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November 2004                                                                            Volume 7 - Number 2

Fire Reports...

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James Lee Witt Associates “Report of Independent Review of Cook County Administration Building Fire”

By Joseph P. Klein, III

On Friday October 17, 2003 a fire on the 12^th floor of the Cook County Administration Building in Chicago, IL resulted in the death of six people. The State of Illinois retained James Lee Witt Associates, LLC to conduct an independent review of the fire incident to determine the facts of the incident, identify lessons learned and provide recommendations to improve high-rise fire safety throughout the State. Results of the review were published on September 30, 2004. The report is available on the James Lee Witt Associates, LLC web site (www.wittassociates.com). This article summarizes the data and findings presented in that report.

At approximately 5:00 PM on Friday afternoon, a fire broke out in a storage closet in the Office of the State Business Services Division. Building security and management staff received an alarm indicating a fire and they notified the Chicago 9-1-1 Operator at 5:02 PM. Building occupants reported hearing no audible alarm signal but did hear emergency voice instructions to evacuate the building by way of the stairways. Occupants generally proceeded to evacuate using one of two stairways, or against instructions, the elevators.

The first units of the Chicago Fire Department arrived at the scene at about 5:06 PM. The initial fire attack from the southeast stairwell began about 5:16 PM. In mobilizing into the southeast stairwell firefighters breached doors to the stair tower and the adjoining smoke ejection tower allowing smoke and heat to escape into the stairwell. Occupants using the southeast stairway to evaluate the building encountered the firefighters blocking the stairway and were instructed to return to a higher floor. Complying with the instructions occupants retreated to higher floors but found the stairway doors locked, preventing reentry into the building space. Several phone calls to 9-1-1 and to the building management staff reported people missing and/or trapped in the stairwell. That information was not effectively communicated to the firefighters. Ultimately, six people trapped in the stairway died from smoke inhalation. The fire was extinguished by 6:07 PM.

The James Lee Witt report identifies 82 findings of failures, inconsistencies, ineffectiveness and/or non-compliance on the part of various agencies, organizations and individuals. The report four key factors directly contributing to the fatalities:
- Lack of automatic sprinklers
- Failure of the Chicago Fire Department to conduct adequate search and rescue
- Chicago Fire Department’s opening of the 12th floor southeast stairway door allowing smoke into the emergency exit route
- Locked stairway doors that prevented reentry into the building.

Another important set of findings included:
- Failures and inconsistencies by City of Chicago, Cook County and the State Inadequate emergency procedures training of building staff and occupants

- Ineffective communications between 911 dispatchers and on-scene police and fire commanders.

- Inadequate incident command procedures

- Failure to adopt and/or enforce state fire codes.

The report concludes that better mitigations and preparedness actions initiated by responsible parties prior to the incident and more effective response and recovery actions during the incident would have prevented injuries and deaths. Recommended mitigation measures include installing sprinklers, improved emergency management, adoption of a national recognized incident management/command system, improved fire code compliance.

http://www.usfa.fema.gov/inside-usfa/media/2004releases/092404.shtm

http://www.ksffa.com/NVFC/nvfc_update_6282004.htm