Fire Disasters: What Have We Learned?
By Francis L. Brannigan, SPFE and Harry R. Carter, Ph.D.

Every once in awhile, we need to pause and reflect on who we are and what we stand for. As the American Fire Service pauses to celebrate an illustrious history dating back 350 years, let us reflect for a moment on some of the great lessons learned from fire. Some of our greatest progress has occurred just after someone's town was devastated or many lives were lost.

This is not a recent phenomenon. The earliest recorded fire prevention efforts come from ancient Rome. It was surely noted after a major fire that something should have been done to prevent the disaster or at least, have somebody to protect the citizens. This may also be the earliest recorded uttering of the phrase, "How long has this thing been going on?"

Rome continued to tinker with its fire forces. When the slaves who were serving as the firefighting force became unruly, the response was to form the equivalent of what we now term a fire department. Once again, this was a reaction to a problem.

The pages of history are strewn with stories of great cities that were destroyed by fire:

  • London - 798, 982, 1212, 1666
  • Venice - 1106, 1577
  • Boston - 1631, 1653, 1679
  • Moscow - 1752
  • Rome - 1764
  • Chicago - 1871
  • Baltimore - 1904
  • San Francisco - 1906

Something important happened after each of the fires listed laid waste to a city: improvements ensued. The purpose of this article is to show that progress in the American Fire Service has been based upon a series of historic catastrophes. In the wake of each succeeding disaster, improvements were made.

Chicago has been the scene of many historic fires. The city was rebuilt following the 1871 conflagration. Improvements were made in construction styles and methods. By 1903, the Great Fire had become a fading memory to all, as the city was swept by succeeding waves of immigrants from the Old World. The Iroquois Theater was one of the great entertainment venues in this thriving industrial center. It was one of the big stops on the vaudeville circuit, drawing the great performers of its day.

So it was on Dec. 30, 1903, that the stage was set for another epic lesson in fire safety: one which would come at a great human cost.

The comedian Eddie Foy was starring in a matinee performance of the musical comedy, "Mr. Bluebeard." A standing-room-only audience estimated at 2,000 people crowded the theater. At some point during the performance, a spotlight overheated and burst into fire way up in the stagehand's overhead. The fire that ensued spread quickly through the flammable backstage rigging. Workers attempted to beat the fire out with sticks in a vain attempt to extinguish the blaze. A piece of flaming cloth fell to the stage.

In a vain attempt to calm the crowd, Foy had the band continue playing. Suddenly, a woman cried out and the audience made a mad dash for the exits. As the firemen moved in to extinguish the flame, they were met with a tangle of human bodies, all entwined and badly burned. The cause of death for many came from the terrible smoke and flames. Most, however, had been trampled and crushed in the rush to leave the hall. Authorities considered it a miracle that only 602 people succumbed to the fire.

The Iroquois Theater was built of fire-resistive materials. Experts agree that it was well-built, but they also point out that many important fire protection features were missing or inoperable at the time of the fire. These include:

  • Blocked asbestos curtains.
  • Installed ventilators that were not in operation.
  • Exits not properly marked.
  • Exits blocked with draperies, wood and glass doors.
  • No installed alarm system.
  • No fire protection devices such as extinguishers and standpipes.
  • No automatic sprinklers in the stage area, even though it was a municipal requirement.

The investigation that followed led to a variety of fire safety improvements, all of which addressed the problems listed above. In fact, many cities still provide a uniformed firefighter or group of firefighters for major entertainment events. The fire service has long viewed old-style factory buildings as a serious fire hazard. Many of the worst fires during the late 1800s and early 1900s happened in factory buildings. Some are more famous than others.

A 1910 fire in a Newark, NJ, clothing factory killed 24 workers, and there were countless others. All had code-related problems at their heart. It is the 1911 fire at the Triangle Shirtwaist Company in New York City, however, that marked a turning point in how fire codes addressed this type of occupancy.

Chief Edward Croker of the New York Fire Department had long sought improvements in the building codes and factory laws, because of such early fires as the Parker Building. Three firemen were killed in a massive collapse within this 20-story fireproof building. His pleas fell on deaf ears and the resulting catastrophe, which killed scores of innocent young immigrants, will long live in the annals of firefighting lore.

The Triangle Shirtwaist Company was located at 23 Wash-ington Place in lower Manhattan. The work force was primarily made up of young, female immigrants, who labored under classic "sweatshop" conditions. More than 500 workers were jammed into the eighth and ninth floors of the 10-story building, which was supposedly built from fire-resistive materials.

It was about 4:45 P.M. on Saturday, March 25, 1911. A fire started in a rag bin on the eighth floor. It spread rapidly through the mix of combustible cloth, and soon cutting tables and other fixtures were ablaze. One group of workers grabbed the standpipe hoseline and attempted to extinguish the fire. They quickly found that the hose was rotted and the valves frozen shut. Word of the fire soon began to pass through the workers jammed into the loft building. Workers surged toward the exits with which they were familiar. They were met with a wall of fire racing up the stairs. Others moved toward another exit, but were blocked by a locked door. When they were finally able to force it, they found that it opened inward.

By this time, there were so many people pushing toward the door that the door was jammed shut; people began piling up at this point. Very few workers knew that the freight elevator was still working. A number of young girls faced with the prospect of a horrible death by fire chose to leap to their deaths from windows on the eight and ninth floors. Others managed to make it to the roof, and a small number were able to make their way over ladders to the New York University Law School next door.

Bells in New York fire stations began to toll the alarm. But the problems were many. The streets were littered with bodies, making apparatus placement difficult. Ladders could not reach the fire or the roof.

Once lines were in position, the fire was quickly extinguished. The horrible toll was 146 people who leaped to their deaths or were burned or crushed to death in the panic. The public was outraged. This fire had proved Croker correct. More was needed than just fire suppression.

After an intense investigation, a number of changes were instituted. A new bureau of fire prevention was created in the fire department. Labor laws were passed outlawing many of the practices which led to the fire. And in the wake of this tragedy, work began on the codes which eventually led to what we know today as the National Fire Protection Association's Life Safety Code. The ironic part of this story is that the building remained in use for decades after this tragedy.

As we all know, change takes time. Less than a year after the Triangle fire, another major blaze struck New York, taking the lives of six men. The Equitable Building was a giant 10-story structure composed of five individual buildings linked together, which covered the better part of a city block in the financial district. Sad to say, the fire began in a wastebasket and spread throughout the building. It seems that the employee who found it was frightened, and chose to run away. The building was literally riddled with dumbwaiter shafts, elevators and multiple unstopped entrances and passages.

As the fire grew in intensity, it made its way upward through these shafts. Fire personnel quickly moved lines down into the basement and pressed home an aggressive attack, not aware of the fire burning above their heads. Soon after discovering the fire above them, a second alarm was transmitted. As the fire escalated, the number of alarms increased.

The weather could not have been worse, with heavy gale winds blowing freezing, wind-driven spray back onto the firefighters, who were pouring tons of water onto the blaze. Firefighters attempting to rescue the building's occupants on the roof just missed being killed when the roof the men were standing on collapsed, hurling them to their deaths.

The debris from this collapse also trapped three men in the basement. Unbeknownst to the fire department, these men had made their way into the basement of the building to rescue millions of dollars in negotiable bonds which, if they had burned, would have created financial chaos for their owners. Only through the heroism of Seneca Larke Jr., a full-blooded Native American, were these men saved. While laying on his belly over the grate where the men were trapped, under torrents of freezing water and falling rubble, he worked with a hacksaw to cut them free.

The toll from this disaster included the three civilian workers, one of the basement occupants and two fire department members. One of the major lessons learned from this fire was that the latest method of fireproofing structural members had been proven useless. The lessons from the earlier Parker Building fire had been ignored. In that era, engineers and architects had specified cast iron as the supporting members for a number of large buildings. To protect them from the weakening effects of fire, they had been encased in hollow tie blocks. These just did not work. In the wake of these fires, improved fireproofing of structural members was developed.

Schools have never been immune to fire tragedy. Three of great historical interest are:

  • Lakeview Grammar School in Collinwood, OH (176 dead).
  • The New London Consolidated School in Texas (294 dead).
  • Our Lady of the Angels School in Chicago (95 dead).

These fires occurred for different reasons. In Ohio, it was a cellar fire of unknown origin that roared up the main stairway of the school, trapping the existing students and killing them. They only knew one way out. The fire department was not trained or equipped to fight a fire in the school.

The victims of the Texas fire were killed in a massive gas explosion. Later investigation indicated that questionable construction, installation and maintenance processes involving the building's heating system appeared to be the culprit in this disaster.

The fatal fire in the Our Lady of the Angels School began as a small trash fire in the basement. This fire then raced up the main stairway and trapped students in the corridor and in their rooms on the third floor. As a sad footnote, many students were found seated at their desks, heads down, as if praying.

Each of these fires led to improvements which benefit schoolchildren all over North America:

  • Exit drills are mandatory;
  • Construction practices are according to code;
  • More school inspections in most places;
  • Greater emphasis on installed fire protection, alarms, and first-aid firefighting equipment.

It's a shame that so many children have had to pay the penalty for the sins of adults who did not know or care about fire safety issues. There are also a number of classic fires in places of public assembly that have led to upgrades in fire and life safety. Some of them are:

  • 1903 - Iroquois Theater, described above (602 dead).
  • 1919 - Dance Hall, Via Platt, LA (25 dead).
  • 1929 - The Glen Motion Picture Theater in Paisley, Scot-land (70 dead).
  • 1940 - Rhythm Club, Natchez, MS (198 dead). o 1942 - The Cocoanut Grove, Boston (491 dead).
  • 1977 - Beverly Hills Supper Club, Southgate, KY (164 dead).
  • 1990 - Happy Land Social Club, Bronx, NY (87 dead).

In each one of these cases, people died in great numbers because fire safety issues were either ignored or never fully addressed.

The Cocoanut Grove was a one-story nightclub that had been built during the Prohibi-tion era. It was a popular site and was constantly jammed with customers. The night of Nov. 28, 1942, was no different. The official occupancy was supposed to be 600, but estimates from that fateful night ranged as high as 1,000. A small fire started in the basement lounge and quickly raced through the area. Most people knew only the main entrance which they always used. As the crowd surged toward the exit, it quickly became jammed. Fire department sources listed nearly 200 people as being found in this area alone. All told, 491 people were killed by fire, smoke, heat or the effects of being trampled.

Members of the Boston Fire Department were on the scene quickly, as a full alarm response had been made to a nearby area for a box alarm that turned out to be a car fire. The fire quickly escalated to five alarms, but the damage had been done. What was learned from this fire?

Combustible materials must not be used for decorations or in building components.

  • Occupancy limit requirements should be strictly enforced.
  • Exits need to be kept clear of obstructions and plainly marked.
  • Public assembly buildings must have two separate means of egress, remote from each other.
  • Exit doors should swing in the direction of egress traffic flow.

The Beverly Hills Supper Club fire more than three decades later exposed us to a fire the likes of which we thought was a thing of the past. This club was a major regional entertainment center, with many of the country's top entertainers appearing in its lounges. The building was originally erected in 1937. A 1970 fire occurred prior to the building being remodeled. Further expansion occurred in 1974, when the large Cabaret Room was created. It should be pointed out that automatic sprinkler, alarm and kitchen hood fire protection was not installed during any of the construction phases.

Fire struck the club on May 28, 1977. The facility was crowded with patrons who hoped to attend one of the John Davidson shows, which were scheduled for 8:30 and 11:30 P.M. At about 8:45 P.M., employees discovered a fire in the Zebra Room. There appears to have been about a 15-minute delay in notifying the fire department. During this time, employees attempted to extinguish the fire themselves.

Many people stated that the first time they noted a problem was when they noticed a large number of people suddenly leaving the building. There was no building fire safety plan, so word of the fire was spread from person to person. The evacuation appeared to be calm until thick, dark clouds of choking smoke engulfed the exit access areas. One hundred sixty-four people were killed in a tragedy that never should have occurred. The lessons learned in 1942 were not remembered.

  • The list of causes included:
  • No installed fire protection.
  • No fire safety plan.
  • Blocked exits.
  • Crowd in excess of the occupancy load.
  • Inadequate exit capacity.
  • Combustible wall coverings.

You can add to this list the effects of toxic smoke generated by burning electrical wiring.

In a review of this incident, Francis L. Brannigan came to the conclusion that the fumes which killed so many of the patrons were not attributable to the electrical wiring. His review of the incident, and all documentation, led him to posit that the fumes came from a combustible metal deck roof over the Cabaret Room. It was his finding that heat could have moved up through wiring openings in the walls of the building, which would lead heat up to the decking.

It was his opinion that sufficient temperatures could have occurred that would raise the combustible roof materials to the point at which they would burn. He stated that even if sprinklers had been installed, the fire would have continued raging above the sprinklers, with the resultant generation of toxic fumes, much as had occurred at the giant warehouse fire which occurred during 1985 at Tinker Air Force Base in Oklahoma. He muses that this could have led to the first large loss-of-life fire in a sprinklered building.

We would venture to say that many of these hard-earned lessons are still being violated. The Happy Land Social Club fire in 1990 had all of the same issues of crowding, inadequate exit capacity and a lack of installed fire protection. What that situation also had was a human being bent on revenge who killed scores of people. Do not think for one moment that our serious fires have only been in buildings. On June 15, 1904, marine disaster struck New York City. At 9 A.M., the excursion steamer General Slocum moved away from the 13th Street Pier on the East River jammed with 1,400 men, women and children. It carried most of the Sunday school members from St. Mark's Lutheran Church in Manhattan. They were on their way to a summer picnic.

Not long after they began their journey up the East River, a fire broke out at the front of the ship. Crew members deployed a hoseline to attack the fire, but the hose ruptured as they struggled to turn on the water. As passengers donned life preservers, they quickly found them unusable. Lifeboats were lowered incorrectly, dumping many of the passengers into the water. There was a stiff breeze blowing but that did not stop the ship's captain from turning into the wind in a vain attempt to reach nearby land. This caused the fire to move quickly through the ship. One thousand twenty-one people were killed on this sad day; whole families were wiped out. After an extensive investigation, a number of substantive changes were made:

  • Evacuation drills for crew and passengers.
  • Firefighting training for crew members.
  • Sufficient amounts of the proper firefighting equipment.
  • Periodic inspections to insure equipment condition.
  • Sufficient life preservers and lifeboats.

In the wake of the General Slocum disaster, hundreds of ships were inspected for safety-related concerns. Most had the same violations.

Thirty years later, fire on the high seas was once again in the news. The Morro Castle was a popular cruise ship plying the New York-to-Havana tourist run. Unlike the General Slocum, the Morro Castle was protected by a fire detection system. On Sept. 3, 1934, while returning to New York, a fire was detected in a vacant writing-room locker. The ship was equipped with fire doors, and had the door to this area been closed the fire probably would have been held to the room where it started.

While the ship had all of the required fire protection devices, later investigations would show that the crew was not well-trained in their use. There were also problems in boarding and lowering the lifeboats. By the time the burned-out hulk of the Morro Castle floated ashore in Asbury Park, NJ, 137 people had lost their lives. Once again, the lessons of the past had been lost on a new generation. Fire knows no bounds in its drive to kill and maim the innocent. A hot, humid July day greeted the 7,000 people who had chosen to attend the special matinee program of the Ringling Brothers-Barnum & Bailey Circus in Hartford, CT. The extra session had been scheduled owing to the late arrival of the circus a day earlier.

The circus owned a large number of portable extinguishers and water buckets, but they had not been placed around the area on July 6, 1944. There was one strong negative that went undetected by local fire authorities. While the large main tent had been well cared for, it had been waterproofed in a very dangerous manner. It had been coated with a covering of paraffin that had been thinned by using gasoline. Thus the whole circus was held under a highly flammable covering. As the second act was about to begin, a small spot of flame was observed by an on-duty Hartford policeman. Slowly the fire spread up the tent, gaining speed as it heated the fuel which lay just ahead. At about the same time, the circus band leader saw the fire and quickly had the band switch to playing the famous Sousa march, The Stars and Stripes Forever. This is the traditional circus alarm call. As the fire grew in intensity, the tent area became a scene of shear terror and pandemonium. People were pushing toward the main exit, animals were running loose, and burning tent was falling all around.

When the flames were finally extinguished, 168 people lay dead; more than half of these children. In the wake of this tragic fire, a number of changes were made to improve circus and outdoor event fire safety:

  • The National Fire Protection Association (NFPA) formed a technical committee to deal with problems of this nature. The result of this effort led to the development of NFPA Standard 102, Grandstands, Folding and Telescopic Seating, Tents and Membrane Structures.
  • Tent tops and tarps must be made from fire-resistive materials.
  • Tents are relegated to a temporary role.
  • Tents must be properly spaced so that they are not too close to one another.
  • Life Safety Code compliance is mandated.

Once again, tragedy led to improvements in fire and life safety issues.

In this article we have attempted to demonstrate some of the critical fire safety lessons that have been learned over the past three and a half centuries. The one thing which struck us as we worked on this article is that there is nothing really new. We must re-learn the same lessons every generation or so. If the fire service is to become a true element of the future, we must eliminate the hazards which we have covered in this article. It will take time, talent, and diligence. But the rewards will be well worth the effort.

Or we can abide by the classic words of the late author George Santayana. He once noted that people who forget the lessons of the past are condemned to repeat them. It seems as though he had the fire service in mind when he made this statement.

"Each of us can make a difference. Learn from the past and prepare for the future."

About the Authors: Francis L. Brannigan, a Firehouse¨ contributing editor, was a fireground commander from 1942 to 1949. Since 1966, he has concentrated on the hazards of building to firefighters. His 667-page Building Construction For The Fire Service, third edition, is available from NFPA, (800) 344-3555. Harry R. Carter, Ph.D., a Firehouse¨ contributing editor, is an acting deputy chief of the Newark, NJ, Fire Department and commander of the Training Division. He also is past chief of the Adelphia, NJ, Fire Company.