1. Automatic fire sprinkler systems will not control all fires involving preheated
combustible liquids nor will they prevent the rapid collapse of lightweight
unprotected construction exposed to rapidly developing fires.
Plain water automatic sprinkler systems are not always effective on fires that
involve spills of combustible liquids, especially those that are heated above their flashpoint.
The quantity of liquid spilled and the type of surface the liquid falls onto often
influence the success or failure of the fire to be extinguished. Incidents that continue to
discharge combustible liquid, especially heated ones, reduce the likelihood of success of
full fire extinguishment. Heated liquids spilled onto cooler floor surfaces, such as concrete
on ground, cools the liquid, reducing the hazard. Spills onto porous surfaces, such
as cardboard and carpet material, allow the liquid to “wick”, improving vaporization and
increasing the hazard. Combustible liquids heated above 212oF present additional challenges
because of their ability to quickly turn water into steam and to rapidly destroy fire
fighting foams covering their surface. Combustible liquids also have the ability to float
on the water’s surface and this can cause the fire to spread to adjacent combustibles.
In this incident, the fire reportedly also involved a propane fueled lift truck while
employees were using small hose streams. This likely resulted in the release of propane
gas which intensified the fire even though no rupture of the gas cylinder was reported. It
is doubtful that the automatic sprinkler discharge was able to absorb much of the heat
being released by the burning oil and propane gas.
The building’s lightweight, unprotected steel roof construction was unable to
resist the fire and began to fail. The collapse of the roof structure most likely caused
the failure of large supply mains for two automatic sprinkler systems which were
located in the area of origin.
2. Process controls must include procedures to effectively manage expected equipment
failures. In addition, employees must receive training and practice in the
implementation of these procedures.
Limiting the amount of combustible heat transfer fluid that can be spilled is critical
to controlling this type of incident. The operating conditions of the thermal transfer
system are such that the fluid was operating above its flashpoint and would be easily
ignited. Milliken reported that the hot oil subloop circulation had been stopped but it was
unknown if the main loop’s circulation was still running. In addition, stopping the circulation
alone may be insufficient to control the oil release and other means to reduce the
amount of leaking oil, such as emergency drain down, may be needed. Fire officials need
to review the process controls with plant officials to identify potential liquid (or gas) fuel
sources and understand how to stop accidental releases. Preplans must incorporate the
location and identification of these controls and emergency features such as drains.
3. When automatic fire alarms are placed out-of-service, the plant should institute
pre-arranged procedures to assure that real emergencies will be promptly
reported to the fire department.
In this incident, considerable delay occurred in the response of the LaGrange
Fire Department because of the fire alarm system’s status at the Troup County 911
Center. Pre-arranged procedures for reporting real alarms should have been established
and the reason for taking the fire alarm out-of-service understood and monitored by a
responsible person at the plant. For example, if the alarm system was removed from service
to work on automatic sprinkler riser 6, then an alarm from riser 10 should result in an immediate emergency response because this alarm would be unexpected and likely
be an indication of a real emergency. Indications are that such procedures either did not
exist or were not followed in this incident.
4. Maintenance and repair of fire doors must be performed on a regular basis and
damage that affects the door’s operation should be promptly corrected.
Most of the fire doors protecting large openings in the several fire separation
walls within this complex failed to close either automatically or manually. The overhead
rolling steel type fire door utilizes a “U” shaped channel on each end of the
interlocked slots that holds the door to the wall and guide it to the floor. These channels
can be pinched closed such that the door will not close or they can become misaligned
enough that the door will hang-up as it falls toward the floor. Milliken
reported performing weekly checks of fire protection systems and the fire door operational
deficiencies were brought to their attention several weeks before the fire.
Apparently repairs had not been completed.
5. Pre-incident planning must include the preparation of fire equipment and staffing
response needs for each of several alarm levels. In addition, the mutual aid fire
departments involved should conduct regularly scheduled drills to become familiar
with multiple department operations.
In operations of this magnitude, it is imperative that the incident commander
have prearranged equipment and staffing resources available and understand the
response characteristics of these resources. It is difficult to develop and implement an
effective tactical plan without the knowledge of available resources. The capabilities of
these resources should be identified through drills so they may be incorporated into the
incident commander’s tactical plan. Good preplans should include alternate tactics that
might be needed if a built in fire protection feature is not in-service or has failed. In this
fire, the automatic sprinkler systems failed early, yet support of the fire separation walls
did not appear well planned.
6. Regularly scheduled fire prevention inspections and review of plans for construction
and major remodeling should be conducted and the information incorporated
into the pre-incident plan.
One purpose of fire prevention inspections is to check the operational condition of
active fire protection systems and passive features such as fire doors. In addition, changes to plant equipment, operations, and hazards can be identified and incorporated into preincident
planning activities. In this case, it had been approximately a year since an inspection
had been made. The Milliken facility was both large and complex in terms of physical
characteristics and it contained significant production and process hazards. In addition, the
carpet storage presented serious fire suppression challenges to both the automatic fire
sprinkler systems and fire department operations. A fire nearly anywhere in the complex
would have represented a significant challenge to even a well prepared fire department.
7. Through fire company in-service visits and pre-incident planning, the fire
department leadership and plant officials should become familiar with each
other’s resources, operating procedures and capabilities. This includes the
plant’s active and passive fire protection features (automatic sprinklers and
fire separations for example).
Pre-incident planning, especially in a complex manufacturing facility, involves
not only the typical physical objects such as sprinkler systems boundaries, control
valve locations, hydrants, fire pumps, alarm systems, and fire doors, but also for
senior officers and chief officers to become familiar with plant managers of key
departments such as engineering, maintenance, and production. Respect and candor on
both sides is important to successful outcomes during emergencies. The time for the
fire department and the property owner to become acquainted with each other is not as
the facility is burning to the ground.
For example, there was apparently confusion regarding the contents and hazards
represented by the vertical and horizontal storage vessels located near the northeast corner
and along the east side. Keeping contents and hazards information up-to-date may
be difficult for the fire department but not for the plant. When both parties are familiar
with each other, rapid and candid information exchange can occur that can be relied
upon by all involved. Such information might have been proprietary and the plant reluctant
to disseminate it before an emergency but having it during the incident from a reliable
source can often be sufficient for fire department needs. Furthermore, it is difficult
for fire department officers to be intimately familiar with each plant. Therefore, a prearranged
plant contact is a tremendous resource during an emergency.
8. Failed and collapsed automatic sprinkler systems need to be promptly isolated
from water supplies in order to maintain water to viable automatic sprinkler systems
and fire ground operations.
Fire protection water supplies for a large complex are not usually capable of supporting
multiple sprinkler system operations. The large number of broken and damaged
risers diverted water from viable systems and from fire department suppression operations.
Outside post-indicator-valves (PIV) were available to shut-off individual systems or to isolate
or sectionalize parts of the underground fire main loop. A plan showing each sprinkler
system boundary and the control valve was posted in the plant guard house in Sector A.
This information in combination with the PIV’s could have been used to effectively control
important water supplies. This is also another example of the importance of pre-incident
planning and developing alternative tactical plans for fire protection system failures.
9. The diesel engine driven fire pumps failed early in the fire most likely due to the
loss of cooling water circulation through each unit’s heat exchanger.
Due to the number of collapsed and broken automatic sprinkler systems, the
amount of water leaving each fire pump was likely beyond the usual operating range.
This placed additional stress on the diesel engine and it is believed that an insufficient
amount of cooling water entered the heat exchanger, resulting in the diesel engine overheating.
During an emergency, the plant should dispatch knowledgeable personnel to
attend to fire pumps and the fire department should also consider sending firefighters
to act as liaisons. The loss of the pumps reduced the complex’s fire protection water
supply by over 50 percent.
10. Large conveyor openings protected by deluge automatic sprinklers can lose protection
when the water supply fails leaving an easy path for fire spread.
The protection of openings in fire separation walls by deluge or automatic sprinklers
should be noted during pre-incident planning. Failure of piping or water supplies
leaves these openings unprotected by usual means. Fire department tactics should include
sending a crew with hose line to cover these openings in order to prevent fire spread. In
addition, it would be appropriate to check all fire separation wall openings to be certain
doors have closed and combustible stock nearby have not ignited. All types of fire doors
allow the transmission of considerable heat and smoke and even small amounts of flame
are permitted around door edges. Nearby combustible stock or construction can be
ignited by the heat and flames. Routine monitoring of all openings and penetrations in the
separation walls must be part of the incident commander’s tactical plan. Even when the
doors, deluge sprinklers or fire stopping performs within Standards, these are weak points
through which fire can spread. Blank fire separation walls should also be monitored for
fire penetration and even standby hose lines advanced to key locations.
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