1. 1 Unit 9 Human Behavior Study Cook County Administration Building Fire October 17, 2003 – Chicago, IL

2. 2 INTRODUCTION Studying occupant behavior during a fire incident is one of the best ways to learn about the impact of human factors on the circumstances and outcome of a fire. The victims of a fire are prime witnesses; they can easily describe their perception of the event, their interpretation and their reactions during the fire. 8

3. 3 STUDY OBJECTIVES The first objective was to document the occupants’ behavior and evacuation on the day of the fire. Occupants who were in the building at the time of the fire can provide information on the cues they perceived, their responses, evacuation movement and their estimated time at key moments. 8

4. 4 STUDY OBJECTIVES The second objective of this human behavior study was to obtain information from all building occupants on their training and fire safety experience prior to the fire. Information was gathered on past drills and exposure to the fire alarm system and Public Address (P.A.) system. 8

5. 5 STUDY OBJECTIVES Particularly interesting were the occupant’s perceptions of the building’s evacuation procedure, and how these perceptions differed from the official evacuation plan. 8

6. 6 STUDY OBJECTIVES On Friday, October 17, 2003 at approximately 5 p.m. One of the female employees smelled smoke and mentioned it to her co-workers; according to her watch, it was 4:57 p.m. 8

7. 7 THE FIRE INCIDENT She moved around to investigate and discovered a yellow-orange flame on the top shelf of a bookcase located inside a storage room that always had its door open.

8. 8 THE FIRE INCIDENT This employee told others “there is a fire in there”. She gathered her personal belongings and left by the exit door next to the storage room. 9 8

9. 9 THE FIRE INCIDENT She then took the elevator down to the first floor lobby with 5 other people from other offices on the 12th Floor who were leaving for the day. Meanwhile, other employees in Suite 1240 had a quick look in the storage room.Without entering the storage room, they could see flames at the ceiling and smoke. 9

10. 10 THE FIRE INCIDENT One employee called the building emergency number to report the fire. The 3 remaining employees secured files and money in a safe, took their personal belongings and left the office by the main door with the client. 9

11. 11 THE FIRE INCIDENT By that time, the smoke was down to head-level in the office. They took the elevator to the lobby with another employee from another office on the 12th Floor. 9

12. 12 THE FIRE INCIDENT At the same time, in the first floor lobby, at the Security Desk, one of the security officers heard an alarm from the Fire Alarm Control Panel; he opened the panel at 5:00:19 p.m. Using a portable radio he contacted the building engineer and advised him of a 5-star alarm and its location. 9

13. 13 THE FIRE INCIDENT A moment later, the building engineer arrived by the stairwell on the 12th Floor to investigate the alarm. Using his key he unlocked the main door of Suite 1240. Upon opening the door, he was knocked down by a backdraft. 9

14. 14 THE FIRE INCIDENT Stumbling down the corridor in thick black smoke, he instructed the front desk by radio to call 911 and to evacuate the 12th Floor using the P.A. system. A security officer placed the call to 911 at 5:02:29 p.m. 9

15. 15 THE FIRE INCIDENT The first P.A. message was issued to “evacuate the 12th floor” at 5:03:15 p.m.The building engineer radioed in shortly thereafter, giving instructions to evacuate the two floors above the fire floor and the five floors below. Almost immediately after this message he then gave orders to evacuate the whole building. (6 minuets have passed) 10

16. 16 THE FIRE INCIDENT The Chicago Fire Department (CFD) arrived at the building at 5:06:29 p.m. According to fire department personnel, fire fighters took the elevators to the 9th Floor and then walked up the Southeast stairwell to investigate; they soon found the fire on the 12th Floor. Fire fighters then connected a hose line to the building’s standpipe system on the 11th and 9th Floors. 10

17. 17 THE FIRE INCIDENT During that period occupants began evacuating the building using the stairwells and elevators. As they moved downward, however, the smoke became heavier. 10

18. 18 THE FIRE INCIDENT When some people reached the 12th Floor they reported that they met firefighters who were preparing to advance hose lines into the 12th Floor; according to their accounts, these fire fighters instructed them to do what ? 10

19. 19 THE FIRE INCIDENT Go back up the stairwell. However, the doors from the stairwell were locked and they were unable to re-enter. In trying every door on the way up, one of the evacuees found a door, which had not latched in the locked position on the 27th Floor. He opened the door and forced a wooden wedge under the door to hold it open. 10

20. 20 THE FIRE INCIDENT At 6:39:30 p.m., a progress report was provided by the fire department stating that the fire was out. Primary and secondary searches were completed and a final top to bottom search was initiated. During this search, fire fighters found six fatalities in the Southeast stairwell near the 20th to 24th Floors as well as several injured occupants. 10

21. 21 BUILDING AND OCCUPANT DESCRIPTION It is a 36-story high office building that housed essentially Cook County Offices. Each floor had a different floor plan design organized around a common central core.

22. 22 BUILDING AND OCCUPANT DESCRIPTION The central core common to all floors contained 16 passenger elevators as well as the 2 stairwells called Southeast and Northwest, which travelled the full length of the building. The Southeast stairwell was equipped with a smoke tower. 11

23. 23

24. 24 BUILDING AND OCCUPANT DESCRIPTION The central core common to all floors contained 16 passenger elevators as well as the 2 stairwells called Southeast and Northwest, which travelled the full length of the building. The Southeast stairwell was equipped with a smoke tower. 11

25. 25 BUILDING AND OCCUPANT DESCRIPTION The tenant space in the Northwest stairwell were permanently locked from the inside; once a person entered the stairwell they had to travel the full length of the stairwell to the lobby to exit. Re-entry was not possible on any floor and no access to the roof was available. 12

26. 26 BUILDING AND OCCUPANT DESCRIPTION The locked doors in the stairwells did not unlock upon alarm activation or power failure; these doors could be unlocked only with a master key. The building engineer held one master key and another was kept in the security office on the3rd floor. 12

27. 27 BUILDING AND OCCUPANT DESCRIPTION There was no sprinkler system in this building except for the Day Care Center and the lobby area. The building was equipped with smoke and heat detectors that were connected to the Fire Alarm Control Panel located in the lobby. The building fire alarm could only be manually activated from the Fire Alarm Control Panel. 12

28. 28 Past Experience and Training Respondents were asked to qualify the clarity of P.A. messages,16% that they were ‘unclear’, and 38% reported messages of ‘varying clarity’. There are many factors that could explain varying sound quality; there may have been problems with some speakers. 17

29. 29 Fire Drills and Fire Safety Training Respondents were asked if they had participated in an evacuation drill at the Cook County Administration Building over the last 2 years. Of the 543 people who responded to this section, the vast majority – 85% (461) – reported having participated in a fire drill in the past two years. 18

30. 30 Fire Drills and Fire Safety Training The tendencies to move to another floor or to evacuate the building to the ground were significantly linked to the respondent’s location in the building. Those who worked in the Upper Level were more likely to move to another floor during a fire drill. 18

31. 31 Fire Drills and Fire Safety Training Conversely, those who worked in the Lower Level were more likely to evacuate the building to the ground during a fire drill than those who worked in the Mid Level. There were 10 respondents who report that they ‘never’ moved to another floor, and ‘never’ evacuated to the ground. 18

32. 32 Fire Drills and Fire Safety Training When asked if there was a floor fire warden for their floor, 523 (95%) people responded. Of those who provided information, 90% indicated that they had a fire warden on their floor. 19

33. 33 Fire Drills and Fire Safety Training Of 542 (98.5%) people who responded when asked if they had ever used the stairwell in the building, 75% reported having used the building’s stairwells before the fire, while 25% indicated that they had not. 20

34. 34 Aware That the Stairwell Doors Would Lock When asked if they were aware that the stairwell doors would lock behind them if they used the stairwells, 545 people responded. Of these, 52% were aware that the stairwell doors would lock behind them. There was a sign on stairwell doors on every floor providing information on the fact that the doors were locked. 20

35. 35 Received Fire Safety Training Respondents of the questioner were asked if they had ever received fire safety training 34% indicated that they had received multiple methods of training, 16% that they had received an evacuation procedure manual. 22 19% of respondents indicated they had received no fire safety training.

36. 36 Received Fire Safety Training Respondents were asked who had provided their fire safety training. Of 313 respondents, 68% received training from Building Management, 17% from Cook County,10% from a combination of sources, and 5% received training from the Fire Department

37. 37 Received Fire Safety Training When asked how often they had received training, there were 300 responses, which ranged from having been trained 0 to 46 times. A majority of 59% had received training only once.

38. 38 Received Fire Safety Training Those who had received some sort of fire training were more likely to mention that they following P.A. instructions and used the stairs, and moved to the ground floor. 24

39. 39 Received Fire Safety Training There was an overwhelming link between training and the ‘search floor’, ‘mark empty office doors with a post-it note’ and‘close doors’ behaviors; almost invariably the employees who mentioned these behaviors had received training. 25

40. 40 Received Fire Safety Training The official evacuation plan outlined in the ‘Building/Tenant Fire Safety Plan’ called for employees, under the direction of floor fire wardens, to await instruction from the building’s public address system. were to relocate to another floor at least 5 floors below the fire level. 25

41. 41 Received Fire Safety Training Evacuation was only to take place on those floors directly threatened by the fire, which are defined as the fire floor, 2 floors directly above the fire, and 5 floors below the fire. These floors were to be announced, alarms on these floors were to sound, Complete building evacuation was not mentioned in the fire plan. 25

42. 42 Received Fire Safety Training The plan also included the designation of two ‘searchers’ per floor, one male and one female, who were to inspect restrooms, storage areas, and other ‘areas isolated from the main areas of the office’ to ensure that everyone had left the floor. No mention is made of closing doors, or marking them with a post-it note. 25

43. 43 Received Fire Safety Training This evacuation plan implies that in an evacuation situation, most building occupants were expected to engage in ‘protect in place’ activities. The approach of ‘protect in place’ as an alternative to evacuation was developed in response to numerous fire deaths in high-rise buildings that occurred in corridors and stairwells

44. 44 Received Fire Safety Training While the plan calls for a phased evacuation during which most employees would remain in place, only 3.3% of respondents mentioned ‘protect in place.’ The most frequently mentioned behaviors were to ‘use stairs’ (75%). 25

45. 45 Cues Received From the video recordings of the security cameras it appears that the first message to evacuate the 12th Floor was made at 5:03:15 p.m. The second message to evacuate the entire building was made 1:50 minutes later at 5:05:05 p.m. In parallel, the first person to discover the fire on the 12th Floor looked at her watch as she was investigating the smoke; it was 4:57 p.m., 28

46. 46 Cues Received Respondents were asked what they thought was happening in the initial moments. Of the 84 respondents to this question, 30% thought that there was a fire or emergency, 29% of the respondents thought that there was a minor problem, 29% did not know what was happening, and 12% thought that it was a false alarm or a drill. 30

47. 47 Cues Received It appears that initially, 36% (32) of the respondents thought that the situation was ‘Not at all serious’, 28% (25) thought that it was ‘Moderately serious’, 22% (19) thought that it was ‘Only slightly serious’, and 14% (12) thought that the situation was ‘Extremely serious’. 30

48. 48 Attempt to Obtain Information Before starting to evacuate, 39% of the respondents attempted to obtain information from at least one source. 16% of the respondents called friends or family. Four respondents made calls to persons inside the building and 9 made calls to persons outside the building. 33 Only 3 people were informed that there was a fire in a given location.

49. 49 Alarm and P.A. Messages The building’s fire alarm system could only be activated from either the fire alarm panel at the security desk in the lobby or in the maintenance area on the third floor. It was possible to have an audible warning tone followed by a voice message transmitted over the fire alarm system. 34

50. 50 Alarm and P.A. Messages Two-thirds or 66% (54) of the respondents heard one or several messages from the P.A. system; whereas 34% (28) did not hear any message.

51. 51 Heard Messages On the 12th Floor, where the fire started, none of the respondents heard a P.A. message. When asked if they complied with the second P.A. message heard, 91% complied with the message, whereas 9% did not.

52. 52 CONCLUSIONS The results of this human behavior study of the Cook County Administration Building fire show that although 85% of the overall respondents to the survey had received fire safety training, through drills or other means, they were ill prepared to face an actual fire. 55

53. 53 CONCLUSIONS During drills, occupants were told to move down to a specific floor where somebody would be standing in the stairwell to ensure re-entry on that floor. The building’s security manual instructed the security officers to report to the stairwell during an evacuation and unlock the doors. 55

54. 54 CONCLUSIONS However, a number of the officers were not aware of this and only the security supervisor had a key that would unlock the stairwell door. On the night of the fire there was no supervisor on duty and the key was located in the security office on the third floor. 55

55. 55 CONCLUSIONS A full 48% of the were not aware that stairwell doors would lock behind them upon entering the stairwell. It implies that despite signage and training, respondents did not have the vital knowledge required for effective decision-making during an emergency in the building. 55

56. 56 CONCLUSIONS For over a quarter of the respondents, seeing others milling and commenting on the P.A. message or the smell of smoke was the initial mean by which they became aware of the event. 55-56

57. 57 CONCLUSIONS In the initial moment, respondents were divided on the nature of the problem being a minor problem or a fire emergency. Respondents who were closer to the fire floor were, however, more likely to judge the situation as ‘extremely serious’. 56

58. 58 CONCLUSIONS Overall, 71% smelled smoke and 36% saw smoke on their floor. These perceptions were particularly prevalent on floors below the 22nd Floor. The factors motivating evacuation were: the fire cues for 47% of the respondents, P.A. message 31%, other people’s movement or instructions 27% and leaving for the day 24%. 56

59. 59 CONCLUSIONS Despite that information and the fact that there was a sign at the elevator call button on every floor stating “In Case Of Fire / Elevators Are Out Of Service”, half the respondents to the survey admitted using the elevator to evacuate on that day. 56

60. 60 CONCLUSIONS Respondents with disabilities had received some training and instruction, and were to wait with a designated assistant on their floor. At the time of the fire, the assistant was not necessarily on location but other co- workers took on this task. 56

61. 61 CONCLUSIONS After reviewing all the survey responses, testimonies and interviews as well as all publicly available material, three main contributing factors can be identified to explain the loss of life in this fire: 1) the P.A. messages to evacuate the building, 2) the locked doors inside the stairwells, and 3) the firefighting activities. 57

62. 62 CONCLUSIONS Each of these factors taken individually may not have led to the loss of life, but their combination was fatal. The combination of locked doors and firefighting activity taking place from the stairwell were, unfortunately, the perfect conditions for a tragedy. 57

63. 63 CONCLUSIONS For fire fighting purposes, the stairwell attack is often the only feasible, and timely approach. However, with such a procedure, the door from the stairwell to the fire floor is held open during the fire attack. 58

64. 64 CONCLUSIONS However, with such a procedure, the door from the stairwell to the fire floor is held open during the fire attack. Under these conditions, a considerable quantity of smoke immediately gathers in the stairwell shaft, which acts as a chimney. 58

65. 65 CONCLUSIONS It was impossible to prevent the smoke from entering into the stairwell shaft with this firefighting approach. The locked doors in the stairwell show a complete ignorance of fire safety in high rise structure, ignorance of the potential development of a fire, and complete ignorance of human behavior during fires. 58

66. 66 RECOMMENDATIONS Stairwell Allow re-entry to at least every 5th floor from the stairwells. Don’t rely on electronic systems, which could fail. Make sure that these unlocked doors lead to common corridors so that tenant’s security is not jeopardized. 58

67. 67 RECOMMENDATIONS Stairwell Provide signage inside the stairwell to identify the doors that are locked and on which floor re-entry is possible. Provide signage advising that there is no access to the roof. 58

68. 68 RECOMMENDATIONS P.A. Messages The person issuing the messages should receive training in the system operation and in the message content that should be delivered. The messages should be as accurate and clear as possible. 58

69. 69 RECOMMENDATIONS P.A. Messages Messages should contain three pieces of information: 1) what is happening, 2) where it is happening, 3) what is the best course of action. 59

70. 70 RECOMMENDATIONS P.A. Messages When the fire department arrives on the scene they should immediately take control of the public address system. As new information comes through, the messages should be tailored as closely as possible to the evolving situation. Messages should be given every 15-30 seconds. 59

71. 71 Occupant Evacuation and Firefighting Activity A procedure needs to be developed, and adopted by fire departments, ensuring that a stairwell is empty of civilians when they start their fire fighting activities.

72. 72 Occupant Evacuation and Firefighting Activity There should be a means to warn occupants that the stairwell is contaminated before entry. A progressive approach would be to place detectors in the stairwell that would trigger a green or red light by the exit doors on every floor. 59

73. 73 Recommendations for Occupant Evacuation and Firefighting Activity The practice of fighting fires using the stairwell definitely requires the stairwell doors to be unlocked. It is well documented that the most likely locations of fire fatalities in high rise buildings are in the means of egress. 59

74. 74 Recommendations Building Emergency Action Plan Every building should have developed a Building Emergency Action Plan (BEAP). This plan should identify the different means of egress for the building, the fire safety features, as well as the procedure to follow in case of different types of emergency, and for occupants with different capabilities. 52

75. 75 Recommendations for Occupant Training and Education Conduct regular training with all building occupants and educate them in the different evacuation alternatives that are available for the building.

76. 76 Recommendations for Occupant Training and Education The fire drills should mirror what is going to be done in a real situation. If the occupants are going to have to evacuate all of the way down, then they should do that during drills.

77. 77 Recommendations for Occupant Training and Education At a minimum the fire department should be involved in at least one full- dress fire drill a year to test all of the systems (both mechanical and human).

78. 78 Recommendations for Occupant Training and Education Provide additional training and education to the people that are in the decision-making loop, such as security officers and the building engineer.