| Issues | Comments |
| Fire Building | Three story masonry building used as residential
treatment center.
|
| Fatalities | Two residents died from smoke inhalation as they
tried to exit smoke filled corridors. |
| Origin and Cause | Arson fire in an open waiting area adjacent to the
second floor corridor. Combustible furnishings in the
area of origin generated heavy smoke. |
| Fire Alarm System | The fire alarm system had been shut off. |
| Smoke Detectors | Smoke detectors had not been installed throughout
the building. |
| Smoke Travel | Smoke spread quickly throughout the building
through long undivided corridors, open stairway
doors and partially open sleeping room doors. |
| Exterior Window Access | Heavy smoke in the corridors prevented residents
from leaving their rooms. Hurricane shutters made it
difficult for fire department personnel to evacuate
residents with ladders. |
| Emergency Planning | Emergency planning or fire drills had not been
conducted. Residents varied in their familiarity with
building exits. |
| Triage response | Emergency personnel were overwhelmed by large
numbers of victims. |
Next » The Building and Its Operations
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