United States Fire AdministrationTechnical Report
SeriesHospital Fire Kills Four
PatientsSouthside Regional Medical CenterPetersburg,
VirginiaFederal Emergency
Management AgencyUnited States Fire Administration
United States Fire Administration Fire Investigations
ProgramThe United States
Fire Administration develops reports on selected major
fires throughout
thecountry. The fires usually involve multiple deaths
or a large loss of
property. But the primary criterion fordeciding to
do a report is whether it
will result in significant “lessons learned.”
In some cases these lessonsbring
to light new knowledge about fire -- the effect of
building construction or
contents, human behavior infire, etc. In other cases,
the lessons are not new
but are serious enough to highlight once again, with
yetanother fire tragedy
report.The reports are sent to fire magazines and
are distributed at national
and regional fire meetings.The International Association
of Fire Chiefs assists
USFA in disseminating the findings throughout the
fireservice. On a continuing
basis the reports are available on request from USFA;
announcements of
theiravailability are published widely in fire journals
and newsletters.This
body of work provides detailed information on the
nature of the fire problem for
policymakerswho must decide on allocations of resources
between fire and other
pressing problems, and within the fireservice to improve
codes and code
enforcement, training, public fire education, building
technology, andother
related areas.The Fire Administration, which has no
regulatory authority, sends
an experienced fire investigatorinto a community after
a major incident only
after having conferred with the local fire authorities
to insurethat USFA’s
assistance and presence would be supportive and would
in no way interfere with
any review ofthe incident they are themselves conducting.
The intent is not to
arrive during the event or even immediatelyafter,
but rather after the dust
settles, so that a complete and objective review of
all the important aspects
ofthe incident can be made. Local authorities review
USFA’s report while it is
in draft. The USFAinvestigator or team is available
to local authorities should
they wish to request technical assistance for theirown
investigation.This report
and its recommendations were developed by USFA staff
and by TriData
Corporation,Arlington, Virginia, its staff and consultants,
who are under
contract to assist the Fire Administration incarrying
out the Fire Reports
Program.The United States Fire Administration greatly
appreciates the
cooperation received from Fire ChiefJerry Wallace,
Investigator Rufus L. Atkins,
and Investigator David M. Jolly of the Petersburg,
VirginiaBureau of Fire; and
Robert A. Phelps, Director of Safety and Security
at Southside Regional Medical
Center.For additional copies of this report write
to the United States Fire
Administration, 16825 SouthSeton Avenue, Emmitsburg,
Maryland 21727.
Hospital Fire Kills Four PatientsSouthside Regional
Medical CenterPetersburg,
Virginia(December 31, 1994)Investigated by: J. Gordon
RoutleyReade BushThis is
Report 080 of the Major Fires Investigation Project
conductedby Varley-Campbell
and Associates, Inc./TriData Corporation undercontract
EMW-94-C-4423 to the
United States Fire Administration,Federal Emergency
Management Agency.Federal
Emergency Management AgencyUnited States Fire Administration
Investigated by:Local Contacts:Hospital Fire Kills
Four PatientsSouthside
Regional Medical CenterPetersburg, VirginiaDecember
31, 1994Reade BushJ. Gordon
RoutleyFire Investigator/Inspector Rufus L. AtkinsFire
Investigator/Inspector
David M. JollyPetersburg Bureau of Fire400 East Washington
StreetPetersburg,
Virginia 23803(804) 733-2409OVERVIEWOn December 31,
1994, a New Year’s Eve fire
at the SouthsideRegional Medical Center (SRMC) in
Petersburg, Virginia, killed
fourpatients and injured three firefighters and several
nurses.’ The fire wasthe
worst in terms of number of lives lost in a single
incident in Petersburgin
recent memory.The fire originated in a patient room
on the fourth floor of
thehospital shortly after 9 p.m. Local investigators
believe that
smokingmaterials were involved in the ignition and
that the fire resulted from
thepatient’s actions. They could not determine
if the actions which caused
thefire were accidental or intentional. The fire grew
rapidly due partly to
thefuel load in the fire room. A nurse discovered
the fire but was unable
toextinguish it.The fire was contained to the room
of origin with slight
extensioninto the adjacent corridor. There was heavy
smoke and heat damage tothe
corridor, and heavy smoke infiltrated adjacent patient
rooms (see1Two other
patients, who were on the fire floor but not in rooms
on the corridor of
origin,died within several weeks after the fire. At
the time of this report, it
was unknown whethertheir deaths were from natural
causes or resulted from
exposure to smoke
Appendix A for floor diagram). Hospital staff and
nurses rescued severalpatients
before firefighters arrived. Three patients in rooms
adjacent tothe fire room
died from smoke inhalation, and one patient in the
fire roomdied from a
combination of smoke inhalation and burns. Three firefighterswere
treated for
minor smoke inhalation after their breathing apparatusran
out of air during
rescue operations. Several nurses and patients alsosuffered
minor injuries from
smoke inhalation.The section of the hospital that
was involved in this incident
hadsmoke detectors in the corridors and manually activated
fire alarm
stations.Other parts of the hospital complex were
protected by automatic
sprinklers.Firefighters extinguished the fire with
one 1 3/4-inch handline
stretchedfrom a standpipe.SUMMARY OF KEY ISSUESFire
CauseIssuesCommentsPatient
smoking in bed was the mostlikely cause of the fire.
Patient failed tocomply
with hospital no smoking policy.The hospital staff
was unable to searchthe
patient’s belongings after smokingmaterials
were discovered in the roomdue to
patient privacy rights.Compartmentation EffectivenessFailed
because door to room
of originwas left open. Smoke and heat spreadinto
the corridor.Sprinkler
SystemFire LoadNone in area involved in this incident.Heavy
fire load in patient
rooms,including highly combustible foam/plasticpatient
bedding.Smoke SpreadRapid
spread of heavy smoke into thecorridor through the
open door. Smokespread to
adjacent rooms through theplenum space and through
cracksbetween doors and door
frames, eventhough the doors to patient rooms wereclosed
SUMMARY OF KEY ISSUESIssuesEvacuation of PatientsCommentsMany
patients were
unable to evacuatewithout assistance.Alarm System
PerformanceManual pull station
activated promptlyafter discovery.Construction CodeAppears
to comply with code
that was ineffect when built and fire resistiveconstruction
appears to have
beenmaintained fairly well. Some fireresistive features
failed early in
fire.Leakage of 100 % Oxygen intoRoom of OriginSmoke
Detection SystemSmoke
Control DoorsAppears to have contributed to the rateof
combustion in the room of
origin.None in patient rooms; only in corridor.Released
to close by alarm
system.Contained heavy smoke to one corridor.Structural
DamageColumns and major
beams undamaged.Some light beams and metal deckingslightly
warped.Response by
Hospital StaffPrompt and efficient in most regards.Failure
to close door to room
of originwas a significant factor.Response by Fire
DepartmentPrompt response and
extinguishmentsaved lives of some trapped patients.Hospital
Fire Evacuation
PlanHospital staff conducted regular drillsand Drillsand
safety awareness
training.LOCATIONThe SRMC is located in Petersburg,
Virginia, a city of
40,000people located approximately 25 miles south
of Richmond,
Virginia.Petersburg is an historic city in an area
that is considered a suburb
ofRichmond.
The Petersburg Fire Department is a career department
with 86members operating-
out of four stations. Nineteen firefighters are assignedon
each shift to staff
four engine companies and one ladder company. ABattalion
Chief supervises each
shift. Emergency medical services areprovided primarily
by volunteer rescue
squads; however, the FireDepartment provides first
responder medical care and
operates oneambulance. The department responds to
approximately 3,200 calls
peryear. It has established mutual aid agreements
with several
neighboringjurisdictions.HOSPITAL DESCRIPTION AND
FIRE CONTROL SYSTEMSThe
original parts of the hospital were constructed in
the early1950s. Since then
several additions and renovations have taken place,adding
a variety of
construction types and fire control systems to thefacility.
The main hospital is
a 468 bed, seven story building with threewings (see
Appendix A).The entire
hospital is equipped with a combination smoke detectionand
manual pull station
alarm system. In some areas, smoke detectors areinstalled
in patient rooms;
other areas have smoke detectors only in thecorridors.
The emergency department,
which was recently renovated, isprotected by an automatic
sprinkler system. A
Class 3 standpipe systemserves all floors; outlets
for fire department hose
lines are located in hosecabinets in the corridors.The
seven story south wing of
the hospital was renovated in 1974. Itis a T-shape
with three corridors
extending out from a nurses’ station andelevator
lobby. Smoke control doors were
installed at the opening of eachcorridor to provide
a separation from the lobby.
The doors, which arenormally open, are automatically
released to close upon
activation of thebuilding fire alarm system. An enclosed
exit stairway is
located at the endof each corridor. On the fourth
floor, the T-shaped area
referred to as 4-South includes 27 patient rooms.
The room where the fire
originated is onthe south corridor of the 4-South
wing, which contains rooms 411
through421. Each of the patient rooms in this area
is equipped for two
patients,however, at the time of the fire most of
the rooms were occupied by
onlyone patient each.
Construction Details - When the south wing was renovated
in 1974,it was required
to meet the BOCA building code.2 The construction
ofthe south wing is classified
as “protected non-combustible.” Thefloor/ceiling
system incorporates a concrete
floor slab supported by steelbar joists. The steel
decking and other structural
steel members areprotected by a suspended ceiling.
The suspended ceiling is part
of therated fire resistive assembly, and clips were
required to keep the
ceilingtiles in place.The interior partitions are
gypsum wall board on metal <
studs.Above the suspended ceiling, there was a 3 foot
plenum space3
containingwiring, ducts, and oxygen pipes. The plenum
space is common above
thepatient rooms on each side of the corridor. The
walls that separate therooms
from the corridor extend through the plenum to the
underside of themetal decking
of the floor above. The patient rooms could be consideredapproximately
equivalent to a one hour fire-rated compartment, if
theroom door is closed and
the ceiling is in place. Each patient room alsohad
an exterior plateglass
window.There were dampers activated by heat and smoke
detectors in theair
handling ducts in the plenum space. The air handling
system suppliedfresh air to
the corridors and each room but there was no return
air systemin the south wing.
Heat activated dampers were installed at the pointwhere
each duct penetrated the
corridor walls above the ceiling to supplyair to a
single outlet in each room.
Air was removed continuously by fanslocated in each
patient bathroom.The south
wing is served by three elevators located near the
nurses’station. There were
three additional elevators on the north wing of thehospital.Fire
Alarm System
Details - There were two smoke detectors in eachcorridor
of 4-South, but no
detectors in the patient rooms. There were twomanual
pull alarm stations on the
south corridor. Activation of the firealarm system
released the smoke control
doors and sounded an alarmthroughout the hospital.
The doors to individual
patient rooms did not2At the time of the 1974 renovation
of 4-South, the wing
was constructed to the BOCAbuilding code, which makes
reference to certain NFPA
fire codes including NFPA 99, Standardfur Health Care
Facilities. The BOCA code
does not reference NFPA 101, Life Safety Code.3The
plenum space is the area
between the suspended ceiling and the next floor.
have self-closing devices and did not close automatically
when an alarmwas
sounded. The 4-South wing was not equipped with an
automaticsprinkler system. A
hose cabinet supplied by a Class 3 standpipe riser
waslocated in each
corridor.The hospital’s fire control room is
located in the security office
onthe ground floor. All alarms are monitored from
this location. Fourseparate
fire alarm systems were installed as different parts
of the hospitalwere added
or renovated. The fire alarm system had a manual switch
withthe options of
direct connection to a central alarm monitoring service
orlocal monitoring only,
but it was not connected to a third party centralmonitoring
station at the time
of the fire. The hospital had decided tomonitor the
alarm locally due to a false
alarm problem. In lieu of a firedepartment response,
the normal practice was to
have a security guardrespond to the activation point
to determine if there was
an actualemergency before calling the fire department.
In this case, a nurse
from 4-South notified the hospital switchboard operator
via telephone that
therewas an actual fire, and the switchboard operator
notified the
firedepartment. The operator also announced over a
hospital wide publicaddress
system that “Plan F,” the plan for a working
fire, was in effect.The activated
alarm sounded throughout the entire hospital.Fuel
Load - The fuel load in the
room of origin, which measured10 feet by 12 feet,
was typical for the rooms in
that section of the hospital.It included:Two patient
bedsOne dresser and one
bedside food table made of laminatedfiberboardTwo
small wooden closets affixed
to the wallTwo reclining chairs covered with foam
plastic materialTwo divider
curtains made of a synthetic fiberOne plastic wastebasketA
19-inch
televisionWindow curtainsThe two patient beds were
relatively newly designed
“air beds.” Each bedincorporated an inflatable
mattress and sophisticated
control system. Themattress is constructed with inflatable
air chambers that can
be inflated ordeflated to adjust to the needs and
comfort of each patient. An
electricallyoperated compressor and pressure controls
were mounted in the frame
of the bed. Each inflatable mattress was believed
to contain between 15 to 20pounds
of foam plastic materials.The fire room also contained
some additional objects
such as apatient’s suitcase and clothing.At
some point during the fire, the
oxygen regulator on the wall inthe room of origin
melted and may have released a
flow of 100 percentoxygen into the room for a short
period until it was shut
off. After the firethe damaged regulator was tested
and was determined to
release oxygen atan undetermined rate. The oxygen
flow was stopped when a
maintenanceworker closed the central oxygen valve
approximately three to five
minutesafter the alarm sounded, but before the fire
department arrived on
thefourth floor.CAUSE OF FIREInvestigators determined
that the fire originated
in Room 418. Thepatient in Room 418 had been given
sedatives to reduce her level
ofagitation. Nurses had restrained the patient in
bed because she hadwandered
out of the room on at least two occasions that day
and was beingdisruptive to
other patients on the floor. The patient broke out
of therestraints several
times.The origin of the fire was determined to be
the upper half of thepatient’s
bed. After a thorough investigation, the investigators
ruled outother possible
causes and determined the cause to be the patient
smokingin bed or attempting to
use matches or a lighter. They were unable toconclusively
determine if the fire
was caused by a cigarette or a match.The sudden onset
of smoke and fire suggests
an open flame ignition asopposed to a smoldering ignition
which is more often
associated with acigarette. No smoke or fire was noticed
when nurses were
restraining thepatient approximately 10 minutes before
the fire was detected. At
the timeof ignition, the patient may have broken free
of the restraints or
hadenough slack to reach her smoking materials.DISCOVERY
OF THE FIRE AND
NOTIFICATION OF THEFIRE DEPARTMENTThe fire at Southside
Regional Medical Center
occurred on NewYear’s Eve 1994, which was a
Saturday night. At that time, there
were sixnurses assigned to 4-South. All of the 11
patient rooms on the southPage
corridor were occupied, with one patient assigned
to all but two of therooms.
Several relatives were visiting the patient in Room
417. Thepatients on 4-South
were categorized as general nursing care and ranged
inage from the mid-40s to
late 70s. The age and medical problems of certainpatients
prevented them from
being able to evacuate without assistance;several
patients on the south corridor
were able to evacuate on their own.A nurse discovered
the fire shortly after 9
p.m. She was alerted byscreams from the patient in
the room. The nurse opened
the door to theroom and found the upper half of the
bed and the patient on
fire.Following emergency procedures, the nurse immediately
activated amanual
pull station on the south corridor which sounded an
audible alarmthroughout the
hospital.The fire was reported to the Petersburg 911
Communications Centerby
several different sources almost simultaneously. The
first 911 call camefrom a
patient on 4-South at 21: 11:30 (see Appendix B for
the completetime log of the
incident). Seconds later, at 21: 11:36, an attendant4
from aChesterfield County
ambulance which was at the hospital called thePetersburg
Communications Center
to report that there was fire showingout of a fourth
floor window. At 21: 11:45,
a 911 call was received from thehospital switchboard.At
21: 12:45, a Petersburg
police officer, who was in the hospitalwhen the alarm
sounded, arrived on
4-South and radioed to theCommunications Center that
there was fire.It is
unknown exactly when the fire started. Due to the
variances inclocks at the
different reporting points and the lack of any recorded
timesfrom the hospital’s
alarm system, an exact timelog of the fire is difficult
toreconstruct. The
timelog in Appendix B was developed by localinvestigators.
When the fire was
reported by the Chesterfield Countyambulance attendant
at 21: 11: 36, the fire
was already at a free burningphase visible through
a fourth floor window.INITIAL
ACTIONS BY HOSPITAL PERSONNELThe nurse who discovered
the fire was alerted by
screams from thepatient in Room 418. The nurse opened
the door to the room and
saw fireinvolving the upper portion of the bed and
the patient. She exited
the4The Chesterfield County ambulance attendant was
an off-duty Petersburg
firefighter.room, yelled “Fire, “and then
activated a manual pull station on the
southcorridor, which sounded an alarm throughout the
entire hospital. Thenurse
re-entered the room and attempted to smother the fire
with ablanket but was
forced outside due to smoke conditions. Knowing that
thepatient in Room 418 was
placed in a four point restraint system, she re-entered
the room to attempt to
free the patient by cutting the straps, butshe was
only able to cut one strap
before being forced out of the room bythe smoke.Some
of the other nurses began
closing doors to patient rooms andevacuating some
of the patients from rooms
near the room of origin.Several nurses took fire extinguishers
to the room of
origin, but the rapidlyincreasing volume of fire prevented
them from entering
the room and usingthe extinguishers.Several hospital
personnel responded to the
report of a fire on 4-South according to the hospital’s
emergency response plan.
Immediatelyafter the alarm was activated, one nurse
telephoned the
hospitalswitchboard to report the fire. The switchboard
operator was
thenresponsible for contacting the Fire Department
and announcing the “PlanF”
(the actual fire plan) over the public address system,
which activatedemergency
procedures throughout the hospital.Hospital personnel
did not close the door to
the room of originwhich allowed smoke to fill the
corridor very quickly. The
nurses managedto either evacuate or close the door
to each of the other rooms
thatopened to the south corridor. Within a few minutes
after discovery of
thefire, smoke conditions were so bad that the last
nurse leaving the
corridorhad to crawl out. One nurse attempted valiantly
to drag a patient out
ofRoom 421, but she was forced to leave the patient
in the room and closethe
door because of the rapidly deteriorating conditions
in the corridor.Several
patients were evacuated by nurses to stairwell number
one, but therapidly
deteriorating conditions in the corridor prevented
them from beingable to
evacuate all of the patients.A guard and a maintenance
worker who responded to
the fourthfloor after hearing the alarm encountered
moderate smoke in the
maincorridor and very heavy smoke in the 4-South elevator
lobby. Theyattempted
to enter the elevator lobby area several times but
were forced toretreat behind
the protection of smoke control doors. The maintenanceworker
reached the doors
separating the south corridor from the nurses’station
but was forced to retreat.
He was able to shut off the centraloxygen valve in
the elevator lobby area.
This worker estimated that hearrived on
4-South three minutes after the alarm was activated.
Hereported that the smoke
conditions prevented him from seeing the end ofthe
corridor (approximately 75
feet away).A doctor also responded to the floor and
assisted the patients
whowere being evacuated into the stairwell. He and
nurses not directlyinvolved
in the initial evacuation assisted later with treatment
of patientswho were
rescued by firefighters.INITIAL FIRE DEPARTMENT RESPONSE
ANDFIRST ALARM
ACTIONSThe Petersburg Communications Center initially
dispatched a fullfirst
alarm structural assignment which included Engine
2, Engine 4, Truck1, an
ambulance, and a Battalion Chief at 21: 12 (see Appendix
C for
alarmassignments). The Chesterfield County ambulance
radioed the
respondingPetersburg Battalion Chief that this was
a working fire with flames
comingfrom a window. The Battalion Chief requested
a second alarm before anyof
the first alarm units arrived. The second alarm response
includedEngine 5 and
Engine 3, the last two Petersburg units, plus a ladder
truckon mutual aid from
Chesterfield County. Three Battalion Chiefs and oneDistrict
Chief from
Chesterfield County also responded. (Additional unitswere
requested on special
alarms later. Refer to Appendix C for acomplete list
of units that responded to
the fire,)The first arriving Petersburg units went
to their assigned
positionsoutside of the hospital, based on the pre-fire
plan. Engine 2, the
first duecompany, arrived at 21: 15 : 33 at the main
entrance on the west side.
All ofthe first alarm units arrived within one minute
of each other.The
objective of Engine 2 was to locate the fire and to
initiateinterior rescues and
fire attack. Arriving at the main entrance on the
westside, the crew could not
see the fire coming from the fire room, which wason
the east side. The building
alarm system was sounding when twofirefighters from
Engine 2 entered the
hospital.The second arriving company, Engine 4, went
to the east side,connected
to a hydrant, and supplied water to one of the hospital’s
threestandpipe
connections.Truck 1 positioned on the south side of
the hospital. Twofirefighters from
Truck 1 entered the hospital to assist Engine 2.
Twoother
firefighters from Truck 1 set up a ground ladder to
rescue the patientfrom Room
416 who was leaning out of the window. Due to the
design ofthe building, the
truck could not be positioned to rescue the individual
withits aerial ladder.
The rescue was made using a 28 foot ladder which wasraised
from the roof of a
one-story section of the hospital, below thewindow.Unit
530, Petersburg
Battalion Chief Steve Bowling, established acommand
post on the east side of the
hospital at 21: 16:05. For the initialminutes, the
Incident Commander’s priority
was to ascertain the magnitudeof the fire, determine
what rescues would be
necessary, and find out if thefire was extending to
other parts of the fourth
floor.Engine 2 reported that the alarm panel indicated
an activation of amanual
pull station on 4-South. Engine 2’s crew then
ascended stairwellnumber one (see
Appendix A) to the fourth floor. When the crew reachedthe
fourth floor, they
were met by patients and hospital personnel who hadbeen
evacuated to the
stairwell. They entered the main corridor on thefourth
floor and noticed
moderate smoke conditions. The crew put ontheir SCBAs
and opened the first set
of smoke control doors. Just beyondthe doors, they
connected a 1 3/4-inch attack
line into the Class 3standpipe connection in the corridor5.
The firefighters
then crawled to thenext set of smoke control doors
and opened them to find
heavy, blacksmoke, zero visibility conditions, and
intense heat. At 21: 18:40,
Engine 2radioed to the Incident Commander that they
were in the south
corridorlooking for the fire.As Engine 2 proceeded
down the corridor looking for
the fire, theysearched rooms and rescued patients.
They rescued at least one
patientbefore attacking the fire. When they reached
Room 418, the room wasfully
involved with fire spreading out into the corridor.
Engine 2 appliedwater to the
fire at 21 :24,6 12 minutes after dispatch of the
call, and onlynine minutes
after their arrival on the scene. They were able to
gaincontrol of the fire very
quickly with one attack line.5The 1 3/4-inch attack
line was attached to a 50
foot, 2 l/2-inch leader line with a gatedwye.621:24
is the time that the
Incident Commander reported via radio that he could
see waterbeing applied to
the fire from his vantage point outside the hospital.Engine
2 and two firefighters from Truck 1
then completed aprimary search of the
rooms on 4-South. They removed the patients fromrooms
417,419, and 421, all of
whom died from smoke inhalation. Severalother patients
who survived were also
evacuated by firefighters. Theevacuated patients were
carried from their rooms
to the stairwell and tounaffected parts of the fourth
floor where they were
triaged and treated.The firefighters were using 30
minute SCBA units, and in the
courseof rescue operations, some of them ran out of
air, but many continued
toperform rescues because of their concern that the
patients must beremoved and
treated rapidly. Three firefighters suffered smoke
inhalationin the rescue
process.Crews from the second alarm units were assigned
to check for
fireextension on the fifth floor and to remove smoke
from the corridors.Rapid
smoke removal was important because the longer the
smokeremained in the
corridors, the more it was sucked through openings
aroundthe closed doors to
occupied patient rooms.There was no vertical extension
of the fire above the
fourth floor;however, the radiant heat on the fifth
floor was very noticeable.
Theconcrete floor slab above the fire area remained
very hot for some timeafter
the fire. There was a moderate amount of smoke on
the fifth floor,with heaviest
concentrations in the 5-South area directly above
the fire.The second alarm
crews also evacuated patients from 5-South and otherareas
of the hospital
affected by smoke conditions. They were assisted byhospital
staff.SMOKE AND HEAT
SPREADAlthough the fire was contained to the room
of origin with minorextension
into the corridor, heavy smoke and heat conditions
made the 4-South corridor and
the lobby area around the nurses’ station untenablewithin
several minutes after
discovery of the fire.The extent of the smoke and
heat conditions was evident
after thefire. Heavy smoke stains were evident to
within two feet of the floor
onthe south corridor. The smoke detectors and other
plastic fixtures in
thecorridor melted. The smoke control doors separating
the south corridorfrom
the nurses’ station protected the rest of the
floor from major smokeand heat
damage. Witnesses reported that there was heavy smoke
in thearea of the nurses’
station and elevator lobby during the incident, possiblyPage
13
from the opening of the smoke control doors as patients
were evacuatedfrom the
south corridor.Smoke and heat damage to patient rooms
on the south
corridorvaried significantly. Rooms 411 and 421 suffered
heavy smoke
damage,indicated by major soot stains on the walls
and windows, because the
doorsto these rooms were open during the fire. The
door to Room 411 was
notclosed by nurses because they had rescued the patient
from this room andknew
it was empty. The door to Room 421 was closed by nurses,
but thepatient
apparently opened it while trying to escape and collapsed
in thedoorway.There
was some evidence of smoke leakage between the doors
anddoor frames from the
corridor into all of the patient rooms. The rooms
onthe same side of the
corridor as the fire room, i.e. Rooms 416 to 421,appear
to have been much more
heavily charged with smoke during thefire, while the
rooms on the opposite side
of the corridor appear to havesuffered less smoke
damage.There was evidence of
significant smoke spread into Rooms 416 to421 via
the common plenum space above
the rooms. This was indicated bysoot streaks on many
of the ceiling panels,
indicating that heavy smoke wasleaking into the rooms
via gaps between the
ceiling panels and thesuspension system. The ceiling
above the fire failed,
allowing smoke andheat to enter the plenum area. The
smoke then leaked down
through theceilings, under pressure, into the adjacent
rooms. The heat damaged
someof the lightweight steel members in the floor
assembly immediately aboveRoom
418.The wall that separates these rooms from the corridor
also separatesthe
plenum areas, which limited smoke spread via the plenum
to the roomsacross the
corridor. There was no evidence of smoke spread into
any ofthe rooms via the
HVAC system.LOCATION OF VICTIMSThe patients who died
were located in rooms
417,418,419, and 421.The patient in Room 418 was burned
severely, and skeletal
remains werefound along with the metal parts of the
bed. The patients in rooms
417and 419, immediately adjacent to the fire room,
were found unconscious
intheir beds, and probably succumbed to smoke inhalation
(the MedicalExaminer’s
reports on causes of death were not available at the
time
this report). The patient from Room 421 was found
unconscious in thepartly open
doorway to his room.The patient in Room 416 was awakened
by the odor of the
smokeand was unable to escape through the corridor.
He reported that thesmoke in
his room was very heavy. He leaned out of his window
for freshair and was
rescued by firefighters using a ground ladder.DAMAGE
ASSESSMENTRoom 418 and all
of its contents were completely consumed. Onlythe
metal frames of the beds and
chairs remained. The suspended ceilingin the fire
room collapsed during the
fire. The unprotected steel trussesand the floor decking
immediately above the
suspended ceiling saggedslightly. The top half of
the door to Room 418 was
burned away. Withthe exception of a small area near
the doorway, all of the
floor tiles inRoom 418 were consumed.The south corridor
on the 4-South wing
suffered extensive smokeand heat damage. The patient
rooms adjacent to the south
corridorsuffered moderate heat and smoke damage. The
remainder of the
fourthfloor beyond the smoke control doors suffered
only minor smoke damage.The
fifth floor south wing also suffered minor smoke damage.
The firecaused
approximately $500,000 in damages.HOSPITAL FIRE DRILLSThe
hospital has a
comprehensive fire and safety drill program.Each shift
drills twice each quarter
on emergency procedures. In somecases the shift personnel
are drill
participants, while in other cases they areobservers.The
hospital teaches the
standard four-step RACE procedure for ahandling a
fire. RACE stands for:Remove
victims in the room of origin, or remove the fire
tothe outside (such as in the
case of a burning trashcan).Activate the fire alarm
system.Contain the fire by
closing the door to the room of origin andto other
rooms and areas.Page 15
Evacuate patients.The 4-South nursing staff on duty
the night of the fire
hadparticipated in a fire drill two nights before
the fire occurred. In
general,the staff appeared to have a good understanding
of emergency
procedures.The hospital staff response to this fire
appears to have been
verygood in most respects. The nurse who discovered
the fire followed most ofthe
emergency action steps that she had been taught in
drills. When shediscovered
the fire, she first activated the alarm system, and
thenattempted to smother the
fire with a blanket and to cut the patient loosefrom
the restraints. Other
nurses responded with fire extinguishers butwere unable
to use them due to the
size of the fire and amount of smokethey encountered
when they reached the room.
The nurses then beganevacuating the mobile patients
from 4-South and attempted
to removesleeping patients. They closed all of the
doors to occupied patient
roomsin the south corridor and the two intersecting
corridors.ANALYSISThis
section of the report identifies and analyzes the
significantfindings that can
be drawn from this incident.Fire Growth and Smoke
SpreadBased on accounts of the
fire from hospital personnel and physicalevidence,
it appears that the fire grew
rapidly and that flashover in theroom occurred within
a maximum of five to seven
minutes after the firewas first detected by a nurse.
Reports from the
Chesterfield ambulancecrew indicate that the room’s
window blew out at
approximately 21: 12.The fire generated large quantities
of heavy black smoke
which rapidlyfilled the adjacent area.The rapid fire
growth and smoke spread can
be attributed to severalfactors listed below.The beds
provided the major source
of fuel for the fire. Theplastic parts of the bed,
particularly the foam plastic
in themattresses provided the fuel for rapid fire
growth and heatrelease, with
large volumes of black smoke. The cushions onchairs
in the room also contributed
to the rapid burning
Page 19
smoke production.The door to the fire room was left
open, which allowed thesmoke
and heat to enter the corridor. This exposed all of
theother rooms to smoke and
hindered rescue attempts by thestaff. Had the door
been closed, the bulk of the
smoke andheat would have been contained to the room.
The firegrowth may also
have been slowed by the reduction inventilation.The
suspended ceiling in the
room of origin collapsed whenthe metal frame structure
began to warp, probably
aroundthe time of flashover. This provided an opening
by whichsmoke could travel
through the common plenum space aboveRooms 416-421
and into the rooms.An oxygen
regulator on the wall melted, releasing 100percent
oxygen into the room at an
undetermined rate.The patient was taking oxygen therapy
but was not on oxygenat
the time of the fire.It is believed that the damage
to the oxygen
regulatoroccurred after flashover of the patient room.
The emergencyoxygen
shut-off valve at the nurses’ station was closedapproximately
three to four
minutes after the fire wasdiscovered. The oxygen may
have intensified the fire
for ashort time, however, it does not appear to have
contributedto the rapid
fire growth and smoke production prior toflashover.The
sliding window in the
fire room was open approximatelysix inches at the
time of the fire. This
provided additional airsupply to the fire and may
have contributed to a
draftthrough the room and through the open door into
thecorridor.Hospital Staff
ResponseThe rapid fire involvement and smoke production
appear to haveforced the
nurses to retreat before they were able to close the
door to thefire area. A
maintenance worker responding to investigate the alarmPage
17
Page 20
closed the emergency oxygen valve for 4-South. Although
it would havebeen
preferable for this valve to have been closed immediately
upondiscovery of the
fire, the staff was very busy evacuating patients
and closingdoors during this
period. A general announcement was made over thehospital
public address system
indicating that there was an actual fire inthe building
which notified staff
throughout the hospital to activateemergency procedures.
Hospital personnel,
including a doctor, respondedto the floor to triage
and treat patients removed
by firefighters. Patientcharts were removed from 4-South
by nurses so that other
hospital staffwould know how to treat patients who
had been removed from rooms
anddisconnected from oxygen and intravenous treatments.In
general, it appears
that hospital staff were very familiar withemergency
procedures for a fire and,
in most cases, followed theseprocedures. The efforts
by the hospital’s safety
department to train staffabout emergency procedures
appears to have played a
significant role in anefficient handling of this emergency.
Unfortunately, in
the rush toevacuate 4-South and activate other emergency
procedures following
thediscovery of the fire, the door to Room 418 was
left open. This
illustrateswhy it is important to have alarm activated
self-closing doors
throughoutthe hospital, including patient room doors.7Based
on reports about the
size of the fire when it was discovered, itis very
likely that it could have
been extinguished with one of the waterextinguishers
kept on the south
corridor.Fire Department ResponseIncident Command
- Battalion Chief Steve
Bowling assumedcommand on the east side of the hospital
immediately after
arriving on thescene. Chief Bowling’s initial
plan was to have the first
arriving unitsexecute their planned assignments and
to ascertain as quickly as
possiblethe amount of fire and the extent of evacuations
and rescues that would
benecessary.Planned assignments, which included the
first arriving engine7NFPA
101 recognizes the value of self-closing doors to
patient rooms, but
recommendsthat rooms equipped with self-closing doors
also be equipped with an
automatic detectionsystem connected to an annunciator
panel that indicates which
detectors are in alarm. Self-closing doors may make
it difficult for hospital
personnel to determine the origin of smoke,which is
why the automatic detection
system is recommended when self-closing doors are
used.Page 18
Page 21
checking the fire annunciator panel and the second
arriving engineestablishing
the water supply and charging the standpipe system,
wereexecuted promptly. All
of the 14 personnel on the first alarm were busyeither
fighting the fire or
performing rescues for the first 20 minutes. Untilother
personnel arrived, the
Incident Commander did not have thenecessary personnel
to assign sector
officers.A significant fire in an occupied institutional
facility is more
thanone commander can manage alone. Chief Bowling
noted that thefirefighters
from the first alarm companies were too busy fighting
the fireand rescuing
victims to be able to provide a full evaluation of
theconditions inside the
hospital. Off-duty command officers wereimmediately
called to respond, but most
of them did not arrive on thescene until the fire
had been
extinguished.Coordination Between Incident Command
and Hospital Staff --
TheIncident Commander did not have a representative
from the hospital at
thecommand post to serve as a liaison until over one-half
hour into theincident.
As a result, he was unable to resolve some key questions
aboutventilation
systems, elevator problems, and the hospital’s
immediate needs.Two specific
problems arose that required cooperation andcoordination
between the fire
department and the hospital. First, firedepartment
personnel could not control
the elevators initially because theydid not have the
necessary keys. While
firefighters needed elevators toshuttle equipment
to the fire floor, hospital
staff needed the elevators toevacuate patients. This
is an important issue that
should be addressed inan evacuation plan.The second
problem dealt with transfer
of patients. Several patientsfrom the fire floor suffered
injuries that required
them to be transferred toother hospitals with bum
units. Patients from the
fourth and fifth floorswere moved to areas of the
hospital unaffected by the
fire. The hospitalhad to borrow portable oxygen cylinders
from every fire
department uniton the scene to treat patients who
had been exposed to the
smoke.Hospital ConstructionThe hospital was built
to the 1974 BOCA building
code. The codesrequired institutional buildings to
be divided into fire
resistivecompartments to contain fire spread. The
original building was
notsprinklered.Page 19
Page 22
The effectiveness of many compartmentation systems
tends todecrease over time as
various systems are installed or repaired. Theeffectiveness
of the
compartmentation on the south wing of SRMC appearsto
have been largely
maintained over more than 20 years.Each patient room
was designed to be a fire
resistive compartmentcapable of containing a fire
for approximately one hour.
Thecompartmentation failed early due to the door to
the room being left openand
the failure of the suspended ceiling early in the
fire. The spread ofsmoke and
heat to the corridor and the adjacent rooms resulted
in threeadditional deaths.
If the fire and smoke spread had been contained toRoom
418 only one death would
have occurred.It is unclear why the ceiling assembly
failed during the fire.
Theceiling was part of a fire resistive floor ceiling
system. One or more of
theceiling tiles, which must be secured in place with
pins to function
properly,may have not been secured, allowing them
to be drawn up and out of
theframe of the suspended ceiling by air drafts created
by the fire. Due to
theamount of damage to the ceiling, however, it was
impossible to
determinewhether each ceiling tile was secured in
place with clips.There were
two exits from the corridor, one through the smokecontrol
doors, and the other
to the exit stairway.Hospital Fire Protection SystemsThe
presence of a sprinkler
system in the room of origin would haveextinguished
or controlled the fire and
probably prevented the deaths ofthree patients in
adjacent rooms. Sprinklers
were not required under thecode when the 4-South corridor
was constructed.*On
the night of the fire, the fire alarm system was activated
by thenurse who
discovered the fire and pulled a manual station. A
smokedetector in the room of
origin would have activated the alarm system morequickly,
especially since the
door to the room was closed. The detectorslocated
in the corridor offered only
limited protection; it is ideal to have adetector
in every patient room to
provide the earliest possible alert. This8NFPA 101,
Life Safety Code, recommends
that existing highrise health care occupanciesover
75 feet tall be protected
throughout by an automatic sprinkler system. Southside
RegionalMedical Center is
7 stories tall, making it very close to the minimum
height to qualify as
ahighrise. SRMC was not required to retrofit to meet
the Life Safety Code
standards.Page 20
Page 23
is especially important in hospitals and other facilities
where patients maybe
unconscious, sedated, or otherwise unable to detect
a fire on their own.The
increasing number of electrical appliances in patient
rooms is anotherreason for
locating detectors in each room.The hospital alarm
systems used to be monitored
by a centralstation at night, but this practice had
recently ceased due to
problems withfalse alarms. Hospital policy is to report
an alarm to the
switchboard;security officers check the annunciator
panel and respond to
investigate analarm. If the switchboard receives a
report of an actual fire,
however, itspolicy is to notify the fire department
immediately. At the time of
the fire,the alarm system was not connected to a central
station, and
notificationdepended on a call to the fire department
by the switchboard
operator. Itis preferable to connect the alarm to
a central station or to the
firedepartment, as is recommended by NFPA 101.The
alarm system on the south
corridor of 4-South includes twosmoke detectors and
pull stations. When either
is activated, a generalalarm sounds throughout the
hospital. The alarm system
does not recordan alarm activation time, nor does
it differentiate between which
alarm wasfirst activated because the detectors and
pull stations are on the
samecircuit. When the fire alarm system activates,
the smoke control doors inthe
corridors close automatically. Patient room doors,
however, are not onthis
system.HVAC SystemThe hospital’s ventilation
system supplies fresh air to the
patientrooms via metal ducts that run through the
plenum space. Air is
removedfrom each patient bathroom by fans that run
constantly. There is no
othercentral ventilation system. Cooling and heating
are provided by
individualfan-coil units in each room.The fresh air
supply fans were supposed to
automatically shut downwhen the fire alarm activated,
but this function was
disabled at the time ofthe fire. A hospital technician
manually shut down the
fans approximately30 minutes after the fire was controlled.
The failure of this
system to shutdown may have supplied fresh air to
the fire, but this
contribution does notappear to have played a significant
role in fueling the
fire. Nonetheless,the status of the building systems
should be readily available
to firedepartment personnel.Page 21
Page 24
Smoke stains around the bathroom exhaust fans indicate
that thefans drew smoke
out of rooms. According to one patient, the fans did
notremove the smoke as
quickly as smoke filled the rooms.LESSONS LEARNED1.A
limited fire protection
svstem in an institution offers only minimalprotection.The
most important lesson
that should be derived from this incidentis the importance
of installing
sprinkler and smoke detection systemsthroughout institutional
facilities where
occupant evacuation is difficult andtime consuming.
The smoke detectors in the
corridors did not providesufficient time for hospital
personnel to respond to
try to control theincident since the door to the room
of origin was closed when
the firestarted. Even when smoke detection is installed
to provide early
warning,a real possibility exists that a rapidly growing
fire can occur in a
patientroom with a heavy fire load. In this case,
it is preferable to equip
everyroom with a sprinkler system to control the fire.2.Preparation
of hospital
staff for a fire is an integral part of the fireprotection.In
this incident, the
hospital staff was regularly trained and wellversed
in emergency procedures for
a fire. Some of the staff performedheroic rescues
that probably saved the lives
of some of the patients. Evenwith good training, the
rapid growth of a fire and
accumulation of smokemay prevent hospital staff from
being able to perform all
emergencyprocedures, including closing all of the
doors and evacuating patients.
Inthis case, the door to the room of origin was left
open, due to a variety
offactors. This reinforces the importance of having
automatic
extinguishingsystems in every room of an institution.3.The
intent and
effectiveness of compartment&ion is destroved
whena door or other opening to a
room is left open.An automatic, self-closing door
system on the doors to
patientrooms would have been beneficial in this incident.
The effectiveness
ofcompartmentation features was destroyed by an open
door which allowedsmoke and
heat spread into the corridor, and which provided
a source offresh air for the
fire. The suspended ceiling, which was designed to
be fire-Page 22
Page 25
rated, failed early in the fire, also destroying the
compartmentationeffectiveness.4.Smoke control doors
are an important fire
protection feature tocontrol smoke spread.This fire
demonstrated that smoke
spread can be effectivelycontrolled by smoke control
doors and closed doors.
Smoke spread via thecorridor into other rooms on the
corridor was controlled
effectively byhospital personnel closing doors to
patient rooms. The
self-closing smokecontrol doors at one end of the
corridor contained the heavy
smokedamage to only one corridor on 4-South wing.5.Smoke
can spread readily
through a plenum space to adjacent areaseven though
doors are closed.Smoke
spread very rapidly, through the common plenum spaceabove
six rooms on the
corridor due to rapid failure of the ceiling in theroom
of origin. This allowed
smoke to fill the plenum space and to spreadinto adjacent
rooms. Common plenum
spaces allow for rapid smokespread. Suspended ceilings
should not be expected to
contain smoke dueto leakage between tiles and the
ceiling frame.6.A working
institutional occupancy fire places tremendous resourcerequirements
on fire
departments.The evacuation of institutional facilities
including hospitals,
nursinghomes, schools, and jails is very laborious
and will generally require
morefirefighting personnel than is needed at fires
in other types of
occupancies.Initial dispatch assignments for these
types of occupancies should
includeadditional resources than normally dispatched
for other types
ofoccupancies.7 .Pre-fire planning facilitates fireground
operations.The fire
department had developed planned assignments forresponse
to the hospital. Most
of the firefighters were familiar with theinterior
layout, including where
standpipe connections were located. Pre-fire planning
creates an organized
structure of response before the chaos ofan emergency
incident occurs. It also
allows for quick, efficient operationswithout having
delays created by
unfamiliar surroundings. This firerequired the resources
of mutual aid
departments. Mutual aid departmentsPage 23
Page 26
should participate in pre-fire planning of institutions
or other targethazards
outside of their jurisdiction to which they might
be summoned.8.Command at an
institutional occupancy fire requires a high level
ofcoordination and
cooperation between the fire department and theinstitutional
staff.The Incident
Commander will need the assistance of institutionalstaff
to manage the incident
efficiently. Institutional staff, such as abuilding
engineer and medical or
administrative personnel, will benecessary to answer
questions, to assess needs,
and to assist with patienttreatment and transfer.
The pre-fire plan of an
institution should designatea liaison to the Incident
Commander to assist with
coordination. Theliaison should be equipped with the
appropriate resources such
as keys anda knowledge of the building’s mechanical
systems. This person should
betrained to report to the command post or first arriving
unit as part of
firedrill procedures.ADDITIONAL INFORMATION OF INTERESTAs
a result of this fire,
the Commonwealth of Virginia enactedrequirements under
state code 3699.9: 1
which requires all hospitals in thestate to be fully
sprinklered by January 1,
1998.
phone call reporting fire received at PetersburgEmergency
Communications Center
from patient on 4th floorof hospital911 phone call
reporting fire received at
PetersburgEmergency Communications Center from ChesterfieldCounty
ambulance
attendant outside of hospital reporting fire911 phone
call reporting fire
received at PetersburgEmergency Communications Center
from hospitalswitchboard
operatorDispatch of first alarmPetersburg Police Unit
7103 radios Petersburg
EmergencyCommunications Center from 4th floor of hospital
reportingfireDispatch
of first alarm completeFirst alarm units respondingChesterfield
Fire Department
ambulance radios PetersburgUnit 530 (Battalion Chief)
to report working fire on
4th floorwith fire evident from outside of hospitalSecond
alarm requested by
Unit 530Petersburg Emergency Communications Center
requestsresponse of off-duty
staff officersDispatch of second alarmEngine 2 on
scene, nothing showing West
sideFire/Rescue 4 (Petersburg Ambulance) on scene,
fire andsmoke evident East
side. Remainder of first alarm units onscene within
next minute.
Unit 570 requests landline by Unit 501Unit 530 on
scene, establishes Command on East sideCommand advises
Engine 2 of person
trappedSecond alarm units respondingEngine 2 advises
it is on 4th floor looking
for fireUnit 570 (Asst. Chief of Support Services)
respondingCommand requests
Colonial Heights Fire Department AirUnit (mutual aid)Unit
507 (Safety Officer)
respondingChesterfield Fire Unit 127 on scene (75-foot
Tower Ladder)Patient in
Room 416 being removed by ladder rescue.Command advises
he can see line working
in room of originUnit 507 on sceneUnit 570 on scenePatient
from Room 416 safely
on groundAir bottles requested on 4th floorColonial
Heights Air Unit on
sceneFire knocked downChesterfield Engine 123 (special
request) responding
(mutualaid)Chesterfield Engine 124 (special request)
responding
(mutualaid)Petersburg Emergency Communications Center
advisesCommand that Unit
501 is with Unit 520
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