| AUTOMATIC NOZZLES |
United States Fire Administration Technical Report Series |
High-rise Office Building Fire |
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Federal Emergency Management Agency |
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United States Fire Administration |
| United States Fire Administration Fire Investigation Program |
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The United States Fire Administration develops reports on
selected major fires throughout the country. The fires usually
involve multiple deaths or a large loss of property. But the
primary criterion for deciding to do a report is whether it will
result in significant “lessons learned” in some cases
these lessons bring to light new knowledge about fire - the
effect of building construction or contents, human behavior in
fire, etc. In other cases, the lessons are not new but are
serious enough to highlight once again, with yet another fire
tragedy report. The reports are sent to fire magazines and are distributed at national and regional fire meetings. The International Association of Fire Chiefs assists USFA in disseminating the findings throughout the fire service. On a continuing basis the reports are available on request from USFA; announcements of their availability are published widely in fire journals and newsletters. This body of work provides detailed information on the nature of the fire problem for policy makers who must decide on allocations of resources between fire and other pressing problems, and within the fire service to improve codes and code enforcement, training, public fire education building technology, and other related areas. The Fire Administration, which has no regulatory authority, sends an experienced fire investigator into a community after a major incident only after having conferred with the local fire authorities to insure that USFA's assistance and presence would be supportive and would in no way interfere with any review of the incident they are themselves conducing. The intent is not to arrive during the event or even immediate after, but rather after the dust settles so that a complete and objective review of all the important aspects of the incident can be made. Local authorities review USFA's report while it is in draft The USFA investigator or team is available to local authorities should they wish to request technical assistance for their own investigation. This report and its recommendations were developed by USFA staff and by TriData Corporation, Arlington, Virginia, its staff and consultants, who are under contract to assist the Fire Administration in carrying out the Fire Reports Program. The United States Fire Administration greatly appreciates the cooperation received from the Philadelphia Fire Department. In particular, the assistance and information provided by Fire Commissioner Roger Ulshafer (ret.), Commissioner Harold Hairston, Deputy Commissioner Christian Scheizer (ret.), Deputy Commissioner Phil McLaughlin, Deputy Commissioner Matthew J. McCrory Jr., Battalion Chief Theodore Bateman, Battalion Chief Richard Bailey, and Lieutenant Matthew Medley were invaluable. For additional copies of this report write to the United States Fire Administration, National Fire Data Center, 16825 South Seton Avenue, Emmitsburg, Maryland 21727. |
High-rise Office Building Fire |
Report by : | J. Gordon Routley |
This is Report 049 of the Major Fires Investigation Project conducted by TriData Corporation under contract EMW-90-C-3338 to the United States Fire Administration, Federal Emergency Management Agency. |
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Federal Emergency Management Agency |
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United States Fire Administration |
FOREWORD |
| This report on the Philadelphia, Pennsylvania, One Meridian Plaza fire documents one of the most significant high-rise fires in United States' history. The fire claimed the lives of three Philadelphia firefighters and gutted eight floors of a 38-story fire-resistive building causing an estimated $100 million in direct property loss and an equal or greater loss through business interruption. Litigation resulting from the fire amounts to an estimated $4 billion in civil damage claims. Twenty months after the fire this building, one of Philadelphia's tallest, situated on Penn Square directly across from City Hall, still stood unoccupied and fire-scarred, its structural integrity in question. |
| This fire is a large scale realization of fire risks that have been identified on many previous occasions. The most significant new information from this fire relates to the vulnerability of the systems that were installed to provide electrical power and to support!fire suppression efforts. In this incident there was an early loss of normal electrical power, a failure of the emergency generator and a major problem with the standpipe system, each of which contributed to the final outcome. These experiences should cause responsible individuals and agencies to critically reexamine the adequacy of all emergency systems in major buildings. |
| When the initial news reports of this fire emerged, attention focused on how a modern, fire-resistive high-rise in a major metropolitan city with a well-staffed, well-equipped fire department could be so heavily damaged by fire. The answer is rather simple - fire departments alone cannot expect or be expected to provide the level of fire protection that modern high-rises demand. The protection must be built-in. This fire was finally stopped when it reached a floor where automatic sprinklers had been installed. |
| This report will demonstrate that the magnitude of this loss is greater than the sum of the individual problems and failures which produced it. Although problems with emergency power systems, standpipe pressure reducing valves, fire alarm systems, exterior fire spread, and building staff response can be identified, the magnitude of this fire was a result of the manner in which these factors interacted with each other. It was the combination of all of these factors that produced the outcome. |
| At the time of the One Meridian Plaza fire, the three model fire prevention codes had already adopted recommendations or requirements for abating hazards in existing high-rise buildings. Each of the model building codes contains explicit requirements for fire protection and means of egress in high-rise buildings. Actions were and are underway in many cities and several states to require retrofitting of existing high-rise buildings with automatic sprinkler systems, fire detection and alarm systems, and other safety provisions. Since the Meridian Plaza fire, the National Fire Protection Association's Technical Committee on Standpipe Systems has proposed a complete revision of NFPA 14, Standard for Installation of Standpipe and Hose Systems. The new version of NFPA 14 was approved by the NFPA membership at the 1992 fall meeting in Dallas, Texas. All of these efforts are necessary and commendable. To prove successful, however, they must take a comprehensive, holistic approach to the problem of high-rise fire safety, if we are to keep One Meridian Plaza from being surpassed by yet another devastating fire. |
High-rise Office Building Fire |
Report By: |
J. Gordon Routley |
Local Contacts: |
Commissioner (ret.) Roger Ulshafer
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OVERVIEW |
| A fire on the 22nd floor of the 38-story Meridian
Bank Building, also known as One Meridian Plaza, was reported to
the Philadelphia Fire Department on February 23, 1991 at
approximately 2040 hours and burned for more than 19 hours. The
fire caused three firefighter fatalities and injuries to 24
firefighters. The 12-alarms brought 51 engine companies, 15
ladder companies, 11 specialized units, and over 300 firefighters
to the scene. It was the largest high-rise office building fire
in modern American history - completely consuming eight floors of
the building - and was controlled only when it reached a floor
that was protected by automatic sprinklers. A table summarizing
the key aspects of the fire is presented on the following pages. The Fire Department arrived to find a well-developed fire on the 22nd floor, with fire dropping down to the 21st floor through a set of convenience stairs. (For an elevation drawing of the building and the 22nd floor plan see Appendix A.) Heavy smoke had already entered the stairways and the floors immediately above the 22nd. Fire attack was hampered by a complete failure of the building's electrical system and by inadequate water pressure, caused in part by improperly set pressure reducing valves on standpipe hose outlets. |
| SUMMARY OF KEY ISSUES |
| Issues | Comments |
| Origin and Cause | The fire started in a vacant 22nd floor office in a pile of linseed oil soaked rags left by a contractor. |
| Fire Alarm System | The activation of a smoke detector on the 22nd floor was the first notice of a possible fire. Due to incomplete detector coverage, the fire was already well advanced before the detector was activated. |
| Building Staff Response | Building employees did not call the fire department when the alarm was activated. An employee investigating the alarm was trapped when the elevator opened on the fire floor and was rescued when personnel on the ground level activated the manual recall. The Fire Department was not called until the employee had been rescued. |
| Alarm Monitoring Service | The private service which monitors the fire alarm system did not call the Fire Department when the alarm was first activated. A call was made to the building to verify that they were aware of the alarm. The building personnel were already checking the alarm at that time. |
| Electrical Systems | Installation of the primary and secondary electrical power risers in a common unprotected enclosure resulted in a complete power failure when the fire damaged conductors shorted to ground. The natural gas powered emergency generator also failed. |
| Fire Barriers | Unprotected penetrations in few resistance rated assemblies and the absence of fire dampers in ventilation shafts permitted
fire and smoke to spread vertically and horizontally. Ventilation openings in the stairway enclosures permitted smoke to migrate into the stairways, complicating firefighting. Unprotected openings in the enclosure walls of 22nd floor electrical closet permitted the fire to impinge on the primary and secondary electrical power rises. |
| Standpipe System and Pressure Reducing Valves (PRV's) | Improperly installed standpipe valves provided inadequate pressure for fire department hose streams using 1 3/4 inch hose and automatic fog nozzles. Pressure reducing valves were installed to limit standpipe outlet discharge pressures to safe levels. The PRVs were set too low to produce affective hose streams; tools and expertise to adjust the valve settings did not become available until too late. |
| Locked Stairway Doors | For security reasons, stairway doors were locked to prevent reentry except on designated floors. (A building code variance had been granted to approve this arrangement.) This compelled firefighters to use forcible entry tactics to gain access from stairways to floor areas. |
| Fire Department Pre-Fire Planning | Only limited pre-fire plan information was available to the Incident Commander. Building owners provided detailed plans as the fire progressed. |
| Firefighter Fatalities | Three firefighters from Engine company 11 died on the 28th floor when they became disoriented and ran out of air in their SCBAs. |
| Exterior Fire Spread "Auto-exposure" | Exterior vertical fire spread resulted when exterior windows failed This was a primary means of fire spread. |
| Structural Failure | Fire-resistance rated construction features, particularly floor-ceiling assemblies and shaft enclosures (including stair shafts), failed when exposed to continuous fire of unusual intensity and duration. |
| Interior Fire Suppression Abandoned | After more than 11 hours of uncontrolled fire growth and spread, interior firefighting efforts were abandoned due to the risk of structural collapse. |
| Automatic Sprinklers | The fire was eventually stopped when it reached the fully sprinklered 30th floor. Ten sprinkler heads activated at different points of fire penetration. |
| The three firefighters who died were attempting to ventilate
the center stair tower. They radioed a request for help stating
that they were on the 30th floor. After extensive search and
rescue efforts, their bodies were later found on the 28th floor.
They had exhausted all of their air supply and could not escape
to reach fresh air. At the time of their deaths, the 28th floor
was not burning but had an extremely heavy smoke condition. After the loss of three personnel, hours of unsuccessful attack on the fire, with several floors simultaneously involved in fire, and a risk of structural collapse, the Incident Commander withdrew all personnel from the building due to the uncontrollable risk factors. The fire ultimately Spread up to the 30th floor where it was stopped by ten automatic sprinklers. |
| THE BUILDING |
| One Meridian Plaza is a 38-story high-rise office building,
located at the corner of 15th Street and South Penn Square in the
heart of downtown Philadelphia, in an area of high-rise and
mid-rise structures. On the east side, the building is attached
to the 34-story Girard Trust Building and it is surrounded by
several other high-rise buildings. The front of the building
faces City Hall. One Meridian Plaza has three underground levels, 36 above ground occupiable floors, two mechanical floors (12 and 38), and two rooftop helipads. The building is rectangular in shape, approximately 243 feet in length by 92 feet in width (approximately 22,400 gross square feet), with roughly 17,000 net usable square feet per floor. (See Appendix A for floor plan.) Site work for construction began in 1968, and the building was completed and approved for occupancy in 1973. Construction was classified by the Philadelphia Department of Licenses and Inspections as equivalent to BOCA Type 1B construction which requires 3-hour fire rated building columns, 2-hour fire rated horizontal beams and floor/ceiling systems, and 1-hour fire rated corridors and tenant separations. Shafts, including stairways, are required to be 2-hour fire rated construction, and roofs must have 1-hour fire rated assemblies. The building frame is structural steel with concrete floors poured over metal decks. A11 structural steel and floor assemblies were protected with spray-on fireproofing material. The exterior of the building was covered by granite curtain wall panels with glass windows attached to the perimeter floor girders and spandrels. The building utilizes a central core design, although one side of the core is adjacent to the south exterior wall. The core area is approximately 38 feet wide by 124 feet long and contains two stairways, four banks of elevators, two HVAC supply duct shafts, bathroom utility chases, and telephone and electrical risers. |
| Stairways |
| The building has three enclosed stairways of concrete
masonry construction. Each stairway services all 38 floors. The
locations of the two stairways within the building core shift
horizontally three or four times between the ground and the 38th
floor to accommodate elevator shafts and machine rooms for the
four elevator banks. Both of these stairways are equipped with
standpipe risers. Adjacent to the stairway enclosures are separate utility and HVAC shafts. There are pipe and duct penetrations through the shaft and stairway enclosure walls. The penetrations are unprotected around the sleeved pipes and fire dampers are not installed in HVAC ducts penetrating the fire-resistance rated wall assemblies. This effectively creates many openings between the utility shafts, and the individual floors, primarily in the plenum area above the ceilings, as well as between the shafts and the stairway enclosures. The third enclosed stairway is located at the east end of the building. This stairway attaches the floors of the Meridian Plaza to the corresponding floors of the Girard Trust Building. Adjacent to the east stairway is an additional enclosed utility shaft which also has pipe and duct penetrations through the shaft enclosure walls. There are no fire or smoke barriers around the sleeved pipes and no fire dampers in the HVAC ducts that penetrate the shaft walls. |
| Elevators |
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Elevator service is provided by four zoned elevator banks
identified as A through D. Elevator Bank A serves floors 2-11.
Elevator Bank B has two shafts which enclose seven elevators: six
are passenger elevators that serve floors 12-21, and one is a
freight elevator that serves floors 22-38. Elevator Bank C serves
floors 21-29, and Elevator Bank D serves floors 2937. The
elevator shafts are constructed of concrete and masonry and
extend from the first floor or lower levels to the highest floor
served by the individual elevator banks. At the top of each
elevator bank is the associated elevator equipment room. The elevator shafts that serve the upper floors are express rise and do not have openings to the lower floors. Only the Bank C passenger elevators and the freight elevator served the fire floors. The elevator shafts did not appear to play a significant role in the spread of combustion products. Each elevator lobby is equipped with a smoke detector that, when activated, recalls the elevator cars to the first floor lobby. Firefighter's service (elevator recall) features were added in 1981 under provisions of the State Elevator Code.1 Occupant use of elevators in emergencies is addressed in the Building Emergency Instructions shown in Appendix B. |
| (1) In Pennsylvania, elevators are regulated through the State Department of Labor and Industry. |
| Heating, Ventilation, and Air Conditioning |
| The heating, ventilation, and air conditioning (HVAC) system is composed of four air handling systems. Two systems are located in the 38th floor mechanical room and service the east and west halves of the upper floors The other two systems are located in the 12th floor mechanical room and service the east and west halves of the lower floors. Each system supplies air to its respective floors through one or two supply air shafts located within the building core and receives return air from its associated return air shafts. Return air shafts are located at each of the four building corners. Upon examination at selected locations, the HVAC supply and return air shafts did not appear to have fire dampers at the duct penetrations on each floor. |
| Plumbing |
| The bathroom utility piping extends through the 38 floors through pipe chases that are formed by the space between two walls. These pipe chases transfer location as the bathroom locations change floor to floor. Upon a sample examination of the pipe chases, it was found that floor penetrations were not closed or sealed to maintain the integrity of the fire resistance rated floor/ceiling assemblies. |
| Electrical and Communications Risers |
| The electrical and telephone risers are enclosed in separate rooms on each floor. The rooms are located directly above one another and are intended to function as vertical shafts, with rated separations required at horizontal penetrations from the shafts into floor and ceiling spaces at each level. Within the telephone and electrical rooms, unprotected penetrations of the floor assemblies allow conduits and exposed wires to travel from Floor to floor. Several breaches of fire-resistance rated construction were observed in the walls separating the electrical and telephone rooms from the ceiling plenums and occupied spaces on each floor. |
| Emergency Power |
|
The building electrical system receives power from two separate
electrical substations and is backed-up by an emergency
generator. The two sources of power are arranged so that the load
would automatically transfer to the second source upon failure of
the first. Electrical power for One Meridian Plaza and four
adjacent buildings is distributed from the basement of 1414 S.
Penn Square. The electric service enters the building via the basement from the adjoining building and is distributed to the 12th and 38th floor mechanical rooms via the electrical risers in the building core. From the 12th and 38th floor mechanical rooms, electrical power is distributed to the major mechanical systems and to a buss bar riser, which services distribution panels on the individual floors. Emergency power was provided by a 340 kw natural gas-fired generator located in the 12th floor mechanical room. The generator was sized to supply power for emergency lighting and the fire alarm system, the fire pump located on the 12th floor and one car in each bank of elevators. The generator's fuel was supplied by the building's natural gas service. This generator was not required by the building code, since the building's electrical power was supplied by two separate substations. The generator was reported to have been tested weekly. The last recorded test date was January 30, almost four weeks before the fire, and the maintenance records indicate that problems were encountered during engine start-up under load conditions at that time. During a detailed inspection following that test, a damaged part was discovered and replaced. After the repair, the generator was started without a load and appeared to work properly, but no subsequent tests were performed to determine if the problems persisted under load conditions. |
| Records of earlier maintenance and test activity suggest that load tests were performed only occasionally. Test and maintenance records indicate a long history of maintenance problems with the emergency generator system. Many of these problems became manifest during or immediately after conducting tests under load. |
| FIRE PROTECTION SYSTEMS |
| At the time of construction, the
Philadelphia Building Code required only a local fire alarm
system with manual stations at each exit and smoke detectors in
the supply and return air shafts. Hose stations supplied from the
domestic water service and portable fire extinguishers were
required for occupant use. Dry standpipes were installed for fire
department use. Below ground levels were required to be provided
with automatic sprinkles. As a result of local code changes, several improvements to the fire protection systems were made in the years following the building's construction. In 1981, the Philadelphia Department of Licenses and Inspections implemented amendments to the fire code which were intended to address the life safety of high-rise building occupants. These requirements included installation of stair identification signs, provisions to permit stairway reentry, and installation of smoke detection in common areas in the path of access to exits. The "common areas" provision of the code was intended to address corridors and exit passageways in multi-tenant floors. The smoke detector requirements were interpreted in such a way that single tenant "open plan" floors were only required to have detectors installed at the exits; the entire floor, although open, was not considered a “common area." Smoke detectors were also installed in the return air plenum adjacent to the return air shaft intakes in each corner of the building. These provisions required that building owners file permits for this work within one year of the code change. City records do not indicate when this work was performed in this particular building or if it was inspected and approved. |
| Fire Detection and Alarm Systems |
|
At the time of construction, One Meridian Plaza was equipped with
a coded manual fire alarm system with pull stations installed
adjacent to each of the three exit stairwells on each floor.
Smoke detection was provided in the major supply and return air
ducts at the mechanical floor levels. After the 1981 fire code amendments were enacted, the hardware on stairway doors was required to allow access from stairs back to floor areas or to be unlocked automatically in the event that the fire alarm was activated. One Meridian Plaza was granted a variance from this provision and generally had unlocked doors every three floors. Approximately one and a half years before the fire, a public address system was installed throughout the building. This system was operable from the lobby desk and had the capability of addressing floors, stairways, elevator machine rooms, and elevators. Two-way communication was possible with elevators and elevator machine rooms. As additional devices and systems were installed, they were connected to the fire alarm system to sound through the single-stroke bells originally installed with the manual fire alarm system. Smoke detector and water flow signals were assigned their own codes to allow annunciation not only at the lobby but throughout the building for those members of the building staff who knew the codes. |
| Standpipes |
|
The occupant use standpipe system, which was connected to the
domestic water supply, provided two outlets per floor with 100
feet of 1 1/2-inch hose and a nozzle. The hose cabinets were
located in corridors on each floor. A dry standpipe system was originally installed with 6 inch risers in the west and center stair towers and outlets for 2 1/2 fire department hose lines at each floor level. This system was converted to a wet riser system in 1988, to supply automatic sprinklers on some of the upper floors. An 8 inch water supply was provided to deliver water to two 750 gpm electric fire pumps, one in the basement and one on the 12th floor. The basement pump supplied the lower standpipe zone (floors B-12) while the 12th floor pump served the upper zone (floors 13-38). There was no standpipe in the east stair tower. A November 1988 Board of Building Standards decision permitted both zones to be served by a common fire department connection, as part of a plan that would provide for the installation of automatic sprinklers on all floors by November 1993.2 Due to the height of the zones and the installation of fire pumps, pressures exceeded the 100 psi limit permitted by NFPA 14, Installation off Standpipe and Hose Systems at the standpipe hose outlets on several lower floors in each zone. Pressure restricting devices, which limit the discharge through standpipe outlets by restricting the orifice, were installed on the mezzanine and second floor levels and on floors 26 through 30. Pressure reducing valves, which regulate both static pressure and discharge pressure under variable flow conditions, were installed on floors 13 through 25. Both types of devices prevent dangerous discharge pressures from hose outlets at the lower floors of each standpipe zone. The Philadelphia Fire Department investigators report that the plans submitted at the time the standpipes were converted did not indicate that PRVs were to be installed. |
| (2) Philadelphia Fire Department, “Investigative Report” Section M, p. 2. |
| Automatic Sprinklers |
| Only the service floors located below grade were protected by automatic sprinklers at the time of construction. Conversion of the dry standpipe to a wet system with fire pumps facilitated the installation of automatic sprinklers throughout the building. At the request of selected tenants, sprinklers were installed on several floors during renovations, including all of the 30th, 31st, 34th, and 35th floors, and parts of floors 11 and 15. Limited service sprinklers, connected to the domestic water supply system, were installed in part of the 37th floor. The building owners had plans to install sprinklers on additional floors as they were renovated. |
| THE FIRE |
| Delayed Report |
|
At approximately 2023 hours on February 23, 1991, a smoke
detector was activated on the 22nd floor of the One Meridian
Plaza building. The activated detector is believed to have been
located at the entrance to the return air shaft in the northeast
corner of the building. At that time there were three people in
the building, an engineer and two security guards.3
The alarm sounded throughout the building and elevator cars
automatically returned to the lobby. The building engineer
investigated the alarm using an elevator on manual control to go
to the 22nd floor. The central station monitoring company that
served the building reportedly called the guard desk in the lobby
to report the alarm. The call came in before the engineer reached
the fire floor, and the alarm company was told that the source of
the alarm was being investigated. The alarm company did not
notify the Fire Department at that time. When the elevator doors opened at the 22nd floor, the engineer encountered heavy smoke and heat. Unable to reach the buttons or to leave the elevator car to seek an exit, the building engineer became trapped. He was able to use his portable radio to call the security guard at the lobby desk requesting assistance. Following the trapped engineer's instructions, the security guard in the lobby recalled the elevator to the ground floor using the Phase II firefighter's safety feature. The second security guard monitored the radio transmissions while taking a break on the 30th floor. This guard initially mistook the fire alarm for a security alarm believing that he had activated a tenant's security system while making his rounds. He evacuated the building via the stairs when he heard the building engineer confirm there was a fire on the 22nd floor. The roving guard reported that as he descended from the 30th floor the stairway was filling with smoke. He reached the ground level and met the engineer and the other security guard on the street in front of the building. The Philadelphia Fire Department report on the incident states that the lobby guard called the alarm monitoring service to confirm that there was an actual fire in the building when the engineer radioed to her from the 22nd floor. After meeting outside and accounting for each other's whereabouts the three building personnel realized that they had not yet called the Fire Department. The first call received by the Philadelphia Fire Department came from a passerby who used a pay telephone near the building to call 911. The caller reported smoke coming from a large building but was unable to provide the exact address. While this call was still in progress, at approximately 2027 hours a call was received from the alarm monitoring service reporting a fire alarm at One Meridian Plaza. |
| (3) The building staff regulated the after-hours population of the building through a lighting request system where tenants lights would be turned on for the duration of their work. In addition, there was a security system in the building that recorded any passage through stairwell doors. |
| Initial Response |
|
The Philadelphia Fire Department dispatched the first alarm at
2027 hours consisting of four engine and two ladder companies
with two battalion chiefs. The first arriving unit, Engine 43,
reported heavy smoke with fire showing from one window at
approximately the mid-section of the building at 2031 hours. A
security guard told the first arriving battalion chief that the
fire was on the 22nd floor. Battalion Chief S ordered a second
alarm at 2033 hours. While one battalion chief assumed command of the incident at the lobby level, the other battalion chief organized an attack team to go up to the fire floor. (The Philadelphia Fire Department's "High-rise Emergency Procedures" Operation Procedure 33 is presented in Appendix C.) The battalion chief directed the attack team to take the low-rise elevators up the 11th floor and walk up from there. |
| Electrical Power Failure |
|
Shortly after the battalion chief and the attack team reached the
11th floor there was a total loss of electrical power in the
building. This resulted when intense heat from the fire floor
penetrated the electrical room enclosure. The heat caused the
cable insulation to melt resulting in a dead short between the
conductor and the conduit in both the primary and secondary power
feeds, and the loss of both commercial power sources. The
emergency generator should have activated automatically, but it
failed to produce electric power. The events left the entire
building without electricity for the duration of the incident in
spite of several efforts to restore commercial power and to
obtain power from the generator. This total power failure had a major impact on the firefighting operations. The lack of lighting made it necessary for firefighters to carry out suppression operations in complete darkness using only battery powered lights Since there was no power to operate elevators, firefighters were forced to hand carry all suppression equipment including SCBA replacement cylinders up the stairs to the staging area that was established on the 20th floor. In addition, personnel had to climb at least 20 floors to relieve fellow firefighters and attack crews increasing the time required for relief forces to arrive. This was a problem for the duration of the incident as each relief crew was already tired from the long climb before they could take over suppression duties from the crews that were previously committed. |
| Initial Attack |
|
As the initial attack crews made their way toward the 22nd floor
they began to encounter smoke in the stairway. At the 22nd floor
they found the west stair tower door locked. The door was already
warped and blistering from the heat, and heavy fire could be seen
through the door's wire glass window. A 1 3/4-inch hand line was
stretched up the stairway from a standpipe connection on the
floor below and operated through the window while a ladder
company worked on forcing open the door. It took several minutes before the door could be forced open and an attempt could be made to advance onto the fire floor with the 1 3/4-inch attack line. The crews were not able to penetrate onto the 22nd floor due to the intense heat and low water pressure they were able to obtain from their hose line. An entry was also made on the 21st floor where the firefighters were able to see fire on the floor above through the open convenience stair. They attempted to use an occupant hose line to attack the fire but could not obtain water from that outlet. They then connected a 1 3/4 inch attack line to the standpipe outlet in the stairway, but they could not obtain sufficient pressure to attack the flames A Tactical Command Post was established on the 21st floor and a staging area was set up on floor 20. |
| Fire Development |
|
By this time fire was visible from several windows on the 22nd
floor and crews outside were evacuating the area around the
building and hooking up supply lines to the building's standpipe
connections. As flames broke through several more windows around
a major portion of the fire floor, the floor above was subject to
auto-exposure from flames lapping up the side of the building.
Additional alarms were called to bring personnel and equipment to
the scene for a large scale fire suppression operation. As the fire developed on the 22nd floor, smoke, heat, and toxic gases began moving through the building. Vertical fire extension resulted from unprotected openings in floor and shaft assemblies, failure of fire resistance rated floor assemblies, and the lapping of flames through windows on the outside of the building. |
| Water Supply Problems |
|
The normal attack hose lines used by the Philadelphia Fire
Department incorporate 1 3/4-inch hose lines with automatic fog
nozzles designed to provide variable gallonage at 100 psi nozzle
pressure. The pressure reducing valves in the standpipe outlets
provided less than 60 psi discharge pressure, which was
insufficient to develop effective fire streams. The pressure
reducing values (PRVs) were field adjustable using a special
tool. However, not until several hours into the fire did a
technician knowledgeable in the adjustment technique arrive at
the fire scene and adjust the pressure on several of the PRVs in
the stairways. When the PRVs were originally installed, the pressure settings were improperly adjusted. Index values marked on the valves did not correspond directly to discharge pressures. To perform adjustments the factory and field personnel had to refer to tables in printed installation instructions to determine the proper settings for each floor level.4 For more detailed information about PRVs see appendices D and E. |
| Several fire department pumpers were
connected to the fire department connections to the standpipe
system in an attempt to increase the water pressure. The
improperly set PRVs effectively prevented the increased pressure
in the standpipes from being discharged through the valves. The
limited water supply prevented significant progress in fighting
the fire and limited interior forces to operating from defensive
positions in the stairwells. During the next hour the fire spread
to the 23rd and 24th floors primarily through auto-exposure,
while firefighters were unable to make entry onto these floors
due to deteriorating heat and smoke conditions and the lack of
water pressure in their hose lines. Windows on the 22nd floor
broke out and the 23rd and 24th floor windows were subject to
auto-exposure from flames lapping up the sides of the building. On the street below pedestrians were cleared from the area because of falling glass and debris as more and more windows were broken out by the fire. Additional hose lines were connected to the standpipe connections, attempting to boost the water pressure in the system. However, the design of the PRVs did not allow the higher pressures to reach the interior hose streams. Additional alarms were requested to bring a five-alarm assignment to the scene. |
| (4) The pressure reducing valves in the vicinity of the fire floor (floors 18 through 20) were set at "80" on the valve index which corresponded to a discharge pressure between 55 and 57 psi depending on the elevation. This would provide a nozzle pressure of 40 to 45 psi at the end of a 150 to 200 foot hose line. |
| Three Firefighters Lost |
|
As firefighters attempted to make entry to the burning floors
from the stairways, heavy smoke continued to build up within the
stair shafts and banked down from the upper floors. An engine
company was assigned to attempt to open a door or hatch to
ventilate the stairways at the roof level to allow the smoke and
heat to escape. A Captain and two firefighters from Engine 11
started up the center stair from the 22nd floor with this
assignment. Engine 11 subsequently radioed that they had left the
stairway and were disoriented in heavy smoke on the 30th floor.
Attempts were made to direct the crew by radio to one of the
other stairways. Shortly thereafter a radio message was received at the Command Post from Engine 11's Captain requesting permission to break a window for ventilation. This was followed moments later by a message from a crew member of Engine 11 reporting that “the Captain is down." Approval was given to break the window and rescue efforts were initiated to search for the crew. Search teams were sent from below and a helicopter was requested to land a team on the roof. The search teams were able to reach the 30th floor, which was enveloped in heavy smoke, but were unable to find the missing firefighters. They then searched the floors above without success. An eight member search team became disoriented and ran out of air in the mechanical area on the 38th floor, while trying to find an exit to the roof. They were rescued by the team that had landed on the roof and were transported back to ground level by the helicopter. Several attempts were made to continue the search, until helicopter operations on the rooftop had to be suspended due to the poor visibility and the thermal drafts caused by the heat of the fire. The helicopter crew then attempted an exterior search, using the helicopter's searchlight, and at 0117 located a broken window on the southeast corner of the 28th floor, in an area that could not be seen from any of the surrounding streets. Another rescue team was assembled and finally located the three missing members just inside the broken window on the 28th floor at approximately 0215. At that time the fire was burning on the 24th and 25th floors and extending to the 26th. The victims were removed to the Medical Triage Area on the 20th floor, but resuscitation efforts were unsuccessful and they were pronounced dead at the scene. An estimated three to four hours had elapsed since they had reported that they were in trouble and all had succumbed to smoke inhalation.5 The three deceased members of Engine Company 11 were Captain David P. Holcombe (age 52), Firefighter Phyllis McAllister (43), and Firefighter James A. Chapped (29). Prior to being assigned to this task, the crew had walked up to the fire area wearing their full protective clothing and SCBAs and carrying extra equipment. It is believed that they started out with full SCBA cylinders, but it is not known if they became disoriented from the heavy smoke in the stairway, encountered trouble with heat build-up, or were exhausted by the effort of climbing 28 floors. Some combination of these factors could have caused their predicament. Unfortunately, even after breaking the window they did not find relief from the smoke conditions which were extremely heavy in that part of the building. |
| (5) The exact time that Engine 11 was assigned to attempt ventilation and the time the crew reported they were in trouble are not known, since the tactical radio channel they were using is not recorded and detailed time records of this event were not maintained during the incident. Estimates from individuals who were involved suggest that the assignment was made between 2130 and 2200 hours and search efforts were initiated between 2200 and 2230 hours The bodies were located at approximately 0215 hours. |
| Continuing Efforts to Improve Water Supply< |
| Because of the difficulty in obtaining an adequate water supply, a decision was made to stretch 5-inch lines up the stairs to supply interior attack lines. The first line was stretched up the west (#1) stairwell to the 24th floor level and was operational by 0215, approximately six hours into the fire. At 0221, a 12th alarm was sounded to stretch a second line, in the center (#2) stair. At 0455, a third 5-inch line was ordered stretched, in the east (#3) stair. The operation in the east stair was discontinued at the 17th floor level at 0600. While the 5-inch lines were being stretched, a sprinkler contractor arrived at the scene and began manually adjusted the pressure reducing valves on the standpipe connections. This improved the discharge pressure in the hoses supplied by the standpipe system, finally providing normal handline streams for the interior fire suppression crews. At this point, however, the fire involved several floors and could not be contained with manual hose streams. |
| Firefighting Operations Suspended |
|
All interior firefighting efforts were halted after almost 11
hours of uninterrupted fire in the building. Consultation with a
structural engineer and structural damage observed by units
operating in the building led to the belief that there was a
possibility of a pancake structural collapse of the fire damaged
floors. Bearing this risk in mind along with the loss of three
personnel and the lack of progress against the fire despite
having secured adequate water pressure and flow for interior fire
streams, an order was given to evacuate the building at 0700 on
February 24. At the time of the evacuation, the fire appeared to
be under control on the 22nd though 24th floors. It continued to
burn on floors 25 and 26 and was spreading upward. There was a
heavy smoke condition throughout most of the upper floors. The
evacuation was completed by 0730. After evacuating the building, portable master streams directed at the fire building from several exposures, including the Girard Building #1 and One Centre Plaza, across the street to the west were the only firefighting efforts left in place. |
| Fire Stopped |
| The fire was stopped when it reached the 30th floor, which was protected by automatic sprinklers. As the fire ignited in different points this floor level through the floor assembly and by auto-exposure through the windows, 10 sprinkler heads activated and the fires were extinguished at each point of penetration. The vertical spread of the fire was stopped solely by the action of the automatic sprinkler system, which was being supplied by Fire Department pumpers. The 30th floor was not heavily damaged by fire, and most contents were salvageable. The fire was declared under control at 3:01 p.m., February 24, 1991. |
| ANALYSIS |
| Smoke Movement |
|
The heated products of combustion from a fire have a natural
buoyancy, which causes them to accumulate in the upper levels of
a structure. In a high-rise building the stairways, elevator
shafts, and utility shafts are natural paths for the upward
migration of heated products of combustion. Stack effect is a natural phenomenon affecting air movement in tall buildings. It is characterized by a draft from the lower levels to the upper levels, with the magnitude of the draft influenced by the height of the building, the degree of air-tightness of exterior walls of the building, and temperature differential between inside and outside air.6 This effect was particularly strong on the night of the fire due to the cold outside temperature. Interior air leakage rates, through shaft walls and openings, also modulate the rate of air flow due to stack effect. Smoke and toxic gases become entrained in this normal air movement during a fire and are carried upward, entering shafts through loose building construction or pipe and duct penetrations. The air flow carries smoke and gases to the upper portions of the structure where the leakage is outward. At the upper portions of the structure, smoke and toxic gases fill the floors from the top floor down toward the fire, creating a dangerous environment for building occupants and firefighters. During the investigation of this fire, this upward flow was evidenced by the presence of heavy soot in the 38th floor mechanical room and all the upper floors of the building. The path of smoke travel to the upper floors was vividly evidenced by the soot remnants in HVAC shafts, utility chases, return air shafts, and exhaust ducts. |
| (6) Fitzgerald, R (1981), Smoke Movement in Buildings," in Fire Protection Handbook, 15th ed., McKinnon, G. P., ed., Quincy, MA National Fire Protection Association, p. 3-32. |
| Fuel Loading |
| Fuel loading on the fire floors consisted mainly of files and papers associated with securities trading and management consulting. At least one floor had a significant load of computer and electronic equipment. In some cases, correlation could be found between heavy fuel load and damage to structural members in the affected area. From the 22nd floor to the 29th floor, the fire consumed all available combustible materials with the exception of a small area at the east end of the 24th floor. |
| Structural Conditions Observed |
| Prior to deciding to evacuate the building, firefighters noticed significant structural displacement occurring in the stair enclosures. A command officer indicated that cracks large enough to place a man's fist through developed at one point. One of the granite exterior wall panels on the east stair enclosure was dislodged by the thermal expansion of the steel framing behind it. After the fire, there was evident significant structural damage to horizontal steel members and floor sections on most of the fire damaged floors. Beams and girders sagged and twisted - some as much as three feet - under severe fire exposures, and fissures developed in the reinforced concrete floor assemblies in many places. Despite this extraordinary exposure, the columns continued to support their loads without obvious damage. |
| INCIDENT COMMAND |
| During nearly, 19 hours of firefighting, the Philadelphia Fire Department committed approximately 316 personnel operating 51 engine companies, 15 ladder companies, and 11 specialized units, including EMS units, to the 12-alarm incident. The incident was managed by 11 battalion chiefs and 15 additional chief officers under the overall command of the Fire Commissioner. All apparatus and personnel were supplied without requesting mutual aid. Off-duty personnel were recalled to staff reserve companies to maintain protection for all areas of the city. Philadelphia uses an incident management system known within the department as Philadelphia Incident Command (PIC). It is based on the ICS system taught at the National Fire Academy. |
| Operations |
|
The Department's standard operating procedures for a high-rise
incident were implemented at the time of arrival. Incident
commanders were confronted with multiple-simultaneous systems
failures. As a result, command and control decisions were based
on the need to innovate and to find alternate approaches to
compensate for the normal systems that firefighters would have
relied on to bring this incident to a more successful conclusion. Philadelphia Fire Department tactical priorities in a high-rise fire focus on locating and evacuating exposed occupants and making an aggressive interior attack to confine the fire to the area or at least the floor of origin. Confronted with total darkness, impaired vertical mobility because the elevators were inoperable, water supply deficiencies which made initial attack efforts ineffective, vertical fire spread via unprotected interior openings and external auto-exposure, and worsening heat and smoke conditions in the stairways, the tactical focus shifted to finding something (perhaps anything) which could be accomplished safely and effectively. When Engine 11's crew reported their predicament, the priority changed to attempting to locate and rescue the trapped firefighters. Unfortunately, these efforts were in vain and nearly proved tragic when the eight firefighters conducting search and rescue operations became disoriented and ran out of air in the 38th floor mechanical room and nearly perished while trying to locate a roof exit. The rescue of these members was extremely fortunate in a situation that could have resulted in an even greater tragedy. |
| Communications |
|
As is often the case, communication at such a large incident
presented a serious challenge to maintaining effective command
and control. The loss of electrical power plunged the entire
building into total darkness, forcing firefighters to rely on
portable lights. This impacted even face-to-face communications
by making it difficult for people to identify with whom they were
talking. Radio communication was also affected by the significant duration of the incident. A field communications van was brought to the scene early in the incident with a supply of spare radios and batteries, but it was a major challenge to provide charged batteries for all of the radios that were in use in the incident. To ease congestion on fireground radio channels, cellular telephones were used to communicate between the Command Post in the lobby and the staging area on the 20th floor. Several other communications functions took advantage of the cellular telephone capability. |
| Logistics |
|
The Logistics Section was responsible for several functions
including refilling SCBA cylinders, supplying charged radio
batteries, and stretching the 5-inch supply line up the
stairways. These were monumental endeavors which required the
labor of approximately 100 firefighters. Equipment and supplies
were in constant demand including handlights and portable
lighting, deluge sets, hose, nozzles and other equipment. The
Staging Area on the 20th floor included the Medical and
Rehabilitation sectors. The Philadelphia Fire Department used its high-rise air supply system to refill air cylinders on the 20th floor. Falling glass and debris severed the airline, which is extended from the air compressor vehicle outside the building to the staging area, and the system had to be repaired and reconnected at the scene. |
| Safety |
|
When things go wrong on a scale as large as One Meridian Plaza,
safety becomes an overriding concern. Firefighters were
continually confronted with unusual danger caused by multiple
system failures during this incident. The deaths of the three
firefighters and the critical situation faced by the rescue team
that was searching for them are clear evidence of the danger
level and the difficulties of managing operations in a dark,
smoke-filled high-rise building. A perimeter was set up around the building to prevent injuries from falling glass and stone panels, but it was necessary for personnel to cross this zone to enter and exit the building and to maintain the hose lines connected to the standpipe system. One firefighter was seriously injured when struck by falling debris while tending the hose lines. In addition, all supplies and equipment needed inside the building had to cross the safety perimeter at some point. Many firefighters working inside the building were treated for minor injuries and fatigue during the fire. Rest and rehabilitation sectors contributed to firefighter safety by improving mental and physical stamina, and a medical triage treatment area was established on the 20th floor. The physical and mental demands on personnel were extraordinary. In addition to managing the physical safety of personnel, their emotional and psychological well-being were considered. The Department activated its critical incident stress debriefing program and relieved first and second alarm companies soon after discovering that the crew of Engine 11 had died on the 28th floor. More than 90 firefighters were debriefed on site after the dead firefighters were evacuated. The CISD involvement continued after the fire, due to the tremendous impact of the loss and the risk to the hundreds of firefighters who were involved in the incident. The most courageous safety decision occurred when Fire Commissioner Roger Ulshafer ordered the cessation of interior firefighting efforts and evacuated the building due to the danger of structural collapse. Firefighters did not reenter the structure until the fire had been controlled by the automatic sprinklers on the 30th floor and burned out all of the available fuels on the fire-involved lower levels.< |
| BUILDING AND FIRE REGULATIONS |
| When One Meridian Plaza construction began in 1968, the City of Philadelphia was enforcing the 1949 edition of the Philadelphia Building Code. This code was of local origin and contained minor amendments that had been incorporated since its enactment. This building code made no distinction between high-rise and other buildings; and therefore, no special high-rise construction features were required. The general focus of the code was to provide a high degree of fire-resistive construction rather than relying on automatic sprinkler protection or compartmentation. |
| In 1984, Philadelphia switched from a
locally developed building code to one based on the BOCA
Basic Building Code/1981. That code has since been updated,
and the BOCA National Building Code/1990 is currently in
force in Philadelphia. Both of these codes contain provisions
expressly addressing high-rise building fire protection,
including a requirement for automatic sprinkler systems in all
new high-rise buildings. As a result of this fire, the City of Philadelphia has adopted an ordinance requiring all existing high-rise buildings to be protected by automatic sprinklers by 1997. Also, officials of the Philadelphia Fire Department have discussed proposing adoption of the BOCA National Fire Prevention Code with local amendments, as opposed to continuing to develop their Philadelphia Fire Prevention Code locally. In 1981, the City enacted amendments to its Fire Code requiring the installation of special fire protection features in existing high-rise buildings. These modifications included: |
| • | Fire alarm systems with smoke detection in elevator lobbies, entrances to exit stairways, return air plenums, corridors, and other common or public areas. |
| • | Stairway identification signs, (i.e., identification of the stairway, floor level, and the top and bottom levels of the stairway). |
| • | Stairway reentry to permit occupants to retreat from stairways compromised by smoke or fire and return to tenant spaces. (In the event doors were locked from the stairway side for security reasons, provisions had to be made to unlock doors automatically upon activation of the fire alarm system.) |
| In November 1984, the Philadelphia Department of Licenses and Inspections issued a notice of violation to the owners of One Meridian Plaza requiring compliance with these amendments. The Board of Safety and Fire Prevention later granted the owners a variance to permit stairway doors to be locked, provided that doors were unlocked to permit reentry every third floor.7 |
| (7) Records and reports provided by the Philadelphia Fire Department during this investigation do not indicate the dates of either the appeal or this variance. Firefighters did report having to force entry on several floors during firefighting because some stairway doors were locked. |
| FIRE CODE ENFORCEMENT |
| The preparation and adoption of fire
safety regulations is managed by the Philadelphia Fire Department
under the direction of the Fire Marshal. However, the department
does not perform or direct compliance inspections of individual
properties. Fire code enforcement is delegated to the Department
of Licenses and Inspections (L&I) by city charter. This
department performs the functions of the building official in
Philadelphia. The Fire Department conducts inspections of properties applying for variances, follows-up citizen complaints, and makes referrals to L&I. The block inspection program detailed in Fire Department Operational Procedure 4 (see Appendix F) provides for the annual inspection of all buildings except one and two family dwellings. However, Fire Department activities to detect and abate hazards are primarily of an educational nature. Guidelines for referring serious or continuing hazards to L&I are not detailed in the Block Inspection procedure; however, information regarding the maintenance of referral and appeal records for individual properties is detailed. It has been questioned whether the working relationship between line company personnel, the Fire Marshal's office, and the Department of Licenses and Inspections produces effective fire code compliance. Senior Fire Department officials have expressed considerable dissatisfaction with the relationship between the Fire Department and L&I, and continue to advocate a more active role for the Fire Department in code enforcement matters. Fire inspection records for One Meridian Plaza were examined after the fire to document code enforcement actions requiring the installation or upgrade of fire protection features required by the 1981 fire code amendments. An August 17, 1990, L&I violation notice cited the owner for failing to pay a non-residential inspection fee and noted that a re-inspection would be conducted within 30 days. However, no record of a subsequent inspection was produced. |
| Perhaps the most striking lesson to be
learned from the One Meridian Plaza high-rise fire is what can
happen when everything goes wrong. Major failures occurred in
nearly all fire protection systems. Each of these failures helped
produce a disaster. The responsibility for allowing these
circumstances to transpire can be widely shared, even by those
not directly associated with the events on and before February
23, 1991. To prevent another disaster like One Meridian Plaza requires learning the lessons it can provide. The consequences of this incident are already being felt throughout the fire protection community. Major code changes have already been enacted in Philadelphia (see Appendix G) and new proposals are under consideration by the model code organizations. These changes may eventually reduce the likelihood of such a disaster in many communities. 1. Automatic sprinklers should be the standard level of protection in high-rise buildings. The property conservation and life safety record of sprinklers is exemplary, particularly in high-rise buildings. While other fire protection features have demonstrated their effectiveness over time in limiting losses to life and property, automatic sprinklers have proven to provide superior protection and the highest reliability. Buildings in some of the nation's largest cities, designed and built around effective compartmentation, have demonstrated varying success at containing fires, but their effectiveness is often comprised by inadequate design or installation and may not be effectively maintained for the life of the building. Even with effective compartmentation, a significant fire may endanger occupants and require a major commitment of fire suppression personnel and equipment. Retrofitting of automatic sprinklers in existing buildings has proven effective in taking the place of other systems that have been found to be inadequate. 2. Requirements for the installation of automatic sprinklers are justified by concerns about firefighter safety and public protection effectiveness, as well as traditional measures such as life safety and property conservation. The property protection value of sprinklers was recognized long before life safety became a popular justification for installing fire protection. Life safety has become the primary concern in recent times, justifying the installation of automatic sprinklers in high-rise buildings. The value of sprinklers as a means of protecting firefighters has rarely been discussed. Members of the fire service should promote automatic fire sprinklers if for no other reason than to protect themselves. Requiring the installation and maintenance of built-in fire protection should become a life safety issue for firefighters.8 The opposition to retrofit protection has consistently cited cost concerns. Communities need to be made aware that the costs they defer may be paid by firefighters in terms of their safety. This is above and beyond the potential loss to citizens and businesses that is usually considered. |
| (8) A study by Charles Jennings reports that the firefighter injury rate in non-sprinklered high-rise buildings is seven times higher than in comparable buildings equipped with automatic sprinklers. “In High-rise Fires, Sprinklers Beat Compartmentation—Hands Down." U.S. Fire Sprinkle Reporter, April 1992, pp. 1, 5-7. |
| 3. Code assumptions about fire department standpipe tactics proved invalid. |
| One of the principal code assumptions affecting fire department operations at One Meridian Plaza concerned the installation of standpipe pressure reducing valves. The rationale for PRVs is the concern that firefighters would be exposed to dangerous operating pressures and forces |
| Firefighters at One Meridian Plaza had great difficulty determining how to improve flow and pressure from hose outlets during the fire. Even if
firefighters could have closely examined the valves, with good light and under less stressful conditions, it is unlikely that they would have been able to readjust the
valves. Numerical indicators on the valve stems represented an index for adjustment not the actual discharge pressure. (This may have confused the
technicians responsible for installing and maintaining the valves. Investigators found valves set at "20" and "80" on the index markings.
To achieve 65 psi would have required a setting from 88 to 91 on the index. A setting of 150 to 158 was necessary to produce the maximum allowable 100 psi.)
Pressure regulating devices come in three different types: | ||||||
|
||||||
| Further differentiation within each of these types results from differences in manufacturer specifications. (Details are provided in the Philadelphia Fire Department fact sheet on pressure regulating devices in Appendix G.) Some devices are field adjustable, some are not. Some can be removed to permit full, unrestricted flow, others cannot. |
| if they connected hose lines to outlets near the base of
standpipe risers of substantial height, particularly those
supplied by stationary fire pumps. For example, in a 275 foot
high standpipe zone (the highest permitted using standard pipe
and fittings), a pressure of 184 psi is required at the base of
the riser to overcome elevation and- produce the minimum required
outlet pressure of 65 psi at the top of the riser. At this
pressure, a standard 2 1/2-inch fire hose fitted with a 1
1/8-inch straight bore nozzle would produce a back pressure
(reaction force) in excess of 500 pounds. This is a well-founded
concern; however, it is built upon the assumption that fire
departments use 2 1/2-inch attack lines and straight bore nozzles
to attack fires from standpipes. Most fire departments today use
1 3/4-inch and 2-inch hose with fog nozzles for interior attack.
These appliances require substantially greater working pressures
to achieve effective hose streams. In the aftermath of this incident, the NFPA Technical Committee on Standpipes has proposed a complete revision of NFPA 149 to more closely reflect current fire department operating practices. Section 5-7 of the proposed standard requires a minimum residual pressure of 150 psi at the required flow rate from the topmost 2 1/2-inch hose outlet and 65 psi at the topmost 1 1/2-inch outlet (presumably for occupant use). Minimum flow rates of 500 gpm for the first standpipe and 250 gpm for each additional standpipe remain consistent with past editions of the standard. The proposed new requirements limit the installation of pressure regulating devices to situations where static pressures at hose outlets exceed 100 psi for occupant use hose or 175 psi for fire department use hose. This will provide substantially greater flow and pressure margins for fire department operations. These requirements are intended to apply to new installations and are not retroactive. |
| (9) The report of the Technical Committee on Standpipes appears in the NFPA 1992 Fall Meeting Technical Committee Reports, pp. 331-367. |
| 4. The requirements and procedures for design.
installation. inspection. testing. and maintenance of standpipes
and pressure reducing valves must be examined carefully. The proposed revision of NFPA 14 (1993) and a new NFPA document, NFPA 25, Standard for the Installation, Testing, and Maintenance of Water-Based Fire Protection Systems (1992), address many of the concerns arising from this fire regarding installation and adjustment of pressure reducing valves. NFPA 14 requires acceptance tests to verify proper installation and adjustment of these devices. NFPA 25 requires flow tests at five year intervals to verify proper installation and adjustment. Neither of these standards proposes changes in the performance standards for the design of pressure reducing valves. Standard performance criteria for the design and operation of each type of valve should be adopted to encourage user-friendly designs that will permit firefighters to achieve higher pressure and flow rates without interrupting firefighting operations. The operation and adjustment of valves should be easy to identify and clearly understandable by inspection and maintenance personnel without reliance on detailed operating or maintenance instructions. It is extremely important to have all systems and devices thoroughly inspected and tested at the time of installation and retested on a regular basis. Fire suppression companies that respond to a building should be familiar with equipment that is installed in its fire protection systems and confident that it will perform properly when needed. |
| 5. Inconsistencies between code assumptions and
firefighting tactics must be addressed. The inconsistency between fire department tactics and design criteria for standpipe hose outlet pressures was widely recognized before this fire. However, little was done to change fire department tactics or to amend the code requirements for standpipe installations. Fire departments utilize lightweight hose and automatic nozzles for the same reasons the code requires pressure reducing valves: firefighter safety. The inconsistency between these approaches can cause serious problems. Where pressure reducing valves are not installed, fire departments can usually augment water supplies by connecting to the fire department connections. However, when contemporary firefighting tactics are employed and improperly adjusted PRVs are installed, the combination is likely to produce hose streams with little reach or effectiveness. The PRV equipped hose outlets on the 22nd floor of One Meridian Plaza, adjusted as reported at the time of the fire, would have produced nozzle pressures of approximately 40 psi. This is insufficient for a straight stream device and dangerously inadequate for a fog nozzle. Standard operating procedures for high-rise buildings, particularly those not protected by automatic sprinklers, should reflect the potential need to employ heavy firefighting streams, which may require higher flows and pressures. |
| 6. Pre-fire planning is an essential fire
department function. The availability of information about the building was a problem in this incident. The purpose of conducting pre-fire plans is to gather information about buildings and occupancies from the perspective that a fire will eventually occur in the occupancy. This information should be used to evaluate fire department readiness and resource capabilities. At a fire scene, pre-fire plan information can be used to formulate strategies for dealing with the circumstances which present themselves. Pre-fire planning activities should identify building and fire protection features which are likely to help or hinder firefighting operations and record this information in a format usable to firefighters at the scene of an emergency. Recognizing and recording information about pressure restricting devices and pressure reducing valves should be among the highest priorities. Information on fire alarm systems and auxiliary features such as elevator recall, fan control or shutdown, and door releases should also be noted. The Fire Department was unable to obtain important details about the installed fire protection at One Meridian Plaza during critical stages of the fire attack. Detailed information about the design and installation of standpipes, pressure relief valves and the fire pump, could have aided firefighters significantly if it had been available earlier in the fire. Pre-fire plans and standard operating procedures should also consider evacuation procedures and plans for the removal of occupants. |
| 7. Standard Operating Procedures (SOPs! and training
programs for fires in high-rise buildings should reflect the
installed protection and high-rise fire behavior.
Training and SOPs should consider ways to achieve adequate fire flow with available pressures and ways to improve flow and pressure when required. Tactics for placing multiple lines in service simultaneously must also be developed and discussed. Extensive pre-fire planning and training are required for fire department control of mechanical smoke management systems to be effective. Training in the management of smoke should consider stack effect and the ability to predict and/or direct ventilation in a real incident. |
| 8. Safety-oriented strategies should dominate
command decisions when multiple systems failures become evident. This incident presented command officers with an unprecedented sequence of system failures. As more things went wrong, officers had to seek alternative approaches to manage the situation. The time pressure and stress of fireground command can make it difficult to thoroughly evaluate each alternative approach, particularly as new and unanticipated problems are presented in rapid succession. Conservative tactics, oriented toward protecting the firefighters who must execute them, should take precedence when confronted with an unknown and unanticipated situation, since the potential consequences of fireground decisions can rarely be fully evaluated during the incident. As much as possible, these alternatives should be considered beforehand in pre-fire planning, standard operating procedures, and training materials, and by reviewing post-fire critiques and reports of other incidents. This is an incident that will make a major contribution to the knowledge of what can and will happen when major system failures occur in the worst imaginable sequence. |
| 9. Fire code enforcement programs require the active
participation of the fire department. In Philadelphia, responsibility for the fire code is fragmented. The Fire Department is responsible for developing and maintaining fire code requirements, supervising the appeals process, and investigating and referring fire code complaints. However, it does not conduct regular periodic code enforcement inspections, issue permits, or develop target hazard protocols for ensuring that inspections conducted by the responsible agency are addressing critical fire protection problems. Many of the model code requirements that apply to high-rise buildings are predicated upon assumptions about firefighting strategies and tactics. Most model code organizations designate the fire department, fire prevention bureau, or fire marshal's office as the principal enforcement authority for fire protection system requirements. Fire department personnel are in the best position to validate code assumptions and see that the built-in fire protection and life safety systems are functional and compatible. Moreover, the first-hand knowledge and experience of firefighters with fire behavior is often an invaluable resource when interpreting fire and building code requirements. |
| 10. Code provisions should be adopted requiring
high-rise building owners to retain trained personnel to manage
fire protection and life safety code compliance and assist fire
department personnel during emergencies. Model fire prevention codes require building owners to develop high-rise fire safety and evacuation plans to manage the life safety complexities of these buildings. The requirements are not specific about what must be included in these plans, and they give no explicit consideration to the problems of firefighting and property conservation. Mandating the appointment and certification of individuals with specialized knowledge in code requirements and building systems would go a long way toward ensuring that the unique aspects of each high-rise building are incorporated into detailed plans. (New York City Local Law 5 requires that each owner designate a fire safety director. The responsibilities of this individual for managing the life safety plan during an incident are clearly established in this ordinance.) |
| 11. Occupants and central station operators must
always treat automatic fire alarms as though they were actual
fires. especially in high-rise buildings. Building personnel, alarm services, and fire departments must develop an expectation that an automatic alarm may be an indication of an actual fire in progress. Automatic detection systems have gained a reputation for unnecessary alarms in many installations. This has caused an attitude of complacency that can be fatal in responding to such alarms. To change such attitudes and expectations, it will be necessary to improve the reliability and performance of many systems. By choosing to investigate and verify the alarm condition, the building engineer nearly lost his life. If not for the ability to communicate with the lobby guard to relay instructions for manually recalling the elevator, this individual would likely have shared the fate of his counterpart who died in a service elevator at the First Interstate Bank Building Fire in Los Angeles (May 4, 1988). Technological advances and improved maintenance procedures are the answers to solving the nuisance alarm problem. In addition to requiring regular maintenance of systems by qualified individuals, Philadelphia and other cities have stiffened the penalties on owners, occupants, and central station operators who fail to report automatic fire alarm activations. |
| 12. Incomplete fire detection can create a false sense
of security. Automatic Fire detectors, like automatic sprinklers, are components of engineered fire protection systems. A little protection is not always better than none. Over-reliance on incomplete protection may lead to a false sense of security on the part of building owners and firefighters alike. Automatic fire detectors can only notify building occupants or supervisory personnel at a central, remote, or proprietary station that an event has occurred, and in some cases initiate action by other systems to limit the spread of fire, smoke, or both. (In this case, automatic detectors initiated an alarm, recalled elevators, and shutdown air handling equipment; however an elevator was subsequently used to go to the fire floor to investigate the alarm.) Smoke detectors at One Meridian Plaza were installed in particular areas as required by the 1981 amendments to the fire code; that is at the point of access to exits, at the intakes to return air shafts, and in elevator lobbies and corridors. The apparent underlying logic was to protect the means of egress and to detect smoke in the areas where it was most likely to travel. It appears in this case that the partitions and suspended ceiling contained the smoke and heat during the fire's incipient phase and prevented early detection. In all likelihood, the first detector may not have activated until after the room of origin had flashed-over. Shortly after flashover, the suspended ceiling in this area probably failed permitting the fire to spread throughout the return air plenum. Once the fire broke the exterior windows and established an exterior air supply there was little that could be done to control the fire. Firefighters were disadvantaged by the delay in reporting the fire. |
| 13. Nationally recognized elevator code
requirements for manual control of elevators during fire
emergencies work. Elevator control modifications at One Meridian Plaza were accomplished in accordance with Commonwealth of Pennsylvania requirements based on ANSI/ASME A17.1, Safety Code for Elevators and Escalators. The elevators performed as expected by the standard. The only problem with the elevator response was the decision of the building engineer to override the system to investigate the alarm. |
| 14. The ignition source provided by oil-soaked rags is
a long recognized hazard that continues to be a problem. Had the contractor refinishing paneling on the 22nd floor not carelessly left oil soaked cleaning rags unattended and unprotected in a vacant office, this fire would not have occurred. To pinpoint the particular source of ignition of this fire as the sole cause of the death and destruction that followed is a gross oversimplification. Nevertheless, failure to control this known hazard is the proximate cause of this disaster. The danger of spontaneous heating of linseed oil-soaked rag waste is widely recognized. Each model fire prevention code requires precautions to prevent ignition of such materials. At a minimum, waste awaiting removal from the building and proper disposal must be stored in metal containers with tight-fitting, self-closing lids. Leaving these materials unattended in a vacant office over a weekend was an invitation to disaster. This is both an education and an enforcement problem for fire prevention officials. |
| 15. Building security personnel should be vigilant for
fire safety as well as security threats especially while
construction demolition. alteration. or repair activities are
underway. Earlier in the day, the building engineer had become aware of an unusual odor on the 22nd floor which he associated with the refinishing operations which were underway there. When the alarm system activated later that evening he first believed the solvent vapors had activated a smoke detector. The roving security guard made no mention of anything unusual during his rounds of the fire area earlier in the evening. It is conceivable that no detectable odor of smoke or audible or visible signals of a fire were present when the guard last checked the floor. However, a cursory check is not adequate when construction, demolition, renovations, or repair activities are underway in a building area. Fire hazards are often associated with construction activities, and buildings are especially vulnerable to fire during such operations. For these reasons, it should be standard practice to check these areas even more carefully and thoroughly than usual. All building operating and security personnel should have basic training in fire prevention and procedures to be followed when a fire occurs. |
| 16. Emergency electrical systems must be truly
independent or redundant. Article 700 of the National Electrical Code recognizes separate feeders as a means of supplying emergency power. However, Section 700 12(d) requires these services to be "widely separated electrically and physically...to prevent the possibility of simultaneous interruption of supply." Installing the primary and secondary electrical risers in a common enclosure led to their almost simultaneous failure when the fire penetrated voids in the walls above the ceiling of the 22nd floor electrical closet. The intense heat melted conductor insulation resulting in dead shorts to ground which opened the overcurrent protection on each service interrupting power throughout the building. Auxiliary emergency power capability was provided by a natural gas powered generator located in the basement mechanical room. This generator was intended to supply one elevator car in each bank, fire pumps, emergency lighting and signs, and the Fire alarm system. However, this generator set failed to produce power when needed. (Generator maintenance records indicated a history of problems; however, the root cause or mechanism responsible for these problems was not identified.) Supplying the generator from the building natural gas service also left the emergency power system vulnerable in the event of simultaneous failure of the electrical and gas public utilities. The transformers that provided power for the adjacent building were installed in the basement of the One Meridian Plaza Building. These transformers had to be shut down due to the accumulation of water in the basement, resulting in the loss of power to this building as well. As a result the elevators in the adjoining building could not be used. |
| 17. The regulations governing fire-resistance
ratings for high-rise structural components should be
reevaluated. The degree of structural damage produced during the fire at One Meridian Plaza suggests that the requirements for structural fire resistance should be reexamined. Floor assemblies deflected as much as three feet in some places. The fire burning on multiple floors may have produced simultaneous exposure of both sides of these assemblies, which consisted of concrete slabs on corrugated decks, supported by structural steel beam and girder construction, sprayed with cementitious fireproofing materials. The standard fire test for floor and ceiling assemblies involves exposure from a single side only. Columns and certain other structural elements are normally exposed to fire from all sides. In this fire, the steel columns retained their structural integrity and held their loads. Experience in this and similar high-rise fires suggest that columns are the least vulnerable structural members, due to their mass and relatively short height between restraints (floor to floor). Major damage has occurred to horizontal members, without compromising the vertical supports. The development of uniform criteria for evaluating structural fire endurance accompanied the development of skyscrapers in the early 20th century. Test methods developed at the beginning of the century became the first fire-resistance standard in 1909,10 which endures today as ASTM E119, Method of Fire Test of Building Construction and Materials. One of the principal criticisms of this standard has been its lack of correlation with actual fire conditions. Many fire protection professionals believe that the standard time-temperature curve used to produce the standard fire exposure during testing is less severe than actual fires involving contemporary fuel loads. (The original test method was based on less volatile, primarily cellulosic, fuels, while modern plastics and hydrocarbon-based furnishings and finishes produce much more dangerous and severe fire exposures.) Others believe that the current test method works well because it provides a good yardstick for comparing the performance of different systems and has been in widespread use for many decades, generating volumes of data on many systems.11 |
| (10) Fitzgerald, R W. (1981), 'Structural Integrity During Fire," in Fire Protection Handbook, 15th ed., McKinnon, G. P., ed., Quincy, MA National Fire Protection Association, p. 542. |
| (11) Actual conditions in most fires produce heat release curves similar to the standard exposure up to the point where oxygen, i.e., ventilation, becomes restricted by fire product release, i.e., smoke and heated gases. However, at this point, actual fires usually diminish in size unless ventilation improves or a renewed oxygen supply is established. Once refreshed with a new air supply, most fires will resume growth, reach a peak, and then diminish as the fuel supply is consumed. |
| 18. Inspections must be conducted during and after
construction to verify that penetrations in fire-resistance rated
assemblies are properly protected. Voids and so-called poke-throughs in horizontal and vertical fire separation assemblies presented ideal avenues of fire spread during the One Meridian Plaza fire. Openings in the partitions enclosing electrical equipment on the floor of origin permitted the fire to reach and damage the electrical risers, plunging firefighters into darkness early in the fire. Voids in stairwell enclosures permitted smoke to spread in stairwells making firefighting operations difficult and exposing upper floors. Smoke and fire also extended via pipe chases, and telephone and electrical closets. Through-penetration protection has been a continuing concern and has received considerable attention in building and fire codes in recent years. Each of the model building codes now contains provisions requiring protection of poke-throughs in fire-resistance rated assemblies. Moreover, a whole new industry has been developed to fill the technological void in through-penetration protection which developed with the widespread acceptance of plastic pipe and cable. The absence of fire dampers in mechanical system supply and return ducts at shaft penetrations on each floor is of particular concern. There is evidence of smoke and fire spread through the air handling system. Nationally recognized model building, fire, and mechanical codes have contained requirements for fire dampers in these locations for many years. The installation of smoke detectors in these locations was an ineffective substitute for protecting the integrity of smoke and fire barriers. This fire clearly illustrates that smoke and fire spread through mechanical system plenums, ducts, and shafts is substantial even without the aid of operating fans.12 |
| (12) HVAC fans were shut down at night and on weekends, and were not operating at the tine of the fire. |
| 19. Features to limit exterior vertical fire spread
must be incorporated in the design of high-rise buildings. Exterior vertical fire spread or auto-exposure can be a significant fire protection problem in construction of high-rise buildings if interior fire growth is unrestricted. Because of the difficulty with retrofitting exterior features to restrict fire spread, the installation of automatic sprinklers to restrict fire growth is the most simple approach to managing this risk in existing buildings. Exterior features to prevent fire spread must usually be designed and built into new buildings. Many modern (international style) and post-modern building designs present difficult exterior fire spread challenges because of their smooth exterior facades and large glazing areas. Variegated exterior facades and larger noncombustible spandrels significantly reduce exterior fire spread effects by increasing the distance radiant and conductive heat must travel to stress exterior windows and to heat materials inside the windows on floors above the fire. |
| CONCLUSION |
| The ultimate message delivered by this fire is the proof that automatic sprinklers are the most effective and reliable means at our disposal to protect high-rise buildings. When all other systems failed, automatic sprinklers were successful in controlling the fire. The Philadelphia Fire Department was confronted with an essentially impossible situation and did a commendable job of managing the incident. The loss of three firefighters is a tragedy that will always be remembered by the Philadelphia Fire Department. Analysis of the situation reveals, however, that the toll could have been much worse, had it not been for the courage, skills, and experience of this Department. Several extremely difficult decisions were made under the most severe conditions. This fire will also be remembered for the lessons that it brings with respect to fire protection systems. To work effectively, such systems must be properly designed, installed, and maintained. When those requirements are not satisfied, the results can be devastating, as clearly demonstrated by this incident. |
| SOURCES OF INFORMATION |
| In addition to references to codes and standards cited in the text, news media accounts of the fire, and interviews with officials of the Philadelphia Fire Department, the following resources were used in the preparation of this report: |
| Alert Bulletin: | Pressure Regulating Devices in Standpipe Systems (May 1991). Quincy, MA: National Fire Protection Association |
| Butters, T., and T. Elliott (March 1991). | "How the Philadelphia FD Handled the Worst High-Rise Fire in the City's History," IAFC on Scene, March 15,1991. |
| Eisner, H., and B. Manning (August 1991). |
"One Meridian Plaza Fire," Fire Engineering, August 1991. pp. 50-70. |
| Factory Mutual Engineering Corporation (March 1990). | High-Rise Buildings, Loss Prevention Data Sheet 1-3. Boston, MA: Factory Mutual Engineering Corporation. |
| Factory Mutual Engineering Corp. (December 1986). |
Pressure Reducing Valves for Fire Protection Service, Loss Prevention Data Sheet 3-11. Boston, MA: Factory Mutual Engineering Corporation. |
| Klem, T. J. (May 1991). | Preliminary Investigative Report: On Meridian Plaza, Philadelphia, PA, February 23, 1991, Three Fire Fighter Fatalities. Quincy, MA: National Fire Protection Association. |
| Klem, T. J. (September/October 1991). | "High-Rise Fire Claims Three Philadelphia Fire Fighters," NFPA Journal, Sept/Oct 1991. pp. 6467, 89. |
| Linville, J. L., ed. (1991). | Fire Protection Handbook, 17th ed. Quincy, MA: National Fire Protection Association. |
| McKinnon, G. P., ed. (1981). | Fire Protection Handbook, 15th ed. Quincy, MA: National Fire Protection Association. |
| One Meridian Plaza: | 12-Alarm High-Rise Fire (1991), Philadelphia, PA: Philadelphia Fire Films. Videotape. |
