The actual fire was contained to a small area, and quickly controlled by the first
arriving engine company, however, the unimpeded spread of heavy smoke compromised
two floors of this large building. Only a few moments after the first recognition of a
problem, the hallways on both the second and third floors were filling with thick black
smoke, forcing residents back into their rooms. A functioning fire detection and alarm
system equipped with the code recommended number of smoke detectors and alerting
devices would have provided earlier warning of the developing fire. An earlier warning
of the fire would have allowed time for the residents to evacuate before dangerous levels
of smoke accumulated in the hallways.
There was no record of inspection or testing having been performed on the fire
alarm system. The staff was unable to identify or locate the fire alarm control panel. The
inclusion of the illegal on/off switch effectively disabled the fire alarm system but fire
department investigators were not able to determine if the system was operable.
One fortunate characteristic of this fire scenario compared with other Board and
Care fires was the general health and alertness of the resident population. The residents
were healthy adults, without serious medical, mobility or mental awareness limitations,
and capable of self-evacuation. When confronted with smoke filled hallways, most of
the residents had the physical capability to break out the shuttered windows and climb
unassisted down makeshift escapes and fire department ladders.
The lack of smoke separations in the corridors contributed to the rapid spread of
smoke throughout the second and third floors. Stairway doors were propped open and
provided vertical routes for the smoke to spread. As smoke filled two of the three stairways,
those emergency exits were effectively nullified, forcing residents to depend on
egress through the shuttered windows for escape.
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