James Lee Witt Associates (JLWA) released Friday the Final Report, Findings and Recommendations of the Independent Review of the Cook County Administration Building Fire and forwarded to the governer’s office recommendations to improve the quality of public safety in public buildings across the state of Illinois.

On Oct. 17, 2003, a fire broke out at the Cook County Administration Building in Chicago. Gov. Rod Blagojevich commissioned James Lee Witt Associates to conduct an independent review in order to discover the facts associated with the fire. It was one of the largest and most exhaustive fire investigations in the nation. More than 15 subject matter experts participated in the fire review team.

The findings in this report expose the fact that fatalities could have been avoided if there had been better mitigation and preparedness actions prior to and more effective response and recovery actions during the incident.

Report recommendations include changes that must be made at the incident site level, the city level, the county level, and the state level. They will assist the State of Illinois in improving the fire safety of buildings in Chicago and throughout the entire state.

The research and methodology for gathering the facts for this full report include: 1) the Guylene Human Behavior Study, a thorough survey of occupant behavior during the fire incident, which is one of the best ways to learn about the impact of human factors on the circumstances and outcome of a fire; 2) the study of a Cook County Administration building fire replication done by the National Institute of Standards and Technology (NIST) based on extensive data specific to the building; 3) results from hearings related to the incident; 4) an extensive review of operational procedures; 5) a comparative analysis of other major city fire departments and of similar incidents; 6) an examination of building history, renovations and improvements made during its lifetime, and a codes review; and 7) meetings with more than a dozen interested and involved parties.

Review Highlights

At approximately 5 p.m. on Friday, Oct. 17, 2003, a fire broke out in a storage closet in Suite 1240, on the 12th floor of the building within the office of the Secretary of State's Business Services Division. Security officers and building management personnel responded to the alarm, 9-1-1 was notified, and evacuation of the building commenced. Building occupants heard no audible fire alarm, but through the emergency voice/alarm communication (EVAC) system they were instructed by security personnel to evacuate by way of the stairways.

A group of occupants evacuating via the southeast stairway were unable to pass the fire floor once firefighting operations had begun. Occupants reported that when they reached the 12th floor, they were instructed by a firefighter to go back up the stairway. In compliance with the firefighter's instruction, these tenants reversed course. They attempted to re-enter floors above the 12th floor, but all stairway doors were locked.

Of the thirteen occupants who were not able to evacuate safely, six were overcome by the smoke in the southeast stairway and perished. They, along with seven others who ultimately survived, were not discovered until approximately 90 minutes after the initial alarm.

Findings

* Inconsistencies in Building Codes were discovered such that the Municipal Code of Chicago, which is supposed to be equal to or higher than state standards were, in fact, not.

* The building was not equipped with an automatic fire sprinkler system that would have controlled or extinguished the fire. Locked stairway doors in the southeast stairway prevented occupants from gaining re-entry into the building in order to find refuge. Given that the Municipal Code of Chicago (MCC) does not require both an automatic sprinkler system and automatically unlocking stairway doors, MCC essentially endorsed the design flaws that contributed to the fatalities.

* The City of Chicago promulgated a fire code that was less stringent than the requirements of state fire code adopted two years ago. The Office of the State Fire Marshal did not effectively inform jurisdictions within the State of Illinois of the changes made to the State Fire Code in January 2002, specifically the requirement of sprinkler systems in high-rise buildings.

* Chicago Fire Department gave a higher priority to firefighting operations over considerations for occupant safety and search/rescue activities. Chicago Fire Department did not initiate an effective search and rescue operation of occupants in the southeast stairway prior to forcibly opening the fire floor door.

* Fatalities could have been avoided if there had been better mitigation and preparedness actions prior to and more effective response and recovery actions during the incident.

Recommendations

* An automatic fire sprinkler system and a failsafe system for automatically unlocking stairway doors during emergencies should be installed as quickly as possible at the Cook County Administrative Building.

* Municipal Code of Chicago should be brought up to state standards by requiring both an automatic sprinkler system and a system that automatically unlocks stairway doors.

* The State Fire Marshal should develop a formal procedure to officially notify all jurisdictions within the state of any changes to the State Fire Code. The Chicago Fire Department must review and update protocols, policies and training guidelines related to search and rescue as a priority for life safety, occupant accountability and life saving operations.

* The Chicago Fire Department should immediately adopt and implement a nationally recognized Incident Management System (IMS) to address many of the issues related to fire ground operations.

* Building Management should develop a Building Emergency Action Plan to provide the framework and implementation of a coordinated response to any emergency.

Research & Methodology

The approach to the Fire Review was based on the four phases of emergency management -- Mitigation, Preparedness, Response, and Recovery. Reviewing the events of this fire through these four phases allowed researchers to:

* Identify the building systems, procedures, and personnel that were in place at the time of the fire;

* Document the actual performance of these systems, procedures, and personnel during the fire;

* Identify the gaps between actual performance and expected performance;

* Evaluate the adequacy of the systems, procedures, and personnel in place at the time of the fire, including applicable building and emergency management code and standards; and,

* Recommend changes for improving the performance of existing systems, procedures, and personnel and changes to these systems, procedures, and personnel where they were found to be inadequate.

The collection of data included, among other things: audio tapes, detailed timeline, floor plans, graphics, interview transcripts, photographs, reference materials, schematics and videotapes.

Guylene Human Behavior Study

* The Human Behavior Study identified three main contributing factors to explain the loss of life in this fire: 1) Emergency Voice/Alarm Communication (EVAC) system messages to evacuate the building, 2) Locked doors inside the stairwells, and 3) Fire-fighting activities. Each of these factors taken individually may not have led to the loss of life, but their combination was fatal.

* 551 building occupants were surveyed. 80% of respondents were unaware of the building's evacuation plan and 48% were unaware that stairway doors would lock behind them. This implies that despite signage and training, respondents did not have the vital knowledge required for effective decision-making during an emergency in this building.

* Building staff (management, security and housekeeping) did not have a unified and clear understanding of the existing evacuations plans and procedures or how to execute them properly.

* The locked doors in the stairwell show a complete ignorance of fire safety in high-rise structure, ignorance of the potential development of a fire and complete ignorance of human behavior during fires.

National Institute of Standards and Technology (NIST)

* The NIST team recreated the fire using the NIST-developed Fire Dynamics Simulator (FDS), a physics-based computer model and Smokeview, a scientific visualization tool.

* Information collected by NIST included measurements and documentation of the areas of the fire, the location, size and time of opening of windows and doors, and the fuels (i.e. furnishings, carpeting, wall covering, etc.) that were involved.

* The NIST team documented the fire damage in order to compare the predicted fire model results with the observed physical damage.

* Suite 1240 contained chairs, desks, paper, forms, brochures, boxes of envelopes, paper towels, Styrofoam cups, toner cartridges, computers and holiday decorations. The fuels that existed are very typical and could possibly be found in any office across the United States. The computer modeling conducted by NIST determined that the fire is not one that involved an unusual amount of fuel. Based on the estimated timeline of fire development, the fire spread from the storage room and throughout the open plan office space in approximately 10 to 12 minutes.

* The fire that occurred in Suite 1240 could be considered a "typical" fire in that, given similar fuels and conditions, the same fire could occur again unless an automatic fire sprinkler system is installed.