Portland State Cook County Administration Building Fire Incident Summary Report Produce a 3-5 page not including the title and the reference review of the

Portland State Cook County Administration Building Fire Incident Summary Report Produce a 3-5 page not including the title and the reference review of the Cook County Administration Building Fire incident. Review the report provided in the week two assignments folder and produce a three page summary of the Cook County Administration Building Fire IN YOUR OWN WORDS.Focus on life and fire safety lapses and what was recommended or done to address the issues noted.This paper should be at least three pages, double spaced. Cook County
Administration Building
Fire
Review
P R E P A R E D
B Y
JA ME S LEE WIT T A SS O CIATE S
In Memoriam
WHILE REVIEWING all of the factors related to the tragic ?re at the Cook County Administration Building, we were continuously reminded and will be forever mindful that six lives were lost.
We cannot fail them. We must learn from this tragedy and tirelessly peruse improvements in
high rise building safety in the City of Chicago, Cook County and the State of Illinois.
We therefore dedicate this report, presented to Governor Rod Blagojevich, to the six individuals
who perished on October 17, 2003:
Sara White Chapman
Janet Grant
Felice Lichaw
Maureen McDonald
John Slater III
Teresa Zajac
— James Lee Witt Associates
October 1, 2004
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PREPARED BY
James Lee Witt Associates, LLC
1201 F Street, NW, Suite 850
Washington, DC 20004
PREPARED FOR
Governor Rod R. Blagojovich, State of Illinios
PREPARED UNDER
Contract for Cook County Administrative Building Fire Review
This report documents work by author, JLWA and contracted with and/or requested by:
an agency of the State of Illinois. The author’s opinions ?ndings, conclusions, and/or
recommendations are provided solely for the use and bene?t of the requesting party. Any
warranties (expressed and/or implied), unless explicitly set forth herein, are speci?cally waived.
Any statements, allegations, and/or recommendations in this report should not be construed
as an Illinois State position, policy, or decision, unless so designated by other documentation.
The report was based on the most accurate data available to author at the time of publication,
and therefore is subject to change without notice. The use of trade names in this report does not
constitute an o?cial endorsement or approval of the use of such commercial products.
Copyright 2004 by James Lee Witt Associates, LLC.
All rights reserved. No portion of this report may be reproduced or transmitted in any form or by any means without
the written permission of James Lee Witt Associates, LLC.
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Acknowledgements
The James Lee Witt Fire Review Team would like to acknowledge and thank the following
agencies, o?ces and individuals for their invaluable assistance, guidance, information
and cooperation in the development of this Cook County Administration Building Fire
Review Report.
State of Illinois
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O?ce of the Governor
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O?ce of the State Fire Marshal
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O?ce of the Attorney General
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Department of Financial and Professional Regulation
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Department of Labor
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Department of Central Management Services
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Department of Emergency Management
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Division of Building Codes and Regulations
Capital Development Board
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Department of Management and Budget
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State Police
Cook County
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O?ce of the President
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O?ce of the States Attorney
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The Cook County Commission
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O?ce of the Public Guardian
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O?ce of the Medical Examiner
City of Chicago
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O?ce of the Mayor
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Department of Fire
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Department of Police
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O?ce of Emergency Management and Communications
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Department of Building and Code Enforcement
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Department of Law, Torts Division
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Argus Security Services
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69 West Washington Management Company, LLC
Cli?ord Law O?ces
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Hinshaw & Culbertson
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Building Owners and Managers Association of Chicago
We would also like to acknowledge our appreciation for those working in the Cook County
Administration Building at 69 West Washington St. who took the time to complete the
questionnaire associated with our human behavioral factors study. This study yielded signi?cant
information about this event and the level of knowledge regarding emergency procedures for
this building.
JAMES LEE WITT ASSOCIATES TEAM
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Mr. James Lee Witt, Chairman and CEO, JLWA
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Mr. Mark S. Ghilarducci — Review Team Leader
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Mr. Patrick J. Crawford — Deputy Team Leader and Logistics Section Chief
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Mr. Ed Comeau — Operations Section Chief and Technical Writer
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Mr. John Brenner, Sr. — Plans and Information Section Chief
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Mr. Pate Felts — Finance and Administration Section Chief
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Mr. Morrie Goodman — Public A?airs and Communications
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Ms. Kim Fuller — Public A?airs and Communications
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Ms. Dorothy Shapiro — Administrative Assistant, Document Control, Technical Specialist
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Mr. Alan Young — Investigator; Fire Department/Fire Ground Operations
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Mr. Ken Mallette — Investigator; Building Management Operations, Security Operations,
Occupant/Tenant Interviews.
Dr. Guylene Proulx — Human Behavior Specialist
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Mr. Dan Madrzykowski — Fire Modeling and Behavior Analysis
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Mr. Tad Bell — Writer-Editor
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Mr. Reginald Salvador — Writer-Editor
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Mr. Dallas Jones — Quality Assurance
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Ms. Laura Hagg — Quality Assurance
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Ms. Lennette Dease — Administrative Support
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Mrs. Kay Handrahan — Finance and Administration
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Mr. Barry Scanlon — Technical Assistance
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Ms. Cathy Madrzykowski — Graphic Designer
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Mr. Larry Shapiro — Photographer/Technical Documentation
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Bluecrane, Inc, Redondo Beach, California — Information Technology Support and
Document Control
FirePro, Inc, Massachusetts — Code and Emergency Plan Review
National Institute of Standards and Technology (NIST), Maryland — Fire Modeling and
Analysis
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National Research Council of Canada, Ottawa — Human Behavior Study
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Ignite Consulting, Sacramento, California — Report Graphics and Design
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Memorium
Acknowledgements
Chapter 1
SECTION 1: Executive Summary
Methodology
Incident Summary
Major Findings
Major Recommendations
Brief Overview and Edited Timeline
Index of Findings
Summary of Findings and Recommendations
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1
2
3
5
7
10
14
18
SECTION 2: Incident Overview
Actions of Security O?cers
Building Management Personnel Activities
Occupant Activities
Fire Department Operations
Fatalities and Injuries
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66
69
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104
SECTION 3: Reorts of Trapped/Missing Occupants
First 9-1-1 Call
Second 9-1-1 Call
Third 9-1-1 Call
First Radio Communication
Fourth 9-1-1 Call
Fifth 9-1-1 Call
Second Radio Communication
Third Radio Communication
Sixth 9-1-1 Call
Seventh 9-1-1 Call
Eight 9-1-1 Call
Fourth Radio Communication
115
115
116
119
124
124
125
126
127
128
128
129
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SECTION 4: Building Description
Egress
137
138
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Table of Contents
SECTION 4: Building Description Continued
Smoke-proof Tower
Communications
Vertical Openings
Fire Ala
Alarm
rm System
Fire Standpipe System
Fire Pumps
Fire Department Connection
nnection
Sprinkers
System Maintenance and Testing
Findings and Recommendations
Building Codes
Comparative Analysis
Code Matrix
Matrix
139
141
142
142
143
143
144
144
145
145
147
148
152
SECTION 5: Emergency Procedures and Planning
Municipal Code of Chicago Chapter
Chapter 13-78 High-rise
High-rise Buildings — Emergency
Emergency Procedure
69 West Washington Building / Tenant Fire Safety Plan
153
153
162
SECTION 6: Building Security Operations
Sta?ng
Standard Operating Procedures
173
173
173
SECTION 7: Chicago Fire Department Operations
Overview
Standard Operating Procedures (General Orders)
Personal Protective Equipment
179
179
179
195
Chapter 2
SECTION 8: Fire Modeling
Chapter 3
SECTION 9: Human Behavior
197
337
APPENDICES
1. 69 West Washington Building/Tenant Fire Safety Plan
2. Reserved
3. Chicago Fire Department 9-1-1 Audio Cassette Transcription, October 17, 2003
4. Chicago Fire Department General Order 91-002, January 6, 1991, Incident Command Management
System
5. Chicago Fire Department General Order 91-010, Primary, Secondary, and Final Search & Examination
6. Chicago Fire Department Main Fire Radio Audio Cassette Transcription, October 17, 2003
7. Chicago Municipal Code, Chapter 13-78, High Rise Buildings – Emergency Procedure, Substitute
Ordinance as amended on May 7, 2002.
8. Chicago Police Department 9-1-1 Audio Cassette Transcription, October 17, 2003
Table of Contents
APPENDICES Continued
9. Comparison Study for High Rise Operations
10. Cook County Administration Building Fire Timeline.
11. Fire Incident Comparative Analysis: Prudential High-Rise Fire, Boston Massachusetts, January 2, 1986
versus Cook County High-Rise Fire, Chicago Illinois, October 17, 2003
12. Reserved
13. Incident Command System – High Rise Structure Fire Operational System Description
14. Incident Command System Position Manual – Base Manager – High Rise Incident
15. Incident Command System Position Manual – Ground Support Unit Leader – High Rise Incident
16. Incident Command System Position Manual – Lobby Control Unit Leader – High Rise Incident
17. Incident Command System Position Manual – Medical Unit Leader – High Rise Incident
18. Incident Command System Position Manual – Safety O?cer – High Rise Incident
19. Incident Command System Position Manual – Staging Area Manager – High Rise Incident
20. Incident Command System Position Manual – Systems Control Unit Leader – High Rise Incident
21. NIST Sp-1021 Appendices
22. Rules and Regulations pursuant to Chapter 13-78 of the Municipal Code of Chicago “High Rise
Buildings – Emergency Procedure” and associated code provisions as amended July 2002
23. Key Members of the Cook County Administration Building Fire Review Team
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Chapter 1
Incident Review
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S E C T I O N 1 : Executive Summary
Executive Summary
Overview
ON FRIDAY, OCTOBER 17, 2003 at approximately 5:00 pm a ?re broke out on the 12th ?oor
of the Cook County Administration Building at
69 West Washington Street in Chicago, Illinois.
The ?re, which originated in a storage closet in the
southeast corner of the building, led to the deaths
of six people. On Thursday, October 23, 2003, Governor Blagojevich retained James Lee Witt Associates (JLWA), to conduct an independent review in
order to discover the facts associated with this ?re
that led to the deaths and injuries, to address lessons
learned and to make recommendations to improve
high-rise ?re safety throughout the state.
Since 1980, there have been minimal instances of
?re related fatalities nationwide in high-rise o?ce
buildings (excluding the terrorist incidents at the
World Trade Center in 1993 and 2001 and the 1995
Oklahoma City Bombing). Like other historic and
tragic ?res in Chicago such as the Great Chicago Fire
Exterior view of 69 West Washington
of 1871, the Iroquois Theater Fire in 1903, and the
Our Lady of Angels Fire of 1958, the Cook County
Administration Building Fire is not only tragic for those most directly connected to the
victims and survivors, but serves as a signi?cant incident from which we can learn a great deal.
The ?ndings and recommendations in this report will not only point the way to improved ?re
safety in Illinois, but will also add to the growing body of knowledge regarding emergency
procedures for high-rise buildings. The lessons learned from this incident will serve to catalyze
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COOK COUNT Y ADMINISTR ATION BUILDING FIRE REVIEW
positive change regarding how buildings are built and operated, how occupants and building
sta? are trained and the manner in which emergency personnel operate in Chicago, the State of
Illinois, and throughout the country.
Methodology
James Lee Witt Associates based its approach to this Cook County Administration Building
Fire Review, as it does for all crisis and consequence management reviews, on the four phases of
emergency management — Mitigation, Preparedness, Response, and Recovery.
Recovery Although each
phase of emergency management has speci?c characteristics, the relationship among them is
dynamic and interconnected. Mitigation includes actions taken to eliminate or reduce the impact
of a hazard or future disaster; examples include changes to building codes or building systems.
Preparedness includes all aspects of planning, preparing, training, and exercises. Response
includes actions taken to save lives and property during an emergency. This may include
search and rescue, ?re suppression, evacuation, and emergency sheltering. It may also include
behind-the-scenes actions that include the implementation of emergency plans, establishment of
incident command centers, or activation of an Emergency Operations Center (EOC). Recovery
involves actions taken to return a community to normal or near normal conditions. This
may touch on reconstruction of facilities, securing ?nancial aid or immediate assistance for
disaster victims, and review / critique of response activities.
Reviewing the events of this ?re through these four phases of emergency management has
allowed JLWA to:
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Identify the building systems, procedures, and personnel that were in place at the time of
the ?re;
Document the actual performance of these systems, procedures, and personnel during
the ?re;
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 ?re, including applicable building and emergency management code and standards, for
attaining the desired results; 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.
This review focused on the contributing factors that led to the loss of life and the damage
that occurred. No e?ort was made to determine the area of origin nor the cause of the
?re. Information regarding the area of origin used in this review was based on eyewitness
statements and information provided from o?cial reports.
In support of this approach, data was collected from multiple sources that included:
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Interviews with close to 70 individuals;
S E C T I O N 1 : Executive Summary
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Survey responses of 551 building occupants as part of a Human Behavior Factors Study;
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Hearings related to the incident;
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Extensive review of operational procedures and research including a comparative
analyses of other major city ?re departments and of similar incidents, building history of
renovations / improvements, and a codes review; and,
Meetings with the: Chicago Building Owners & Manager’s Association; City of
Chicago / Chicago Fire Department (CFD); Cook County Commission; Cook County
Public Guardian; Cook County State’s Attorney; Illinois State Attorney General’s O?ce;
Illinois Association of Fire Chiefs; Illinois Department of Labor; Illinois Department of
Professional Regulation; Illinois Emergency Management Agency; and, The Illinois State Fire
Marshal’s O?ce; and the, Northern Illinois Fire Sprinkler Advisory Board.
This collection of data includes, among other things: audio tapes, detailed timeline, ?oor plans,
graphics, interview transcripts, photographs, reference materials, schematics and videotapes. This
data was the foundation for a detailed analysis of:
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Building management operations;
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Building performance;
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Building codes;
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Fire protection systems;
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Fire behavior and spread (including ?re behavior computer modeling);
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?re department operations and ?re ground command, coordination and procedures; and,
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Human behavior factors.
Incident Summary
The following summary is intended to highlight the major events of Friday, October 17, 2003.
A detailed narrative and timeline of the event can be found in the body of this report.
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At approximately 5:00 pm, a ?re broke out in a storage closet in the o?ce of the Secretary
of State’s Business Services Division (Suite 1240), on the 12th ?oor of the Cook County
Administration Building.
Security o?cers and building management personnel responded to the alarm, 9-1-1 was
noti?ed, and evacuation of the building commenced.
Building occupants heard no audible ?re alarm signal (such as a horn), but they were
instructed by security personnel through the emergency voice / alarm communication
(EVAC) system to evacuate by way of the stairways. occupants evacuated either through
the stairways as they were instructed or via the elevators despite the public address system
instructions.
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COOK COUNT Y ADMINISTR ATION BUILDING FIRE REVIEW
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Those that evacuated via the northwest stairway and the elevators were able to safely exit the
building. Those that evacuated early in the event via the southeast stairway, or evacuated
from ?oors below the ?re ?oor, also were able to safely exit.
A group of occupants evacuating via the southeast stairway were unable to pass the ?re ?oor
due to ?re?ghting operations. occupants reported that when they reached the 12th ?oor, they
were instructed by a ?re?ghter to go back up the stairway. In compliance with the ?re?ghter’s
instruction, these occupants reversed course. They attempted to re-enter ?oors above the
12th ?oor, but the stairway doors were locked.
However, one occupant discovered that the door to the 27th ?oor had not latched
closed allowing a number of occupants to escape from the worsening conditions in the
southeast stairway.
Other occupants still in the stairway above the 12th ?oor were unable to reach the
27th ?oor and subsequently were overcome by the smoke and lost consciousness between the
16th and 22nd ?oors.
The front desk security o?cer placed a call to 9-1-1 at 5:02 pm. The ?rst units of the Chicago
Fire Department arrived on the scene at 5:06 pm with the initial ?re attack from the southeast
stairway beginning at approximately 5:16 pm.
The southeast stairway is located adjacent to the smoke ejection tower system located in a
vestibule between the tenant space and the stairway. Once the stairway and smoke tower
doors were breached by the ?re department, heat and smoke escaped into the stairway
thereby creating a toxic environment within the same area that the occupants were
attempting to evacuate.
The initial interior ?re attack — from both the southeast and northwest stairways — was
unsuccessful because intense heat and smoke prevented the ?re?ghters from entering the
?oor to attack the seat of the ?re. The interior attack team was withdrawn and an exterior
?re attack was initiated using tower ladders at approximately 5:52 pm, which concluded at
approximately 6:06 pm.
Throughout the response operations, numerous calls for help, and noti?cations of
missing persons were made to ?re department and police department personnel via
9-1-1 operators and through on-scene, face-to-face encounters. Due to a multiplicity of
command and communication failures, thorough search e?orts were not immediately
initiated and many calls regarding people who were missing, unaccounted-for, or trapped in
the southeast stairway were not acted on in a timely fashion nor were reports received by the
incident commander.
Of the thirteen occupants who were not able to escape from the southeast stairway, six
perished. They, along with 7 others who ultimately survived, were not discovered in the
southeast stairway until approximately 90 minutes after the initial alarm.
S E C T I O N 1 : Executive Summary
Major Findings
Our review process found more than 80 examples of failures, inconsistencies, ine?ectiveness
and / or non-compliance on the part of several agencies, organizations and individuals, several of
which directly c…
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