Interstate Bank Building Fire Los Angeles, California
(May 4, 1988) |
| On Wednesday, May 4 and continuing in to May 5, 1988, the Los Angeles
City Fire Department responded to and extinguished the most challenging
and difficult high-rise fire in the city's history. The fire destroyed
four floors and damaged a fifth floor of the modern 62 story First
Interstate Bank building in downtwon L.A., claimed one life, injured
approximately 35 occupants and 14 fire personnel, and resulted in
a property loss of over $50 million. This was one of the most destructive
high-rise fires in recent United States history. The fire presented
the greatest potential for the "Towering Inferno" scenario
of any U.S. fire experience and was controlled only through the
massive and dedicated manual fire suppression efforts large metropolitan
fire department. It demonstrated the absolute need automatic sprinklers
to provide protection for tall buildings.
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SUMMARY OF KEY ISSUES
| Occupancy |
62-story high-rise
office building. |
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Construction
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Steel frame; exterior
of glass and aluminum.
Unusually good application of fire resistive coating helped
maintain structural integrity in fire.
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Delayed Reporting
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Building security
and maintenance personnel delayed notifying Fire Department
for 15 minutes after first evidence of fire.
Smoke detectors on
several floors had been activated and reset a number of
times before reporting to Fire Department.
A maintenance employee
died while trying to investigate source of alarms prior
to calling Fire Department.
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Automatic Fire Sprinklers
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Sprinkler system was installed
in 90 percent of the building, including on fire floors;
valves controlling the systems had been closed, awaiting
installation of water-flow alarms.
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Interior Design and
Contents
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Large open area with
readily combustible contents contributed to quick fire growth. |
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System Failures
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Main fire pumps had been shut
down, reducing available water pressure for initial
attack.
Radio communications were overtaxed
and disrupted by building's steel frame.
Fire and water damaged telephone
circuits making them unusable.
Sound-powered emergency phone
system in building was ineffective.
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| BUILDING DESCRIPTION The First Interstate Bank
building, the tallest in the city (and the state of California),
is located at the intersection of Wilshire Boulevard and Hope Street
in downtown Los Angeles. It was built in 1973, one year before a
high-rise sprinkler ordinance went into effect, and had sprinkler
protection only in the basement, garage, and underground pedestrian
tunnel. The 62-story tower measures 124 feet by 184 feet (22,816
sq. ft.). It contains approximately 17,500 net square feet of office
space per floor, built around a central core. It is occupied primarily
by the headquarters of the bank corporation with several floors
occupied by other tenants. Approximately 4,000 people work in the
building.
The tower contains four main stairways (numbered 5, 5-A, 6, and
6-A in the 12th-floor plan in Appendix A). Stairs 6 and 6-A are
enclosed within a common shaft, and stairway 5-A has a pressurized
vestibule separating each floor with the stair shaft. Each stairway
contains a combination standpipe with a pressure reducing valve
at each landing. The building is topped with a helicopter landing
pad.
The building has a structural steel frame, protected by a sprayed-on
protective coating, with steel floor pans and lightweight concrete
The exterior curtain walls are glass and aluminum.
A complete automatic sprinkler system costing $3.5 million was
being installed in the building at the time of the fire. The installation
was not required by codes at the time the owners decided to provide
increased fire protection for the building. The project was approximately
90 percent complete, with work in progress at the time of the incident.
The piping and sprinkler heads had been installed throughout the
five fire floors and connected to the standpipe supply. However,
a decision had been made to activate the system only on completion
of the entire project, when connections would be made to the fire
alarm systems, so the valves controlling the sprinklers on completed
floors were closed.
THE FIRE
The fire originated in an open-plan office area in the southeast
quadrant of the 12th floor. (See Appendix A.) The area of origin
contained modular office furniture with numerous personal computers
and terminals used by securities trading personnel. The cause is
thought to be electrical in origin, but the precise source of ignition
was not determined. The fire extended to the entire open area and
several office enclosures to fully involve the 12th floor, except
for the passenger elevator lobby, which was protected by automatic
closing fire doors.
The fire extended to floors above, primarily via the outer walls
of the building; windows broke and flames penetrated behind the
spandrel panels around the ends of the floor slabs. The curtain
wall construction creates separations between the end of the floor
slab and the exterior curtain wall. (For a discussion of this type
of fire spread see NFPA Fire Journal, May/June 1988, pages 75-84.)
There was heavy exposure of flames to the windows on successive floors
as the fire extended upward from the 12th to 16th floors. The flames
were estimated to be lapping 30 feet up the face of the building.
The curtain walls, including windows, spandrel panels, and mullions,
were almost completely destroyed by the fire. There were no "eyebrows"
to stop the exterior vertical spread, and fireground commanders were
concerned about the possibility of the fire "lapping" higher to involve
additional floors. Minor
fire extension also occurred via poke-through penetrations for electricity
and communications, via HVAC shafts, and via heat conduction through
the floor slabs. A minor fire occurred in a storeroom on the 27th
floor, ignited by fire products escaping from an HVAC shaft that
originated on the 12th floor. This fire self-extinguished due to
oxygen deficiency, but could have greatly complicated the situation
if it had continued to burn. The secondary extensions were minor
compared to the perimeter fire spread at the curtain walls.
The fire extended at a rate
estimated at 45 minutes per floor and burned intensely for approximately
90 minutes on each level. This resulted in two floors being heavily
involved at any point during the fire. The upward extension was
stopped at the 16th floor level, after completely destroying four
and one-half floors of the building.
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INITIAL STAGES
At 2222 on the night of the fire, the buildings
two fire pumps were shut down by the sprinkler contractor, and the
combination standpipe system was drained down to the 58th floor
level to facilitate connecting the new sprinkler system to the standpipe
at that level. Three minutes later, at 2225, employees of the sprinkler
system contractor heard glass falling and saw light smoke at the
ceiling level on the 5th floor. A manual alarm was pulled but sounded
for only a few seconds. It is believed that the alarm was silenced
by security personnel on the ground floor.
At 2230, a smoke detector on the 12th floor
was activated and was reset by security personnel. At 2232, three
additional smoke detectors on the 12th floor were activated and
were again reset by security personnel. At 2234, four smoke detectors
on the 12th floor were activated and reset.There was heavy exposure
of flames to the windows on successive floors as the fire extended
upward from the 12th to 16th floors. The flames were estimated to
be lapping 30 feet up the face of the building. The curtain walls,
including windows, spandrel panels, and mullions, were almost completely
destroyed by the fire. There were no "eyebrows" to stop
the exterior vertical spread, and fireground commanders were concerned
about the possibility of the fire "lapping" higher to
involve additional floors.
Minor fire extension also occurred via poke-through penetrations
for electricity and communications, via HVAC shafts, and via heat
conduction through the floor slabs. A minor fire occurred in a storeroom
on the 27th floor, ignited by fire products escaping from an HVAC
shaft that originated on the 12th floor. This fire self-extinguished
due to oxygen deficiency, but could have greatly complicated the
situation if it had continued to burn. The secondary extensions
were minor compared to the perimeter fire spread at the curtain
walls.
The fire extended at a rate estimated at 45 minutes per floor and
burned intensely for approximately 90 minutes on each level. This
resulted in two floors being heavily involved at any point during
the fire. The upward extension was stopped at the 16th floor level,
after completely destroying four and one-half floors of the building.
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| FIRE DEPARTMENT OPERATIONS
At 2237, the Fire Department received
three separate 9-l-l calls from people outside of the First Interstate
building reporting a fire on the upper floors. At 2238, a Category
"B" assignment was dispatched consisting of Task Forces
9 and 10, Engine 3, Squad 4, and Battalion 1 -- a total of 30 personnel.
(A Task Force in Los Angeles consists of 10 personnel operating
two pumpers and one ladder truck.)
The first report of the fire from inside the building was received
at 2241, as the first due companies were arriving at the scene.
While en route, Battalion 1 had observed and reported a large "loom-up"
in the general area of the building. As he arrived on the scene,
the Battalion Chief observed the entire east side and three-fourths
of the south side of the 12th floor fully involved with fire. Battalion
Chief Don Cate immediately called for five additional Task Forces,
five Engine companies, and five Battalion Chiefs. This was followed
quickly by a request for an additional five Task Forces, five Engine
companies and five Battalion Chiefs, providing a total response
of over 200 personnel within five minutes of the first alarm. Two
Fire Department helicopters were also dispatched.
The High Rise Incident Command System was initiated with companies
assigned to fire attack and to logistics and support functions from
the outset. Appendix B shows the system and indicates the changes
in command of various functions during the course of the incident.
Appendix C shows the overall site and the location of the Command
Post.
In accordance with Los Angeles City Fire Department policy, elevators
were not used and all personnel climbed the stairs to the fire area.
The first companies to reach the fire floor found smoke entering
all four stairshafts from around the exit doors. Handlines were
connected to the standpipe risers and the initial attack began at
approximately 2310. Due to the magnitude of the fire on the 12th
floor, attack was initiated from all four stairways. The crews had
great difficulty advancing lines through the doors and onto the
floor. As the doors were opened, heat and smoke pushed into the
stairways and rose rapidly to the upper levels of the building.
The first six arriving companies were sent immediately to attack
the f i r e . The initial attack used primarily 2-inch attack lines.
The attack was hampered by low water pressure for the first few
minutes, until the building fire pumps were started. The standpipes
were also supplied by three Fire Department pumpers via the exterior
hose connections.
As the attack was put into operation, a Staging Area was established
on the 10th floor and a Lobby Control was established at ground
level. The "Base" for the operation was located a block
south of the building (see Appendix C), following the High Rise
Incident Command Plan.
The Command Post was established by the first arriving Battalion
Chief one-half block south of the fire, and the Incident Commander
operated from this location for the duration of the incident. The
Operations Chief went to the 10th floor Staging Area to direct interior
suppression efforts where he would have direct contact with officers
assigned to each floor.
The key positions in the command organization were initially assigned
to Captains or Battalion Chiefs who were later relieved by higher
ranking Command Officers. In most cases the relieved Battalion Chief
stayed at the same location to work as an assistant to the higher
ranking officer.
Deputy Chief Donald F. Anthony, second-in-command of the Los Angeles
City Fire Department, became the Incident Commander upon his arrival
at the scene. Chief Engineer and General Manager Donald 0. Manning
was also present at the Command Post and was involved in strategic
planning for the incident.
EXPANDING OPERATIONS
It soon became evident from the exterior and the interior that
the fire was spreading upward. Companies successively launched attacks
from all four stairways onto the 13th, 14th, 15th, and 16th floors,
often encountering heavy fire from the point of entry and having
to fight their way onto the floors with handlines. At times active
suppression efforts were underway simultaneously on four levels
as crews attempted to push the fire back from the central core to
the perimeter of each floor. As more doors were opened, conditions
in the stairways deteriorated with heat and smoke going up and water
cascading down. (Appendix D shows a vertical cross-section of the
building and the fire floors.)
The Operations Chief communicated with the Command Officers assigned
to the floors above, directing tactical activities and making assignments
of fresh or recycled companies to specific floors and stairways.
Several companies handled three or four different firefighting assignments
as conditions changed during the incident, with only short breaks
to change air cylinders at the 10th floor Staging Area.
The Operations Chief relied primarily on runners to communicate
with the floors above because radio communications were overtaxed
and disrupted by the building's steel frame. In order to communicate
with the Incident Commander, who was located on the street level,
a window was broken out and a Battalion Chief stood at the opening
with a portable radio to provide line-of-sight communications between
the 10th floor and the Command Post. Attempts to use regular telephone
service were unsuccessful due to fire and water damage to telephone
circuits. An installed sound-powered emergency phone system, linking
all floors with the lobby, also proved to be inadequate.
The strategy employed to stop the upward progress of the fire was
to use aggressive tactics on the 14th and 15th floors to reduce
the fire's intensity and the resulting exposure to floors above,
while setting-up with hoselines and waiting for the fire to attack
the 16th floor. This strategy proved to be successful but required
extreme efforts by crews operating handlines on heavily involved
floors, with as many as four floors burning below them. Approximately
20 handlines were used by 32 attack companies on the five involved
floors.
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| LOGISTICS
The logistical considerations involved in this operation
were massive. The 10th floor was used as the Staging Area for personnel
and equipment. Crews would return to the Staging Area to rest and
change air cylinders and then to await reassignment to a fire floor.
Companies went into action with full air cylinders and returned
to the Staging Area when they were out of air. The companies operated
for approximately 20 minutes in each cycle and had approximately
20 minutes to rest and change air cylinders.
Without elevators, every piece of equipment had to be carried up
the stairs, including approximately 600 air cylinders. Every firefighter
entering the building carried hose, nozzles, and other tools up
to the 10th floor. A stairwell support operation, with nine companies
assigned, spent over two hours moving equipment from the street
level, through an underground tunnel from a parking garage across
the street, up to the lobby, and then up the stairs to the Staging
Area.
Crews working below the fire worked under deteriorating, adverse
conditions. Smoke began to fill the 10th and lower floors, and windows
had to be broken for ventilation. Water cascaded down the stairways
and through the ceilings; and electrical power, including emergency
lighting in the stairs, was lost. The operation continued for so
long that even handlights failed due to battery consumption.
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| SEARCH AND RESCUE
Approximately 50 occupants were inside the
building and above the 12th floor when the fire broke out. These
occupants included cleaning and maintenance workers, the sprinkler
fitters, and a few tenants who were working late in offices. The
occupants became aware of the fire as smoke entered the areas where
they were working.
Five of the occupants from upper floors went to the rooftop and
were rescued by helicopters. Others attempted to exit via elevators,
some successfully and some unsuccessfully. At least one group found
themselves on the 12th floor and had to crawl to an exit stairway
in dense smoke and heat. Most of the occupants successfully exited
via the stairs and encountered firefighters coming up the stairs
as they descended.
The Fire Department was able to account for all except three known
occupants of the building by comparing names with the sign-in sheets
maintained by security personnel. Two of these occupants were on
the 37th floor and one was on the 50th floor. Helicopter crews were
able to locate all three at windows.
Due to the heavy smoke and heat conditions in all four stairways,
it was impossible to send search and rescue crews to the upper floors
until the fire was knocked-down at 0219. The Airborne Engine Companies
were unable to penetrate from the rooftop until this time and were
successful in rescuing the 50th floor occupant at approximately
0230.
Crews working from below found the two occupants of the 37th floor
at approximately the same time. One of these occupants was unconscious
and had to be carried down the stairs to the ground level.
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| FALLING GLASS
Falling glass and other debris created a major
problem during this incident. Virtually all of the exterior curtain
wall, from the 12th through 16th floors, was destroyed and fell
to the ground. The falling glass and debris caused significant damage
to pumpers hooked-up to the Fire Department connections. The hose
lines were cut several times and had to be replaced, under the constant
danger of additional falling materials. The entire perimeter of
the building, for over 100 feet out from the walls, was littered
with this debris.
Fortunately, a tunnel between the building and the parking garage
across the street provided a safe path into the building at the
basement level for both personnel and equipment. Without this tunnel
it would have been very difficult to maintain the necessary logistical
supply system and to avoid injuries to personnel from the falling
debris.
The windows were coated with a plastic reflective material which
caused them to hold together as they fell. The glass fell in very
large sections, some of which were flaming due to ignition of the
plastic coating.
The Incident Commander gave blanket approval for crews to break
windows to provide ventilation, since glass and debris were already
falling on all four sides of the building. Firefighters reported
difficulty in breaking the thick windows, and the coating on the
windows may also have been a factor in this regard. A pick-head
axe was found to be the most effective tool for the job. (A Police
sharpshooter offered to shoot windows out from a helicopter, but
the offer was declined.)
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| SPRINKLERS AND STANDPIPE SYSTEM
The building was served by a
single zone combination standpipe system with four risers, one in
each stairway. The standpipe risers provided a 2 l/2 inch outlet
in each stairway at each floor and also supplied 1 l/2 inch hose
cabinets in the occupied areas of each floor. At the time the fire
broke out the building's fire pumps had been shut down, and the
risers had been drained down below the 58th floor to allow a sprinkler
line to be connected to a standpipe riser. This job took only a
few minutes and the jockey pump was in operation to refill the system
when the sprinkler crews noted smoke rapidly filling the stairway.
Being only four floors from the roof, the workers went up to the
helipad to await rescue.
The sprinkler system was virtually complete on the floors that
burned, but the valves were closed between the standpipe riser and
the sprinkler system on each floor. During the fire a Battalion
Chief was assigned to confer with the sprinkler installation supervisor
to explore the possibility of opening these valves to control the
fire. It was determined that the fire on the involved floors would
probably overwhelm the sprinklers and deprive the handlines of needed
water. Eventually, the systems on floors 17, 18, and 19 above the
fire were activated, in case the fire extended past the 16th floor.
The four standpipes are supplied by two stationary fire pumps,
one diesel and one electric, each rated at 750 gpm at 600 psi pressure.
The standpipe system operates with a single vertical zone, depending
on the pressure reducing valves at each outlet to control the pressure.
With the main fire pumps shut down, the only water pressure available
for the first hoselines was the static head in the risers, and crews
reported poor water pressure for the first few minutes. This condition
was rapidly corrected when the combination of both building pumps
and three Fire Department pumpers were placed in operation.
The building pumps were started manually by the sprinkler installation
supervisor who had been rescued from the rooftop by a Police helicopter,
taken to a Police facility, and transported back to the scene in
a Police car. He arrived at the Fire Department Command Post and
informed the Incident Commander of the situation. An engine company
was assigned to drive him into the basement loading dock area in
a car, to avoid the falling glass, and to assist him in starting
the pumps.
The building's two 750 gpm fire pumps drew water from an 85,000
gallon reservoir in the sub-basement. The resupply from the public
water supply system was unable to keep pace with the outflow, estimated
at over 2,000 gallons per minute, and there were fears that the
tank would be emptied.The tank was down to less than one-third of
its capacity when the fire was controlled. If the tank had emptied,
only fire department pumpers would have been left to supply the
standpipes.
The single zone riser system was designed to operate at 585 pounds
per square inch (at basement pump discharge) and relied upon the
pressure reducing valves to limit the discharge pressure at each
outlet on each landing. Problems were encountered with several of
these valves allowing excess pressure to be discharged, including
one that provided over 400 pounds per square inch. The overpressure
caused several hose ruptures and made handlines difficult to control.
The heat of the fire caused several aluminum alloy valves in the
occupant hose cabinets to fail, creating high pressure water leaks.
These leaks took water from the supply that was available for handlines
and caused additional water damage on floors below the fire.
It was estimated that a total flow of 4,000 gallons per minute
was delivered by the standpipe risers. The total effective fire
flow, provided by hoselines attacking the fire, was approximately
2,400 gpm. The attack lines included 1 3/4, 2, and 2 l/2 inch handlines.
No exterior streams or master stream appliances were used.
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| ELEVATORS
No elevators were used by the Fire Department during
this incident. There is a standard policy in the Los Angeles City
Fire Department not to use elevators that have a shaft opening within
five floors of the fire floor. The use of any elevators was ruled
out based on the amount of fire that was visible from the street.
The building contained 31 passenger elevators in four banks above
the main lobby, two banks for sublevels, and two service (freight)
elevators. Both service elevators served all levels and were provided
with a lobby at each floor. All of the elevators were designed to
be recalled to the ground floor lobby on smoke detector activation.
Some elevator cars were returned to the ground floor, but those
that had been in use by cleaning and maintenance crews were on "Independent
Service" and could not be recalled. Other cars were not accounted
for because their doors did not open when they returned to the ground
floor. One elevator stopped on the 22nd floor and one stopped on
the 33rd floor. This caused concern that individuals could be trapped
in the 10 "missing" elevators and attempts were made to
locate these cars. Their locations were eventually determined by
the elevator maintenance personnel who were taken to the rooftop
machine room by helicopter.
The single fatality was found in a service elevator. The building
employee, who went to the 12th floor to investigate the alarm, was
trapped and died when the elevator opened into a burning lobby.
The lobby fire separation was compromised by a cleaner's cart blocking
the door open. The victim was able to call for help on his portable
radio, but other employees had no means to rescue him. This elevator
was put on independent service through the use of a key by the building
employee.
Lobby isolation doors had been installed on the passenger elevator
lobbies of several floors, including the 12th and were successful
in keeping fire and smoke out and providing a potential area of
refuge. The isolation doors were being installed as the building
was renovated.. The fire reached the elevator shafts on floors where
the doors had not been installed, and they became additional vertical
conduits for heat and smoke. The machine room on the 22nd floor,
which served the "low rise" elevators, received extensive
heat and smoke damage. Smoke traveled throughout the building above
the 12th floor via the elevator shafts. |
| SALVAGE AND PROPERTY LOSS
The floors below the fire
received massive water damage, and those above were heavily damaged
by heat and smoke. During the fire, no efforts were directed toward
property conservation as all available firefighters were committed
to stopping the progress of the fire. After the fire, the building
remained closed for several months while the structure was inspected,
and a large force of clean-up contractors worked through the building.
The efforts to save property were conducted on a very large scale
as virtually every part of the building was damaged by flames, heat,
smoke, or water. (As part of the cleanup, 250,000 cloth diapers
were used.) The property loss has been estimated at over $200 million,
without taking into account the business interruption loss.
In spite of the total burnout of four and a half floors, there
was no damage to the main structural members and only minor damage
to one secondary beam and a small number of floor pans. Although
there was concern for structural integrity during the incident,
post fire analysis indicates that there was no danger of major or
minor structural collapse. It was noted that quality control in
the application of the sprayed-on fire protection was unusually
good. |
| LESSONS LEARNED
1. Sprinkler system: Use the protection ASAP.
The value of automatic sprinklers in quickly controlling fire and
preventing fires of this magnitude must be emphasized. If the sprinkler
system had been activated as floors were completed, the fire probably
would have been controlled in minutes with minor damage. As buildings
are constructed, renovated, or demolished, sprinklers should be
kept operational on all the floors possible. Many fires occur during
these stages of the life cycles of buildings, and they often are
severe.
The City of Los Angeles contains over 750 high-rise buildings,
approximately 450 of which are not protected by automatic sprinklers.
This fire provided the lesson that was necessary to have a retroactive
sprinkler installation requirement adopted by the City Council.
2. Unsprinklered high-rise fires create massive manpower
requirements.
The fire took advantage of a large open area, with readily combustible
contents, to quickly reach major proportions. This combined with
an available path for vertical spread to create a situation that
taxed a large, well equipped, and experienced fire department to
its maximum. Many potentially serious problems arose, such as failing
standpipe valves and delayed activation of building fire pumps.
A fire department without the resources, capabilities , and experience
of the Los Angeles City Fire Department would have great difficulty
controlling upward extension, if faced with the same circumstances.
3. High danger to firefighters was mitigated by physical
fitness, good personal safety equipment, and safety training.
The fact that almost 400 Fire Department members operated on this
fire, with only 14 minor injuries, is a credit to the training and
physical fitness of Los Angeles firefighters and the safety procedures
that were employed. The use of protective hoods was found to be
very effective in preventing burns and allowing firefighters to
penetrate into the involved fire floors.
4. Incident Command System is critical for a large, complex
fire.
The High Rise Incident Command System was very effective in managing
the incident. Despite the massive numbers of companies and firefighters
on the scene, the Fire Department maintained good organization at
the scene and effectively -- and safely -- managed their resources.
The Los Angeles City Fire Department is to be commended for its
extraordinarily low injury rate at this fire.
5. Communications within and from a steel frame building
still can be a problem.
The difficulties that were experienced with radio communications
will require additional attention. An operation of this magnitude
involves a high demand for communications capacity. In addition,
the sound powered. telephone system was found to be inadequate (and
completely compromised when the system wires melted). The Los Angeles
City Fire Department is in the process of installing an 18 Channel
800 MHz radio system to address these problems.
6. Radio communications can easily be overloaded without
strict radiodiscipline and an adequate number of channels.
One of the major problems was the over usage of fire ground radio
channels. Also, communications from the air operations and medical
groups interfered with interior tactical communications.
7. Building personnel must be trained to take appropriate
actions when alarms are activated.
The actions of building security and maintenance personnel in the
first minutes of this incident are a cause for concern. The alarm
was delayed in reaching the Fire Department, occupants of the building
were not notified of the fire, and a life was lost while building
personnel attempted to verify the source of the alarms.
8. Fire-resistive structures can maintain structural integrity
if built w e l l .
The structural integrity of the building was a concern during and
after the fire. Analysis revealed that no significant damage occurred
to major structural elements. Part of this credit must go to the
unusually good application of fire resisting materials on support
members. The effects of this magnitude of fire on a less protected
structure must be considered in plans review, inspections during
construction, and developing codes.
9. Protected elevators are needed for fire service use.
The lack of elevators for delivering firefighter personnel and
equipment was a problem in this fire, although it occurred at a
relatively low level in the building. If firefighters had to climb
50 stories instead of 15, the problems would have been compounded.
This points to the need for carefully planning higher level operations.
Different elevator banks may allow limited use of elevators that
do not open on any involved floors.
10. Smoke in stairways is still a problem.
The concept of maintaining at least one stairway free of smoke,
to be used for evacuation, proved ineffective in this incident.
This concept may be valid for a less severe fire, but when the fire
reaches this magnitude all vertical shafts become potential chimneys.
The ventilated vestibule design failed to keep heat and smoke out
of the pressurized smoke tower.
11. Fire departments should develop contingency plans that
contemplate the failure of systems to perform as designed, especially
for major buildings.
Fire departments must contemplate operating in buildings where
fixed fire protection and other systems fail to operate as planned.
If the individual with specific knowledge of the building fire pumps
had not arrived at the Command Post, the pumps might have remained
inoperative. The fire also disrupted HVAC systems, communications,
and electrical power supplies beyond previous experience with high-rise
fires.
12. Vertical and horizontal fire spread can still be rapid
in modern buildings without sprinklers and without adequate compartmentation.
Vertical fire spread and fire development in open floor areas were
major factors in this incident. The floor of origin might not have
become involved as quickly if it had been divided into smaller offices,
providing for more rapid control of the fire. Exterior features
of building design can be provided to reduce the risk of vertical
flame impingement. Automatic sprinklers are usually effective in
dealing with both of these concerns.
13. Old Lesson: Fire protection systems need to be tested
regularly.
All components of fixed fire protection systems, including items
such as pressure reducing valves, must be regularly inspected and
tested. The problems encountered with the standpipe pressure reducing
valves in this building could have had a crippling effect on fire
suppression efforts.
14. Falling glass is a special hazard in high-rise fires.
This has been a common problem at major high-rise fires such as
the Prudential fire in Boston. Large sheets of glass can act as
guillotines. The existence of a tunnel for safe entry of personnel
was fortuitous in t h i s f i r e . Plans for new high-rises should
be reviewed for protected access by emergency personnel. Pre-fire
plans for existing high-rises should be reviewed as to how the local
fire department would cope with this hazard.
15. A major high-rise fire requires a heavy commitment
of personnel to logistics functions.
The L.A. Department had thought in terms of a 3 to 1 ratio between
support troops and firefighting troops. The ratio needed turned
out to be considerably less than that at 1 to 1, but still high.
16. "Fire-proof" vaults worked well to save valuable
papers.
An estimated $100 million in stocks and bonds were successfully
protected in a fire-proof vault exposed to the fire.
17. Building security personnel must be trained to promptly
report fires.
The security personnel are believed to have silenced the alarm
systems and wasted time in going to investigate the source of the
smoke alarm. This not only resulted in a fatality but undoubtedly
led to the fire being much larger by the time it was reported to
the Fire Department. The chain of alarms being set off was still
not recognized as possibly a rapidly spreading, large fire. This
is not the first high-rise where security personnel have exhibited
similar behavior. Fire departments should stress the importance
of prompt reporting and remind building owners of the risks that
are involved in delayed reporting -- including litigation. Fire
departments should also consider requiring automatic alarms to transmit
to Central Station Monitoring Systems.
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