Potential Fire Protection Failures – ASSE Philadelphia Chapter – April 16, 2015

April 7, 2015
Why did this sprinkler head fail to operate in a fire?

Why did this sprinkler head fail to operate in a fire?

I will be presenting, “Potential Fire Protection Failures” at the Philadelphia Chapter of American Society of Safety Engineers’ luncheon meeting on April 16, 2015 at the Parx Casino East (Philadelphia Park Racetrack Building), 2999 Street Road, Bensalem, PA.

The pictured sprinkler head was in an actual fire. Unfortunately, it failed to operate. Why did this sprinkler head fail? What could have been done differently? How could an effective Inspection, Testing, and Maintenance program have prevented this failure?

Fire protection systems have a stellar performance record. Fire sprinklers are effective in 97% of fires in which they operate. What causes failure in the other 3%? See some of the factors which can compromise fire protection systems. The main focus of the topic is to show various parts of a fire protection system and explain why and how they may impact the proper operation of the system. The issues identified in the presentation are typically found in many industries and can be applied to the self inspection program at any facility. The talk will include examples of fire protection items which may be compromised. These items could be detected and identified by a well organized fire protection self inspection program.

On April 16 I will describe the events leading up to the fire this sprinkler head was to have controlled, why it the sprinkler head failed to operate, and the aftermath of the fire. I think you will be interested in what happened.

Additional details may be found at phila.asse.org.

I hope to see you there.

Fire Evacuation: Developing Situational Awareness

September 23, 2014

Fire Alarm Pull Station

The fire alarm sounds! What do I do? Well, first of all, it depends on where I am when the alarm sounds. If I am in a hotel and the alarm sounds in the middle of the night, my job is to evacuate via one of the routes I have previously scoped out. Every time I check into a hotel room, I scope out the evacuation routes. Yes, I am one of those guys who will ask the front desk associate where the stairs exit and I will many times walk the stairs to see exactly where they exit. If you have never done this, try it sometime. You may be surprised the response the front desk agent associate offers – and where you end up after walking the stairs, especially in an old hotel. In one hotel attended for a group meeting, a group of us walked the stairs and found ourselves in the basement, adjacent to the door of the main kitchen, and nowhere near an outside exit. The building was built prior to current-day life safety codes and is grandfathered in by the municipality. The lesson – don’t be surprised by the unexpected.

How about a theater or restaurant? I hope you scope out the exits when you go in – I do. So do many of my friends. It seems safety professionals and firefighters do this automatically – not a conscious effort, but a conditioned response to entering new surroundings. It is maintaining situational awareness. Emergency responders learn to do a quick size-up when entering a situation, and this provides a basis for future plan of action in the event of an emergency. The clues and cues noted during the initial size-up will help if an emergency does arise.

Based upon the initial size-up, clues, and cues, the experienced person will subconsciously anticipate what might happen in the next few minutes, hour, or next “period” of time. This level of situational awareness takes a long time to achieve – years of experience and repetitive assessments.

Many people do have such a sense of situational awareness in some areas of their life, but perhaps not other areas. For example, a new teenage automobile driver does not have the same situational awareness on the road as their parents, and must learn through experience and (hopefully) continued driver safety awareness and education. Auto insurance companies recognize this and respond with increased premiums for those under 25 years of age. To compound this lack of situational awareness, a newly licensed teen driver may not even realize or accept their lack of competence. They are not yet able to anticipate actions, reactions, and situations to which they may be forced to respond within the next few seconds. After a few close calls, a few surprising incidents, a few minor fender benders, they reach a realization that they have more to learn. This level of consciousness is the next step in becoming a good driver who can anticipate possible actions of others on the road. Eventually, after several years of practice, a level of unconscious situational awareness developes, and we can drive as if we are in “auto-pilot” mode. This is a state where we absorb clues and cues, process the information, and respond without so much as a conscious thought. Such as hitting brakes and swerving to avoid a collision.

This same development of situational awareness can also be applied to how we respond to a fire emergency. Transferring this situational awareness to a fire condition is not as easy as one might think. Most people do not respond to fires on a daily basis. Most people think they know what to do and will do the right thing in a fire emergency. Unfortunately, we do not always understand our shortcomings. Our lack of practice, knowledge, and awareness may lead to disastrous consequences.

Our place of business – where we work – where we spend almost a quarter of our working life, should be familiar territory. We enter our workplace as a matter of habit. Taking the same elevator to and from our floor, entering and leaving through the same doorway, taking lunch at the same cafeteria, and following the same route. We can become numb to our surroundings. We can go into “auto-pilot” mode. The “auto-pilot” mode should not be relied upon during an emergency. Our normal exit may be blocked and we may need to escape though an alternate exit at the other end of the building. If we do not possess a situational awareness of our surroundings, we may become confused, lost, and unaware of the appropriate response or action.

As managers and safety professionals, we must ensure that every employee is trained and educated in the proper course of action to take in the event of an emergency. The size of your workplace, the hazardous operations conducted, and hazardous materials handled should be part of your employee training. Every employee should understand the hazards which may create an emergency and know what actions they should take in the event an emergency arises. Every employee should understand the function and elements of your emergency action plan. They should understand the hazards, potential emergencies, emergency shutdown procedures, procedures for reporting an emergency, and activating the alarm system. Hazard communication is very important to educate employees in hazards, flammable liquids, toxic chemicals, radioactive sources, or other special hazards.

Evacuation plans should be practiced regularly. I prefer more than annual drills. A year is a long time to wait between training sessions. Training and educational sessions should be provided for all new employees; whenever an employee changes job tasks or departments; when to process changes or new hazards are introduced; when there is a change which alters the floor plan or evacuation routes; when the emergency response plan changes; and whenever management deems the time is appropriate to conduct an unscheduled drill. Encourage employees to develop a situational awareness mentality. Every employee should take a few seconds before every task to review and evaluate the hazards and anticipate undesired outcomes. After a while, every employee will begin to develop a situational awareness for their work tasks and work sites.

Emergencies happen. It is my opinion that every manager and every employee are responsible for the proper actions and response to prevent a catastrophe. Developing a comprehensive emergency action plan that deals with all types of issues specific to a work site is not difficult, expensive, or burdensome. Management and employees should come together to help safeguard each others’ safety and well being. Evacuation is only one part of an effective emergency response program.

The Great Fire of London

September 1, 2014

The Great Fire of LondonSunday, 2 September to Wednesday, 5 September 1666

Pat a cake, Pat a cake, baker’s man

Bake me a cake as fast as you can;

Pat it and prick it and mark it with a ‘B’,

And put it in the oven for Baby and me.

 A nursery rhyme with origins referencing the Great Fire of London.

At that time, bakeries were viewed as great fire risks. The Great Fire of London is believed to have started in a Baker’s shop on Pudding Lane. Only a short distance from the wharves of London, Pudding Lane was reportedly amid some of the most unsavory parts of the city. The shop and dwelling of Farynor (aka Thomas Farrinor), King Charles I’s baker was on Pudding Lane 10 doors from Thames Street. Flames reportedly broke out from Farynor’s ovens between one and two o’clock in the morning. Farynor, his wife and daughter escaped their hose through a garret window, his man followed, but his maidservant became the first fatality of the fire.

The city was at that time a “walled city” which was designed in the feudal concept for defense. Mediaeval construction was the style of the time. Shakespeare had died a mere 50 year prior. Land was a premium commodity, and houses were nestled in one upon the next. Densely packed narrow houses, timber framed of varied heights with red tiled roofs. Houses treated with pitch to preserve the wood frames. Factories interspersed among the dwellings, getting workers from communities within walking distance. Factories spewing smoke from stacks of furnaces – the heart of soap making, dying, drying, and brewers. Pudding Lane was one of the tightest streets in the city, with only a cart width of space in some tighter areas.

Firefighting in the 1600’s was nothing like today. Houses were built with iron rings near the rooftop for ropes to be affixed and hooks on long poles to grab. The wall of the offending house – or that of a house to be used as a fire break was pulled down by teams of men. Squirts, long, large syringes filled with water by drawing the plunger, then pushing the plunger to expel the water under pressure were the fire extinguishers of the day. Two men would hold the syringe while a third pressed the plunger. Cisterns on wheeled carts would be wheeled to the fire to give a quick means of refilling the squirts. Wood pipes were drilled into to provide a cistern of water along the street. 17th century firefighting was no match for the ravages which fell upon the city.

In the end, the fire consumed 13,200 houses which housed approximately 70,000 of London’s 80,000 citizens. 87 parish churches, including St. Paul’s Cathedral, and most of the buildings of the City authorities were consumed.

The city was rebuilt. Several lent ideas, including Sir Christopher Wren, Captain Valentine Knight, and John Evelyn. During the rebuilding, occupants dispersed to wherever they could find an abode.

The Great Fire of London is not unique among fire history. It is an item of history amid many other cities which burned. The Great Fire of London will continue to remain in the forefront of fire history.

The Monument stands at the junction of Monument Street and Fish Street Hill in the City of London.

The Monument stands at the junction of Monument Street and Fish Street Hill in the City of London.

Visit to the Monument. Standing 202 feet high, the Monument is the tallest isolated stone column in the world.

Stairs going up to the top of the Monument to the Great Fire of London

Stairs going up to the top of the Monument to the Great Fire of London

The monument was designed by Sir Christopher Wren and Robert Hooke and constructed with Portland stone in 1671-7. The simple Doric column is topped by a flaming urn of copper gilded with two layers of gold leaf to symbolize the Great Fire. I am privileged to have climbed the 311 steps to the balcony at the top.


Bell, Walter George. The Great Fire of London. London: Bracken, 1994. Print.

“Great Fire of London.” New World Encyclopedia. New World Encyclopedia, 10 Jan. 2014. Web. 01 Sept. 2014. <http://www.newworldencyclopedia.org/entry/Great_Fire_of_London&gt;.

Photo – Detail of the Great Fire of London by an unknown painter, depicting the fire as it would have appeared on the evening of Tuesday, 4 September 1666 from a boat in the vicinity of Tower Wharf. The Tower of London is on the right and London Bridge on the left, with St. Paul’s Cathedral in the distance, surrounded by the tallest flames. – Wikipedia (Public Domain)

Combustible Dust… Elements of Dust Hazard Assessment

July 3, 2013

Old Factory - Conditions were bleak

Combustible dust assessments are performed to assist management in identifying and defining hazardous conditions and risks so they may be eliminated or controlled. The analysis should examine the process, systems, subsystems, components, actions (or lack of actions), and their interrelationships.

The assessment and review of what can go wrong may not be an easy task. Many dust losses are not the result of a single cause. Rather, it is the confluence of multiple events which occur simultaneously or in a chain of events. Systems should be designed using methods considered to create a “safe” situation. The reliability of the components and assemblies must also be considered. When components or assemblies fail the initial design parameters are compromised. The compromised system is outside of the normal scope of design, and a loss is much more likely to occur.

A dust hazard analysis may be used wherever a dust condition exists. It may be a process which involves drying a liquid sprayed into a drying chamber. It may involve grinding, sifting, screening, or other manipulation of a product. The dust may be released from the process of pouring ingredients from a bag into a vessel. It may be dust within a conveying system. The dust may be tramp dust emissions, or escape material from process leakage points in a manufacturing situation. Dust may also be present from inadequate housekeeping. Dust hazards may exist where large pieces of material are handled, but in the manufacturing process, dusts are created in small amounts and allowed to accumulate over time.

A Look Back in Time

In the grand scheme of the Industrial Revolution, systemized educational curriculums for safety and hazard analysis are relatively recent. Only a few decades ago, finding a college curriculum majoring in safety, fire protection, or process hazard safety were limited. Fortunately, today, such programs are more available and have sprung up at several colleges and universities around the country. Even in universities without dedicated safety programs, safety courses are offered, and even required, in many engineering curriculums. Safety is a topic of discussion in all aspects of engineering.

Early systematic processes were identified in aviation and military applications. Equipment or system failure at 20,000 ft. is not always a survivable event. Moving into the space age, NASA learned through failures that a systematic process must be followed to identify points of failure in each system installed and implemented into the space vehicles launched into outer space.

In the 1960’s, the process and chemical industries embraced Process Hazard Analysis. Calling it HAZOP, for Hazard and Operability Method, it became better identified and published in the 1970’s. Its introduction into process safety regulations in the 1980’s and 1990’s caused a dramatic increase in the implementation of the process. Industries performing high hazard operations have incorporated process hazard analysis into their design and analysis procedures.

Sometimes, product liability drives the need for safety analysis. Today, auto makers perform hazard analysis for each vehicle they make, but this was not always so. Prior to the 1970’s, safety hazard analysis studies were not routinely performed on new car designs. One prominent example was the Ford Pinto. Its gas tank had a tendency to explode into flames upon rear impact. According to some accounts, Ford Motor Company performed cost benefit analysis and identified that the cost to make changes to the vehicle would be greater than the cost of anticipated legal claims. The legal battles over occupant deaths and injuries of the Ford Pinto changed the auto industry’s attitude toward safety analysis on their auto designs. Today, auto makers routinely analyze their vehicles for failure in an attempt to identify weaknesses. The industry has changed over the last 40 years and vehicle safety is a major selling point.

Today, the practice of performing hazard analysis is spreading across general industry. Hazard analysis and safety assessments are provided for many reasons. Companies are concerned with product liability, safety of a hazardous process, property conservation, business continuity, and worker safety. While many corporations have concerned management, there are some who will be dragged into the process through losses, government fines, and litigation.

Preventing Dust Explosions

Unfortunately, there is no easy answer to preventing explosions. NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids discusses many aspects of preventing dust explosions. One of the primary items is designing the processes and facilities that handle combustible particulate solids appropriately. The design must take into account the physical and chemical properties that establish the hazardous characteristics of the materials. The building and processes should undergo a thorough hazard analysis study. The study should look at equipment design, process procedures, worker training, inerting and other protection means. The process system should be designed to limit fugitive dust emissions to a minimum. Any changes, additions, or modifications to the system or process should be reviewed in a management of change evaluation. The major objectives in the review should be life and property conservation. The structural integrity and damage limiting construction is an important aspect. Mitigation for the spread of fire and explosion should be designed into the system. The design should adhere to existing codes, and be of sound, proven technology and technique. NFPA 654 provides a number of sound methods for the design of dust related occupancies, and references several other NFPA codes and standards for specific concerns.

Additional Information – ASSE Safety 2013 Proceedings / Presentation June 25, 2013

For additional information, CLICK HERE see the Proceedings Paper submitted to ASSE for Safety 2013!

Iroquois Theatre Fire – December 30, 1903

December 29, 2010

The Iroquois Theatre fire occurred on December 30, 1903, in Chicago, Illinois. It is the deadliest theater fire in United States history. Over 600 people died as a result of the fire, and it is believed that not all the deaths were reported.

The Iroquois Theater had just opened on November 23, 1903, and was touted as being absolutely “FIREPROOF!” An asbestos fire curtain was installed to isolate the stage from the audience. Despite the warnings of fire officials and engineers, the show went on. The roof over the stage was nailed shut, many of the fire exits reportedly did not have working stairs to the ground, there were no exit signs, exit routes from the balconies were complicated, and there were no exit route signs installed. The asbestos fire curtain at the stage was reported to be of flimsy material which burned to a crisp in the fire. There were no fire drills conducted by the theater for ushers and employees. When the fire broke out, they did not have adequate training and knowledge of what they should do in a fire!

The capacity of the theater was 1,724, but the crowd that night is expected to have far exceeded the rated capacity. On December 30, 1903, during the second act, a light sputtered and a piece of machinery caught fire. The electrician could not pot the fire out, but the performers continued with the show. Back doors were opened, which created an influx of oxygen to feed the fire.

In a all too familiar scene, people were trampled to death in the onslaught of panicking patrons trying to exit the building. Stairs had been blocked and locked with gates, preventing patrons to exit. Several exit doors had been locked to prevent outsiders from slipping in without playing.

After the fire, Carl Prinzler, a salesman for Vonnegut Hardware Company, Indianapolis realized that he was to have been at the performance that day, and a stroke of fate prevented him from going. He became obsessed with the tragedy, and eventually developed a new device in collaboration with Henry DuPont, an engineer: The Crash Bar. The patent was awarded in 1908. Today, variations of the Crash Bar are required on all exit doors of public buildings.

New codes were implemented across the nation for theaters and exiting in all public buildings. Unfortunately, new codes take time to implement. Unfortunately, building owners and managers refuse to learn from the lessons of the past in an effort to meet a personal goal or agenda. These type tragedies would continue. A few years later, some of these same lessons were repeated at another high-profile fire: The Triangle Shirtwaist Fire of March 25 1911.

Watch for the upcoming edition of ASSE Fireline for an in-depth article titled “Carl Prinzler’s Invention and The Iroquois Theater Fire” by Trevor Simon.

84 Die in Hotel Fire – MGM Grand 30th Anniversary

November 20, 2010

The MGM Grand Hotel fire occurred on November 21, 1980 (The MGM Grand is now Bally’s Las Vegas). The fire killed 84 people. The MGM Grand fire is the third worst hotel fire in US history. There were approximately 5,000 people in the hotel at the time of the fire. There were reportedly over 700 injuries. 84 died.

Three months later, February 10, 1981, another major hotel fire occurred at the Las Vegas Hilton Hotel where 8 people perished. As a result of the deadly hotel fires, Las Vegas passed a rigorous sprinkler code for all hotel and casino properties. Since the installation of fire sprinklers, there has not been a loss of life hotel fire in Las Vegas.

The worst loss of life hotel fire is the December 7, 1946 Winecoff Hotel fire, Atlanta, GA that killed 119 people. The next worst fire was the Dupont Plaza Hotel fire in Puerto Rico on December 31, 1986 where 97 lives were lost.