codes are not being enforced . . . . Assuring adequate protection for this growing class of residential occupants may be the greatest challenge facing fire protection personnel in the 1980s.”
“I’m certain that had there been an operable sprinkler system, the fire would never have gotten out of that first floor room. Sprinklers are a necessity when you’re dealing with people who cannot respond in a normal manner in a fire situation.”
“Assuring adequate protection for this growing class of residential occupants may be the greatest challenge facing fire protection personnel in the 1980s.”
