TRAGEDY IN A RESIDENTIAL HIGH-RISE, MEMPHIS, TENNESSEE

TRAGEDY IN A RESIDENTIAL HIGH-RISE, MEMPHIS, TENNESSEE

BY MARK CHUBB AND JOE E. CALDWELL

One of the most dangerous and challenging situations firefighters can confront is a fire in a high-rise building. A multiple-fatality fire in the Regis Tower, a residential high-rise in Memphis, Tennessee, on April 11, 1994, presented such a challenge to one of the Southeast`s largest fire departments. Although 14 occupants were rescued by firefighters, including 11 retrieved using aerial ladders, two firefighters and two civilians lost their lives.

THE BUILDING

Regis Tower, 750 Adams Avenue, constructed in 1964, is an 11-story concrete-and-steel (Type 1, fire-resistive) high-rise building. Its overall dimensions are 140 feet long and 50 feet deep. The central corridors on each floor are 104 feet long and five feet wide. Exit stairways at the east and west ends of the corridor serve all floors and discharge directly to the outside at grade. Each stairway is separated from the corridor by 112-hour fire-resistance-rated doors in fire door frames at each floor level. All doors are equipped with working closers. Internally illuminated exit signs are installed above each stairway door.

At the time of the fire, the exit access corridor was separated from the 13 apartments on each floor by partitions constructed of three sheets of 12-inch gypsum wallboard on each side of a one-inch air gap. Seams in the assembly were overlapping. The assembly was anchored to the top, bottom, and edges between columns by metal channels. No studs were provided between building columns for lateral reinforcement of the assemblies. Separation between apartments was accomplished by these same type of assemblies. Nonfire-rated, 134-inch-thick solid-core wood doors, in hollow metal frames, protected openings from the apartments onto the corridor. These doors were not listed as fire doors or fire door frames and were not equipped with self-closing devices. Corridor walls were covered with a combustible wainscoting and wallpaper. The concrete floors were covered with lightweight carpeting.

Coaxial television cable was installed in the corridor in nonmetallic raceways, secured to the wall approximately four inches below the ceiling. Lighting in the corridor consisted of wall-mounted incandescent fixtures and unit battery-pack emergency lights.

The building has a Class III wet standpipe system. Risers located in both stairways feed 212-inch hose valve outlets at every floor, in the stairways. Hose cabinets with 100 feet of 112-inch “occupant-use” fire hose, fed from a separate riser, are located in the corridors, five feet east of the elevator lobby. (The hose was not used during this fire.) The fire department connection for the standpipe system is located outside at grade near the northwest corner of the building. A building fire pump augments the public water supply to maintain required residual pressure at the topmost hose outlet.

The building was protected by a conventional zone-type central station fire alarm system. The system control unit is located in the first-floor lobby near the building entrance. At the time of the fire, 15 zones were used to monitor alarm and supervisory initiating devices located throughout the building–one zone dedicated to manual fire alarm boxes and corridor smoke detectors on each floor and the remaining four zones to supervise standpipe control valves and the fire pump. Manual fire alarm boxes were installed at the entrance to each stairway. Vibrating horns were provided to sound the alarm signal on each floor. One horn was provided directly above each manual fire alarm box. Alarm signals from the system were monitored by a central station service that retransmitted alarms by telephone to the fire department.

Automatic fire detection had been added to the fire alarm system in the building sometime after its original occupancy, but the exact date of that addition has not been determined. System-type ionization smoke detectors were installed approximately 15 feet from each end of the corridor on each floor. The corridor smoke detectors were not required by the local building or fire codes. Battery-operated, single-station ionization smoke detectors were installed in each apartment in the vicinity of the sleeping area. These detectors were not connected to the fire alarm system in any way.

Two automatic traction elevators, located in a common hoistway, are provided in the center of the building. Both cars serve all floors. (According to Memphis fire officials, the building code in effect at the time the building was constructed recognized the elevators as a means of egress.)1 The elevator lobby on each floor is arranged perpendicular to the exit/access corridor. A trash chute and mechanical shaft are located across the lobby from the hoistway. A mechanical equipment room is located at the end of the elevator lobby on each floor, across from the corridor, and is separated from the corridor by a block wall and hollow metal door.

INITIAL ALARM

At 0205 hours, the central station monitoring service for the Regis Tower called the Memphis Fire Department to report an alarm indicating a trouble alarm on the ninth floor. The normal response to a possible high-rise fire–three engine companies, two ladder companies, and a battalion chief–was dispatched. Engine 7 arrived first, followed shortly after by Snorkel 13, at 0208 hours. Lieutenant Michael L. Mathis of Engine 7 reported “nothing showing” and assumed command. (Firefighters from first-alarm companies later told investigators that they observed lights on in most of the ninth-floor apartments and occupants were peering out at them when they arrived.)

Mathis and a team of firefighters entered the building. The fire alarm control unit in the lobby indicated a smoke detector activation in the ninth-floor corridor. One firefighter was stationed in the lobby to continue monitoring the fire alarm system. The other five members rode the elevator to the fire floor. The elevator was not equipped with recall or emergency control features (no Phase I “Recall” or Phase II “Firefighter” service features required for new elevators by ANSI/ASME A17.12 and for existing elevators by ANSI/ASME A17.33–and A.17.1, where adopted). The firefighters left the elevator in automatic mode.

While interior members made their trip to the fire floor, the driver of Engine 7 transmitted a radio message that smoke had become visible on the southwest end of the building. This is the end of the building opposite the apartment of origin and would suggest that smoke had spread extensively throughout the fire floor. However, the other companies responding with the first-alarm assignment did not enter the structure or connect to the standpipe at this time.

The interior crew encountered thick black smoke and heavy heat conditions on the ninth floor. Four of the firefighters exited the elevator; one remained in the elevator, holding the door open with his foot, while they secured their SCBAs and masks. The firefighter in the elevator experienced problems with his SCBA; while adjusting the apparatus, his foot slipped off the elevator door. The doors closed, and the car returned to the first floor with him and their high-rise pack (containing two 50-foot lengths of hose and nozzles). It is unknown whether Mathis was aware that a crew member and the high-rise pack now were headed to the first floor. Private William E. Bridges also was experiencing problems with his SCBA. Mathis escorted him to the shelter of the protective enclosure of the west stairway. The time was approximately 0211 hours.

Meanwhile, the two firefighters from Snorkel 13 proceeded east down the corridor toward the area of the most intense smoke. Fifteen or 20 feet down the corridor, they encountered intense heat but saw no fire. Intense heat forced them to retreat toward the west stairway.

As these firefighters passed the elevator lobby, they encountered a hysterical male occupant who attacked one of the firefighters, pulling off his SCBA facepiece. The two members were forced to subdue the occupant and, in doing so, retreated into Apartment 905 instead of evacuating the fire floor. They did not close the door to Apartment 905.

Mathis, after escorting Bridges to the west stairway, reentered the corridor and proceeded east toward the fire. He did not know that three members of his crew had retreated back and out of the hallway. He reported to Battalion 1, now on the scene, heavy heat and smoke conditions on the ninth floor and requested additional personnel. This prompted members of Engine 1, who had not yet mobilized, into action: Three firefighters prepared to enter the building, and the driver hooked up to a municipal hydrant and the fire department connection on the east side of the building. The officer and one private from Engine 5 circled the building looking for a fire department connection but instead found Engine 1 already connected to it. (The subsequent incident investigation revealed that it took 25 minutes for members of this company to reach the fire floor from the time they arrived at the scene.)

Battalion 1 acknowledged the message and advised he was taking command of the incident. Then he walked away from his vehicle to make a size-up, carrying a portable radio tuned to the fireground (tactical) frequency. When he observed fire break and blowout of windows in Apartment 912 at the southeast corner of the building, he verbally ordered Snorkel 2 to set up for water tower operations. Then the chief walked back to his vehicle and ordered a second alarm. He was unsuccessful in communicating with personnel operating on the ninth floor.

Between 0214 and 0215 hours, as Mathis approached the east end of the building, the windows in Apartment 912 self-vented and the apartment flashed over. Mathis received a direct blast of flames and superheated gases that blew out into the corridor from the fire apartment. He received second-degree burns on the exposed areas of his neck, face, and hands; the heat damaged his portable radio such that he could receive but not transmit messages; and the heat melted the exhalation valve on his SCBA. Unable to pass Apartment 912 to seek shelter in the east stairway, Mathis retreated toward the west stairway, manually controlling his airflow through his SCBA facepiece by using the emergency bypass valve.

As Mathis approached the west stairway, Bridges heard his commander attempting to find his way out through the dense smoke. Bridges made four attempts to contact his officer by radio over the dispatch (general fire frequency) channel; he received no response. He reentered the fire floor to search for Mathis, after having restored his SCBA to proper operating condition.

DISASTER

Three firefighters from Engine 1, carrying a high-rise pack and extra air cylinders, arrived on the ninth floor via the west stairway. Two of the firefighters stretched a 134-inch handline from the standpipe and advanced down the corridor. Outside, the incident commander ordered Snorkel 2 to discharge its master stream into the window of Apartment 912 for 30 seconds. The first-due division chief, who had arrived on the scene, agreed with this tactic. The incident commander provided no radio warnings to alert firefighters as to the application of the master stream.

The Engine 1 attack crew, about two-thirds of the way down the hallway, was forced to retreat by the heavy volume of fire and smoke driven back on them by the master stream. Visibility in the hallway, very poor to begin with, became zero, and the firefighters became disoriented. During their retreat, they crawled over what they thought was a piece of furniture, although they did not remember it being there when they entered the hallway. They could not find the door to the west exit stairs.

The firefighter from Engine 7 who responded initially with Mathis but accidentally rode the elevator back down had obtained a replacement SCBA and climbed the west stairs to the ninth floor. He made entry onto the floor and found the two Engine 1 firefighters in trouble, just six feet from the stairway door. He pulled these members into the safety of the stairwell.

By now the sense of urgency on the fireground had increased dramatically, made real by six important factors:

The two firefighters accosted by the hysterical resident broke the glass in the window of Apartment 905–one of their low-air alarms was ringing and the occupant still was hysterical–and called for help from the firefighters on the ground. Smoke was flowing from this window.

The fire extended rapidly across the corridor, visible in Apartment 909, where the fire self-vented through the north-side windows.

Numerous occupants were at the north windows on the ninth and tenth floors in a state of severe stress.

Numerous occupants from the fire floor, particularly from apartments on the south side of the building, had self-evacuated or were in the process of self-evacuating.

Some members of Engine 7 and Snorkel 13 had not been accounted for.

Prior to his reentering the fire floor, Bridges made four radio transmissions on the dispatch frequency over the span of about 40 seconds (0217:56 to 0218:37 hours). Although Bridges said only, “7C to 7A,” an evaluation of the dispatch tape indicates the brief transmissions had an urgent tone. At the time of these transmissions, the incident commander was away from the radio, mounted in his vehicle, that would have allowed him to hear transmissions on the general frequency.

Rescue Squad 2 arrived at approximately 0224 hours and requested permission to perform search and rescue on the fire floor. They proceeded up the west stairway. Aware of an unusual hazard, the officer organized a human chain to search the fire floor. Ten feet from the stairway door they discovered the body of Bridges, entangled in television cables that had collapsed after the raceway supporting them collapsed from the heat. They disengaged him from the cables and checked for vital signs. Bridges was in cardiac arrest, his air supply exhausted. Firefighters removed him to the eighth floor, where EMS companies were establishing a medical triage area.

Squad 2 returned to the fire floor and continued its search. In Apartment 901, they found Mathis. He had collapsed in front of a return air register immediately below an outside window while searching for the stairway. His air supply had been completely exhausted, and he was in cardiac arrest. He, too, was brought to the eighth-floor medical units.

EMS units removed Mathis and Bridges to a local hospital, where they were pronounced dead a short time later. Both died of smoke inhalation/carbon monoxide poisoning.

Additional searches by multiple companies resulted in the location of two civilian fatalities. The first civilian victim was found in Apartment 905 during the primary search. The second civilian victim was found under a table in Apartment 901 during a later search. She died of smoke inhalation/carbon monoxide poisoning. During rescue operations, the (hysterical) male oc-cupant from Apartment 905 advised mem-bers of Snorkel 13 of the victim`s possible presence in the apartment; the Snorkel 13 officer made a quick search of the apartment but could not find the victim due to the heavy smoke conditions. The victim al-ready had been overcome by smoke by this time.

Three occupants were rescued from the building by interior-operating companies.

RESCUES

Second-alarm truck companies immediately were positioned on the north side of the structure, where numerous people were severely threatened by the heavy smoke and heat on the ninth and tenth floors. The company officer of Truck Company 4 said, “people were hanging out of windows, some of them by their fingers, desperately waiting for us to rescue them.” His crew rescued the two firefighters and occupant from Apartment 905. Then they rotated the ladder to Apartment 903 and rescued a fourth victim, who had a broken leg. This required two firefighters to climb the aerial and assist the individual to ground level. It was a time-consuming rescue effort.

Truck Company 5 also was directed to the north sector. This truck officer described the operation: “We left staging and went to the north side of the building. While setting up the aerial, plate glass was falling all around us. I looked up on the ninth floor of the `Charlie side` (side 3), and heavy black smoke was coming from the window [of apartment 909]. On the tenth floor above the fire, I saw someone with a flashlight shining it through the window. [We] raised the aerial to the tenth floor and tried to rescue this person. [Note: When they reached the objective, the occupant could not be located.]

“By this time, the heavy black smoke in the window below (ninth floor) turned into a raging fire [from apartment 909]. I looked to my right and saw a woman screaming from a ninth-floor window. Before we could get the aerial to the woman, she had let go and was hanging by one hand. I directed the driver to put the aerial as close to her as possible so she could reach it. At this time she reached out for the ladder with her foot. She let go of the windowsill and landed on the aerial. I sent one of the privates up the aerial to help the victim down.

“The next rescue was a man in the window next to her window. He came running down the aerial, face-forward. [Then] I looked farther to the right, and I saw firemen in the next window, but our aerial would not reach them. Truck 4 already had begun to rescue the firemen. Plate glass was falling on and around us the entire time rescue operations were in progress.

“At this time, Battalion Commander 3 ordered [us] to take down and set up a water tower on the ninth floor. While in the process of following this order, he came back to me and said to `take down,` because we have another rescue problem on the 11th floor on the east side of the building. We raised the aerial to the 11th floor and rescued three children and their mother.”

The members of Truck 5 performed this with a 100-foot aerial ladder. In all, 11 victims were rescued with aerial apparatus during this incident.

EXTINGUISHMENT

Subsequent alarms were called. Three engine companies extinguished the fire through an interior attack. The time of extinguishment was 0317 hours.

INVESTIGATION

Fire investigators determined that the fire had been intentionally set by one of the residents, using combustible materials already present in the apartment. A suspect later was identified, arrested, and charged with one count of arson and four counts of homicide.

Fire Investigator Lawrence E. Reed, of the Fire Marshal`s Office, reported the following:

“The point of origin appears to have been in the living room area, near the southeast corner on and/or around a sofa couch which was located along the south wall in front of an oversized window…. [T]his fire burned upward and outward from the determined point of origin and continued its outward involvement of other combustible furnishing within this room. This investigation also noted that the living room window burst…thus permitting a strong wind current from the south to enter this involved room, providing a continuous flow of oxygen, which sustained the fire`s character to burn with added intensity along with rapid growth and extension across the room, primarily in a south-to-north direction toward and out the apartment`s hallway entry door….

“It appears that flames, hot gases, and smoke being emitted from this apartment filled the corridor, but the east stairwell door and the apartment door to Apartment 911 provided a barrier effect, causing elements to seek the path of least resistance (to the west)….[T]he doors to the apartments on this floor did indeed protect the interior spaces of each unit due to their being closed and latched. These results further suggest that the total involvement of Apartment 909 and its contents occurred because the door to that apartment was in all probability left open. As the flames, hot gases, and smoke filled the corridor and moved to the west, fire drippings from the ceiling involved and ignited the carpeted flooring, which burned to the elevator lobby. With the crosswind current from Apartment 912 into Apartment 909 and the designed protective barrier at the east end of the corridor, a probable draw from the elevator shaft pulled the fire elements to the elevator lobby area, keeping the flames high at that point, and created the high line of demarcation as noted on the elevator lobby walls. Also noted were indications that the hot gases and smoke did fill the entire ninth floor, wall-to-wall, ceiling-to-floor level. Moderate-to-slight radiated heat damage was also noted to several apartment doors and walls west of the elevator lobby.”

An internal review of the fire and firefighter deaths was conducted by the Memphis Fire Department in the aftermath of the incident. Although this inquiry uncovered serious deficiencies in fireground operations, it remains clear that the nature and extent of the fire and its effects could have been mitigated by better built-in fire safety features.

The National Institute of Safety and Health undertook an investigation of the protective equipment worn by Mathis and Bridges. This analysis revealed several important points, including:

All personal protective gear as utilized performed as designed and was not a factor in their deaths.

SCBA facepieces were worn and SCBA operable at the time of their deaths.

PASS devices were attached to the SCBA harnesses of both men, but neither was activated.

FIRE PROTECTION ANALYSIS AND LESSONS LEARNED/REINFORCED

Since 1975, 21 firefighters have lost their lives in 15 separate high-rise fires.4 Forty-three percent of these deaths have occurred within the past two years. A February 1993 fire claimed the life of one White Plains, New York, firefighter when the elevator he was riding in stopped on the fire floor. In August 1994, a San Francisco firefighter died as a result of burn injuries he sustained when fire burst from the doorway of the third-floor apartment he was entering to control the fire. An electrical fire at the Indianapolis Athletic Club killed two firefighters after they had become separated and lost following a backdraft in the air plenum overhead. And, three Philadelphia firefighters lost their lives battling the One Meridian Plaza fire on February 23, 1991, after becoming disoriented and exhausting their air supplies. These incidents all bear striking similarities to the deaths of Mathis and Bridges and underline the fact that such tragedies demand attention by code writers and local officials.

Code requirements. The Regis Towers apartment building was constructed in compliance with the 1949 Memphis Municipal Code (Vol. II, as amended 1950). Although it is not possible to say that the building complied in every respect with applicable code requirements, the building features described above were consistent with the requirements of that code at the time the fire occurred. Moreover, evidence suggests that all required and nonrequired fire safety systems and devices were properly maintained and in working order at the time of the fire. Nonetheless, four fatalities occurred from a fire which, although incendiary, was of predictable scope and severity. This calls into question the adequacy of existing code requirements for high-rise buildings of this type. Presently, the Standard Fire Prevention Code© 5 does not require any fire protection or life safety systems beyond those present in this occupancy at the time of the fire.

Other nationally recognized model fire and life safety codes6,7,8 and many more local codes have recognized the need for special regulations to mitigate the fire danger in existing high-rise buildings. These requirements include provisions for installation of automatic sprinklers, standpipes, automatic fire detection systems, firefighter`s service for elevators, enclosed and pressurized elevator lobbies and hoistways, minimum number and enclosure of exits, and corridor separation.

Automatic detection and suppression. The fact that this fire was incendiary does not mitigate the need for a more direct response to the danger such a fire poses, especially in this type of building. Although the fire was incendiary, it was set in ordinary, available combustible materials–probably with a small flame device such as a match or lighter. Investigators found no evidence to suggest that a flammable or combustible liquid accelerant was used to start the fire. Thus, the ignition and spread of this fire would not have been too dissimilar to one started by a child playing with a disposable butane lighter, misuse of a portable heating appliance, or an electrical short circuit.

The ignition scenario presents another troubling irony. Although a battery-operated, single-station smoke detector was pres-ent in the apartment of fire origin (its operation could not be determined) and this detector was the principal fire protection device required for this occupancy due to the danger of fire to sleeping occupants but was not needed, the occupant who set the fire was in no need of a smoke detector in the apartment of origin to warn him. Without the nonrequired system-type smoke detection devices installed in the corridors, which activated after the alleged arsonist fled the apartment, the fire might have grown much larger and life-threatening before other occupants detected it.

Automatic detection clearly made a difference in the outcome of the fire. However, had automatic detection been followed by automatic suppression, the loss of life could have been totally averted. Automatic sprinklers would have ensured that the original fire was confined to the apartment of origin. Automatic sprinklers also significantly reduce the demand on other fire and life safety features of the building, such as elevators used for firefighter access or as accessible means of egress.9,10 They also reduce the extent of fire damage and number of injuries, including those to firefighters, more effectively than compartmentation alone.11,12 No multiple-fatality fires have ever occurred in buildings protected throughout by properly designed and maintained automatic sprinkler systems. Moreover, no multiple-firefighter fatalities have occurred in properly sprinklered buildings either.

Notification. Although the smoke detector in the corridor probably activated within two to three minutes of the occupant`s fleeing, other residents` past experiences with nuisance alarms probably suggested no reason for alarm. Delayed response of occupants, exhibited by the large number who failed to evacuate prior to the arrival of the fire department and had to be rescued, may also suggest that the effectiveness of the fire alarm signals was questionable. The presence of only two indicating appliances per floor suggests that the signal may not have been initially audible to tenants who were asleep. Studies of alarm signal effectiveness suggest that a minimum loudness of 75 to 80 dBA and a signal-to-noise ratio of 34 dBA must be achieved to wake the average sleeping adult.13 Occupants near the center of the building, like the occupant of apartment 905, would likely have found the signal nearly inaudible from inside their apartments.

Even when a signal is clearly recognized, a history of false alarms often conditions occupants to delayed responses, especially where no other clear signs of danger exist.14 Until the smell of smoke or the activities of firefighters outside their apartments became evident, many occupants may simply have interpreted the fire alarm signal as a nuisance alarm. Such delays have the effect of heightening fear and producing untoward responses as the fire grows and spreads and danger increases.15

Standpipe. After the members of Engine 7 and Snorkel 13 arrived on the fire floor and became separated from their tools and equipment, they began operating without the benefit of protection from hose streams. With a Class III standpipe installed in the building, firefighters had the option of using the occupant-use hoseline located in the hose cabinet in the corridor adjacent to the elevator lobby. Understandably, Mathis was preoccupied with escorting Private Bridges to safety and then locating the other firefighter from Engine 7, who–unbeknownst to Mathis–had remained in the elevator. But the crew from Snorkel 13 may have made a significant impact on the course of the incident had it been aware and taken advantage of the occupant-use hose system. Instead, the crew was overcome by a frenzied occupant. Often firefighters are trained to disregard the use of occupant-use hoselines due to concerns about maintenance of the equipment. In this case, however, even poorly maintained hose might have provided a worthwhile alternative until additional firefighters arrived and advanced lines from the west stairway riser.

Communication. Although all firefighters carried portable radios, communication was irretrievably affected when Mathis was exposed to the intense rollover from the fire in apartment 912. Firefighters` two-way voice communication telephones between the stairways, elevator cars, elevator lobby,16 and the lobby control unit would have allowed firefighters to maintain effective communication after Mathis` radio was damaged. By switching to the two-way voice communication system, the radio channel could be maintained clear for use in attempting to locate or communicate with Mathis. This would have allowed those interior firefighters engaged in the search and in reestablishing the fire attack to coordinate their efforts.

Elevators. Once firefighters entered the building to investigate the alarm, they had the choice of climbing nine flights of stairs to the fire floor or using the elevator. Since the cars had not been equipped with firefighters service features, the latter alternative was clearly dangerous but nonetheless the most expedient. Unfortunately, firefighters may have assumed (based on previous experience with nuisance alarms in the building) that the elevators would safely deliver them to the fire floor. This assumption proved wrong; and although it did not prove fatal, it placed the entire operation off balance from that point onward.

Without lobby segregation, firefighters were exposed to a dangerous environment the moment they arrived on the fire floor. Had a protected lobby been provided, firefighters might have regained their composure and been able to mount an effective attack despite their error in using the elevator to reach the fire floor. Occupants would benefit from enclosed elevator lobbies as well, since such enclosures would provide an area of refuge while waiting for the arrival of an elevator.17

As reported, the 1949 Memphis Municipal Code permitted elevators to be considered means of egress.18 This could have been a serious problem considering that the elevators in Regis Towers were not equipped with safety features to prevent the cars from discharging at an unsafe floor or provisions for placing the cars under the control of firefighters. Sections 1108 and 1004.3 of the Standard Building Code䈗 now require the provision of accessible means of egress, including elevators, for people with disabilities in all new buildings. However, Section 3403.1.3(8) specifically exempts existing buildings from complying with accessible means of egress provisions. This could present deadly consequences when the provisions of ANSI/ASME A17.3 are not enforced.

Corridors. Conditions in the corridor were poor from the outset of the fire attack. The high heat and smoke conditions may be attributable in part to the fact that, although the apartments themselves were separated from the corridor by substantial fire resistant construction (although a nonstandard installation), openings to the apartments were not protected by fire doors. The solid-core wood doors to the apartment of fire origin and the two apartments across the hall from it were almost totally consumed by the fire. Other doors at the east end of the corridor were extensively damaged. Many apartments on the ninth floor were heavily contaminated with smoke residue.

The dense black smoke filling the corridors made escape extremely difficult despite the building`s simple exit arrangement. Low-level exit pathway lighting (similar to that employed on commercial airliners) might have prevented Mathis from becoming disoriented when he was forced to retreat. Although the exit arrangement was straightforward and he had already become familiar with it when he escorted Bridges to the west stairway for refuge just after arriving on the fire floor, Mathis still became disoriented through the combined effects of his exposure to the heat, smoke, and toxic gases and the extraordinary physical exertion his escape attempt required.

Electrical cables. As Mathis struggled to find his way to the stairway, Bridges entered the fire floor only to become entangled in coaxial cables that had collapsed as a result of the failure of the nonmetallic raceway due to heat exposure. The unbundled mass of cables separated when the raceway collapsed. With cables strung across his pathway and no clear way to identify what was obstructing him nor a way to discern the best means of disentangling himself, Bridges could not escape to save himself or his fallen officer.

The use of nonmetallic raceway is permitted by the National Electrical Code®.20 The code prohibits supporting coaxial cables from a raceway (Section 820-52[e]) but does not address support for cables installed in the raceway itself. Indeed, one of the purposes of a raceway would be to support the cables installed inside it. The National Electrical Code® places restrictions on a nonmetallic raceway to limit its contribution to fire; however, these restrictions do not include provisions to address the danger collapsed cables may present to firefighters or fleeing occupants.

RECOMMENDATIONS

This fire illustrates why the scope of the fire code is and must be remedial in nature. Hazards like those that contributed to the loss of life in Regis Towers must be addressed regardless of their origin. Maintenance provisions work only when adequate safeguards already exist. Operating requirements and process controls can manage fire safety only within the margins of existing safeguards. Some fire safety hazards are serious enough that they must be corrected if we are to safeguard life and property.

The following recommendations stem from the analysis of contributing factors in this loss. They serve as suggestions for improving the level of fire safety already specified in the code. However, the only way such recommendations can ensure safety is if they are proposed and adopted for inclusion in the model fire prevention and life safety codes.

1. Automatic sprinkler systems should be required in all existing high-rise buildings. The fire service has long held that the benefits of automatic sprinklers outweigh their costs, especially in high-rise buildings. Case studies of high-rise fires suggest that fires that spread be-yond their room of origin are common in unsprinklered high-rise buildings. Once a fire spreads beyond the room of origin, it becomes an imminent danger to occupants on the fire floor and all floors above it. Moreover, it becomes an extreme danger to the men and women who must combat it. All of the firefighter line-of-duty deaths in high-rise fires have occurred in unsprinklered buildings or portions of buildings not protected by working automatic sprinklers at the time of the fire. The wisdom of requiring automatic sprinklers in all existing high-rise buildings has been recognized by state and local governments across the nation, but so far, only one nationally recognized model fire prevention code has adopted retroactive requirements for automatic sprinkler systems in existing high-rise buildings (see 1994 Uniform Fire Code®, 1003.2.2[5]). Nonetheless, retroactive sprinkler requirements for high-rise buildings have been upheld by state courts as a constitutional use of state and local police powers.21,22,23

2. Adequate provision must be made for fire alarm signaling and communication in accordance with NFPA 72, National Fire Alarm Code®. All required and nonrequired fire alarm systems should be made to comply with certain minimum requirements. Most important of these is the adequate distribution of notification appliances. Care must be taken in design and testing to ensure that adequate signal audibility is obtained in all areas that will be occupied, especially bedrooms in residential buildings. In high-rise buildings, one-way voice communication systems should be provided whenever and wherever possible. These systems have been demonstrated to provide much more timely and appropriate responses than noncoded audible signals alone.24 Two-way communication systems should be provided to establish a means for trapped occupants to communicate with firefighters and for firefighters to communicate among themselves.

3. Firefighters` service should be re-quired for existing elevators in high-rise buildings. Elevators are now recognized as an accessible egress element for people with disabilities. Moreover, many nondisabled people fail to heed the warnings against use of elevators during fire emergencies. This is often compounded by the delayed response common in so many fires. All elevators should be equipped to be recalled under Phase I operation, through the activation of a smoke detector in an elevator lobby, machine room, or hoistway. At least one car in each bank of elevators should be arranged for Phase II operation. To ensure compliance with these requirements, the provisions for firefighters` service in ANSI/ASME A17.3 should be adopted by reference by each of the model fire prevention codes.

4. Areas of refuge, such as enclosed elevator lobbies, could protect occupants as well as firefighters. With the implementation of the Americans with Disabilities Act (ADA), more and more buildings will be made accessible to people with disabilities. Among the contemporary building code requirements for accessible buildings is the requirement that accessible means of egress be provided as well. One of the key features of accessible means of egress is accessible areas of refuge, such as fire resistance-rated and pressurized elevator lobbies or stairway vestibules, for people to use while awaiting rescue. Such areas would also present significant advantages for firefighters preparing to battle fires. By providing an additional barrier between stairways or elevators and the floor, these areas help provide a safe place to prepare for battle. Unfortunately, existing buildings, although required to comply with accessibility provisions, need not provide accessible means of egress.25 Getting into the building is only half the battle; perhaps the advocates for the disabled and firefighters should push for better protection together.

5. Exit pathway lighting should be required in all new high-rise buildings. Building occupants naturally favor their normal routes of travel when entering and exiting buildings.26,27 However, in high-rise emergencies, the normal routes of travel–elevators–should not be their first choice. Quite often, the stairways, perhaps more so in residential buildings than offices, are not well-traveled by building occupants. Coupled with evacuation delays common in residential occupancies, occupants may be at an extreme disadvantage when trying to locate safe egress, due to their lack of familiarity with the stairways and the extent of fire conditions. Pathway lighting that indicates the way of travel is a reasonably cost-effective way to improve way-finding efficacy. Its effectiveness is much greater than low-level signs because legibility is not a problem. In addition, it is less prone to misidentification due to language or cultural barriers. Firefighters can clearly benefit from pathway lighting as well, since they are generally less familiar with the building than other occupants and may have a greater need to locate exits than occupants as the fire progresses.

6. The danger of cable collapse and the resulting risk of human entrapment may justify changes to the requirements of the National Electrical Code®. Current code requirements focus on the electrical hazard and fuel contribution of cables and raceway but overlook the hazard to firefighters and fleeting occupants should a mass of wiring or cable collapse, obstructing the way of egress travel. The use of a nonmetallic raceway may exacerbate this problem because of its poor dimensional stability when compared with other materials when ex-posed to high heat conditions from fire. The installation of communications cable in existing buildings is widespread and may be expected to increase as the so-called Information Superhighway is extended into every office and living room. At pres-

ent, these installations are poorly regulated. Most companies do not apply for electrical permits, and most jurisdictions would likely not be prepared to deal with the in-creased workload if they did. Nonetheless, these installations present an increasing cause for concern due to through-penetrations, combustibility, and now, concerns about human entrapment.

FIREFIGHTING LESSONS LEARNED/REINFORCED

The use of elevators during firefighting operations historically has proven to be extremely dangerous. Only the strict adherence to comprehensive elevator standard operating procedures has minimized this danger. An elevator not equipped with “firefighter`s service” equipment must not be used under any conditions if the elevator serves the fire floor.

In any case, elevators never must be taken to the fire floor. If elevators are to be used, they should be dispatched at least two floors below the fire floor. At this fire, it may have been more advantageous to use the stairs since the fire was on the ninth floor.

Elevator SOPs should include such details as having proper protective and attack equipment in place ready for use (including the serviceability of SCBAs), checking the shaft for a smoke condition prior to entering the elevator, periodic stops of the elevator (every five floors, for example) to verify proper operation of the elevator (including doors) and to again check shaft conditions, procedures to hold the elevator at the fire floor, as well as tactics to be employed if firefighters encounter heavy fire conditions when the elevator door is open.

Officers must be in constant radio contact with firefighting crews at all times. Periodic progress reports by crews allow the incident commander to gain the “big picture” of the incident, confirm the location of companies, and verify the safety of companies operating at the scene. Incident commanders and dispatchers alike must be alert for the “nonmessage” signals indicating trouble.

The importance of having a charged hoseline for protection cannot be overstated (have enough hose to “make” all areas of the fire floor–considering the corridor alone was 104 feet long and only two lengths of hose were initially brought to the fire floor). The handline`s ability to move and contain fire allows crews to create paths to gain access to trapped firefighters and occupants.

PASS devices provide a means of communicating a trapped firefighter`s location. They must be activated every time prior to entering the building, avoiding the need to turn them on in chaotic situations.

SCBAs require complete inspection, especially due to their critical nature–at least a check at the beginning of each tour in career departments and frequently scheduled checks in volunteer departments. When donning SCBA prior to entering a fire building, a quick check of its proper operation should be performed. All firefighters must be thoroughly familiar with the SCBA`s unique construction features.

A “can-do” attitude, while beneficial if restrained to certain limits, can be devastating if allowed to predominate over safety in dangerous fireground situations. Fatal results can occur when a “macho” attitude obscures an objective perspective of life-threatening situations.

The use of the incident command system plays a critical role in keeping track of all company assignments and locations.

High-rise SOPs must create a specific “mind-set” that is followed by all fire department personnel on the scene. These SOPs must be followed on every high-rise response regardless of the exterior appearance of the building on arrival. The high-rise mind-set allows all firefighters to anticipate potential problems. Complacency has no place on the fireground.

Responding engine companies must be in a position to immediately supply a high-rise`s fire department connection immediately on notification of a fire or a potential fire.

Dispatchers must keep constant vigilance over all radio transmissions. Any indication of trouble must be communicated to the incident commander and others on the fireground. At this incident, an inexperienced dispatcher did not pick up on the trouble potential carried by the four unreturned transmissions by Bridges at a critical point in the operation.

Master stream devices never must be used to attack a fire from the exterior when firefighters or occupants are in the interior. Violating this most basic fireground rule will drive fire at people on the floor or the power of the stream itself will seriously injure them.

Span of control is important. Consider that several chief officers will be needed to manage a working high-rise fire.

Although the corridor doors in this building were not fire-rated, they do “buy” some time when closed to put barriers between the fire and operating personnel.

The placement of aerial apparatus at a high-rise fire usually dictates being in close proximity to the building. In this case, numerous rescues were performed at near-maximum extension of the aerial device. n

Endnotes

1. Director`s Inquiry Review Board Report, Memphis (TN) Department of Fire Services, June 21, 1994.

2. ANSI/ASME A17.1, Safety Code for Elevators and Escalators (1986). American Society of Mechanical Engineers, New York, N.Y.

3. ANSI/ASME A17.3, Safety Code for Existing Elevators and Escalators (1986), American Society of Mechanical Engineers, New York, N.Y.

4. Firefighter deaths in high-rise fires, 1994, National Fire Protection Association Fire Analysis and Applied Research Division, Quincy, Mass.

5. Standard Fire Prevention Code, 1994, Southern Building Code Congress International, Inc., Birmingham, Ala.

6. BOCA National Fire Prevention Code® (1993), Building Officials and Code Administrators International, Inc., Country Club Hills, Ill.

7. NFPA 101®, Code for Safety to Life from Fires in Buildings and Structures (1994), National Fire Protection Association.

8. Uniform Fire CodeTM (1994), International Fire Code Institute, Whittier, Calif.

9. Chapman, E.F., 1991, “Utilization of elevators during fire emergencies,” Proceedings of the Symposium on Elevators and Fire, American Society of Mechanical Engineers, Baltimore, Md.

10. Donoghue, E.A., “Building Transportation Systems,” Fire Protection Handbook, 17th ed. Coté, A.E., ed., 1991, NFPA.

11. Jennings, C.R., 1990, “An effectiveness comparison of sprinklers and compartmentation for high-rise office building fire protection as defined by Local Law 5 (1973) for the years 1981-1985,” master`s thesis, John Jay College of Criminal Justice, City University of New York, N.Y.

12. Routley, J.G. Banker`s Trust Fire: New York, NY, 1993, U.S. Fire Administration Technical Report Series: Emmitsburg, Md., Federal Emergency Management Agency.

13. Sultan, M.A. and R.E. Haliwell, 1990, “Optimum location for fire alarms in apartment buildings,” Fire Technology, 26:4, 342-356.

14. Canter, D., ed. 1990, Fires and Human Behaviour, 2nd ed. (David Fulton Publishers, London).

15. Proulx, G., 1993, “A stress model for people facing a fire,” Journal of Environmental Psychology, 13, 137-147.

16. Chapman.

17. Ibid.

18. Memphis Department of Fire Services report.

19. Standard Building Code (1994), Southern Building Code Congress International, Inc., Birmingham, Ala.

20. NFPA 70®, National Electrical Code® (1993).

21. Brannigan, V.M., 1983, “Applying new laws to existing buildings: Retrospective fire safety laws,” Journal of Urban Law, University of Detroit, Mich., 60:3.

22. Callahan, T., C.W. Bahme, 1987, Fire Service and the Law, 2nd ed., National Fire Protection Association.

23. “Fire Sprinkler Law Upheld in Appeals,” Operation Life Safety Newsletter, International Association of Fire Chiefs, Fairfax, Va., Sept./Oct. 1994.

24. Proulx, G., J.D. Sime, 1991, “To prevent `panic` in an underground emergency: Why not tell people the truth?” Proceedings of the Third International Symposium on Fire Safety Science (Elsevier Applied Science, London).

25. Standard Building Code.

26. Proulx, Sime.

27. Sfintesco, D., C. Scawthorn, J. Zicherman, 1992, Fire Safety in Tall Buildings, Council on Tall Buildings and Urban Habitat Monograph Series (McGraw-Hill, New York, N.Y.).



Two perspectives of the Regis Tower residential high-rise. (Left) The south (front) and east sides of the structure, with soot/burn markings indicating the location of the apartment of origin (ninth floor). (Above) Rear of the fire (side 3-north side). Fire blew across the hallway after windows of the fire apartment self-vented, extending into Apartment 909 because the corridor door was left open. Note that this major extension did not occur in the corner apartment, directly across from the apartment of origin: Though corridor doors leading to apartments were not fire-rated, when closed they limited extension under these extreme fire conditions. (Photos by Joe E. Caldwell.)



(Top) The apartment of origin. Failure of the living room window and wind from the south created a horizontal chimney for fire extension and smoke movement. (Bottom) This hose cabinet in the building`s standpipe system was located five feet from the elevator lobby doorway. It may have offered first-responding firefighters some protection at a critical point in the incident had not tragic circumstances prevailed. (Photos by Joe E. Caldwell.)





Truck companies made 11 aerial rescues from the ninth, tenth, and 11th floors. (Bottom right) An injured firefighter is wheeled to an awaiting EMS unit. (Top right and bottom right photos by Robert Cohen, Commercial Appeal; others courtesy of Joe E. Caldwell.)

MARK CHUBB is fire code coordinator for SBCCI and the Southeastern and Southwestern associations of fire chiefs. He is responsible for managing the development, promotion, and interpretation of the Standard Fire Prevention Code©, as well as other fire protection and hazardous materials-related products and services. Chubb participated in an on-scene investigation of the incident that is the subject of this report.

OSHA Commander JOE E. CALDWELL is a 23-year veteran of the Memphis (TN) Fire Department and has been the OSHA safety officer for the past 15 years. He has investigated eight line-of-duty deaths during his tenure with the department. Caldwell was the principal agent in the official Memphis Fire Department investigation and report of the following incident, entitled “Director`s Inquiry Review Board Report,” which is a result of an intense investigation involving more than 500 hours over a three-month period.

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