Chicago high rise fire case study

Fire-panel finds tower of failure ; Faulty assumptions, communications and procedures:[Chicago Final Edition]

Jeff Coen, Mickey Ciokajlo and Jon Yates, Tribune staff reporters. Chicago Tribune. Chicago, Ill.: Mar 28, 2004.  pg. 1

Full Text (1851   words)

Copyright 2004 by the Chicago Tribune)

This story is a composite of versions published in the various editions.

CORRECTION: This story contains corrected material, published March 30, 2004.

The response to the fatal fire in the Cook County Administration Building was plagued by faulty assumptions, communication breakdowns and apparent breaches of protocol, a picture that has emerged from months of testimony before an investigative panel that has grown increasingly critical of the Chicago Fire Department.

Abner Mikva, who heads the commission looking into the fire at 69 W. Washington St., said that while no conclusions have been reached, some issues have become clear.

"There just was too much non-communication, if not miscommunication, in this fire," Mikva said.

Last week, the county-appointed panel completed scheduled testimony from those who were in the building on Oct. 17, when six people died in its southeast stairwell. The panel will hear next from safety and fire-fighting experts and has not ruled out calling more firefighters.

City officials have accused the commission of trying to pin the deaths on the firefighters and have said the panel hasn't given the same scrutiny to potential building defects or building personnel.

Mikva has said the commission is not looking to lay blame for the deaths. Still, he said, "it would be a very, very unusual tragedy if there wasn't somebody who made mistakes somewhere."

Within minutes after the fire started in a 12th-floor storage room, building engineer Dave Rabka made what some have argued was the first breach of protocol, calling for evacuation of the building.

Panel member William Cousins Jr. said there might have been no fatalities if workers had been told to wait in their offices.

Building officials have defended Rabka's decision, saying he could evacuate "additional floors" as called for in the building's fire-safety plan. However, that plan says the authority to order an evacuation "rests solely with the local fire officials."

Soon after the evacuation order, arriving firefighters made more choices that have since been questioned. Fire Department protocol states that firefighters are supposed to take over the building's public-address system upon arriving, but no one did. At the time, a security guard was ordering the building's roughly 400 occupants to evacuate using the stairwells.

Used smoke tower

Moments later, Capt. Michael Gubricky made another critical decision. Faced with a fire raging on the east side of the 12th floor, Gubricky decided to fight the blaze from the southeast stairwell, which was the building's smoke tower. A smoke tower is a vertical shaft, like a chimney, designed to carry smoke out of the building and keep tenants safe while they evacuate.

The Chicago Fire Department's firefighting protocol advises that smoke towers "will be utilized for evacuation of occupants where possible and not for firefighting."

Experts have said fighting a fire from a smoke tower can intensify a blaze.

The smoke tower can be used, the protocol says, if it's "the only logical means" of battling a blaze. Gubricky said he knew the stairwell was the smoke tower when he set up the attack.

"Well, where there's smoke, there's fire," he told the panel.

Gubricky said he did not know there were people in the stairwell, even though some of the firefighters who were with him said they saw fleeing office workers.

Firefighter Daniel Truesdale, among the first to arrive on the 12th floor, said he caught a glimpse of a civilian on the stairs above him just before crews popped open the door to battle the blaze.

Truesdale said he did not speak to the person, nor did he see the person go past him, but he assumed the person continued down the stairs.

Brian Sanchez, a worker in the building, testified he was on the 12th-floor landing when the firefighters were working on the door.

"I said, you know, `Thank God you're here, what do I do next?'" Sanchez told the panel. "And the fireman said to wait until they opened the door from the 12th floor."

Sent back up stairs

Jill Runk of the Cook County public guardian's office said she and others were sent back up the stairs by firefighters on the 12th floor.

"I saw a firefighter standing in front of the door ... and he said, `You can't pass right now. Go back up,' " Runk testified.

Although four firefighters have said they saw people in the southeast stairwell, none has corroborated Runk's statement.

Moments later, firefighters opened the door, sending a cloud of dark smoke into the stairwell.

Workers who were on the stairs testified that the stairwell quickly became a horrific scene, with frantic people gasping for air and screaming for help. Some called 911.

The first calls to come in set the stage for another critical assumption: that everyone who needed to be rescued was in the northwest stairwell when in fact there were people in the southeast stairwell. Only one caller was able to specify which of the two stairwells he was in--the northwest--diverting resources that could have gone to the southeast stairwell.

The first call from the southeast stairwell came at 5:18 p.m. A woman's voice was heard with shouts in the background. The dispatcherasked if the woman was on the 25th floor.

"21!" the caller yelled.

"And you're in the stairwell?" the dispatcher asked. "Yes!" came the response. "The doors are locked. We can't get in."

The dispatcher said firefighters were on their way up, but the woman was unable to say which stairwell she was in.

The first dispatch to the command van on the scene about the stairwells came during that call, just after 5:20 p.m. "We have a report of people on the 21st floor stairwell that can't get out of the door there," the report to the van stated, not specifying which stairwell should be searched.

At almost the same moment, another dispatcher was on the phone with Sanchez, who had made it to the northwest stairwell. It was from there--also at the 21st floor--that he called 911, and he was still on the phone at 5:21 p.m.

Moments after that the communication from 911 to the command van became more specific. "It's going to be the northwest stairwell on the 21st floor, for your information."

Officials have said dispatchers made a judgment call based on the best information available to send rescuers to the northwest stairwell and at the time did not even know there were two stairwells in the building.

But ambiguous emergency calls kept coming in. About the same time, a woman called a 911 operator and said "a bunch of people" were trapped on the 27th floor.

The southeast stairwell was searched and the victims found 75 minutes later.

Shortly after Chief Edmund Enright arrived at the scene about 5:15 p.m., he was told the fire was being fought from the southeast stairwell and the stairwell doors were locked.

Enright heard the ongoing evacuation announcements and became concerned.

Enright said he ordered Lt. Anthony Williams to tell the security guard making the announcements to direct people to the northwest stairwell.

Williams said he did not recall that order. Instead, Williams was sent to the 27th floor after a report of a man trapped there.

Williams and three of his men took a freight elevator up to 27, where they searched the floor but found no one. Then they opened the door to the smoke-filled southeast stairwell.

As they stepped inside, air was running low on two of Williams' men's air tanks, so they decided not to risk searching it.

Williams later radioed Enright and told him the search of 27 was complete. Williams did not tell the chief that he hadn't searched the southeast stairwell.

When Assistant Deputy Fire Commissioner Joe Boatner took over control of the firefighting about 5:30 p.m., he was not given many details about the firefighting effort or searches, he testified.

Erica Yngve, who works for the building's management company, said she went up to a fire chief in the lobby, presumably Boatner, about five times starting about 5:45 p.m. to tell him that a cleaning lady, Teresa Zajac, was missing.

Each time, Yngve said, the fire chief said everything was taken care of. .

Boatner told the commission he was told twice Zajac was missing. He said he "filed it away" in his head with a list of things to do later. Boatner testified that he assumed a search had already taken place.

In that hearing, commission member Sheila Murphy criticized Boatner. "I don't understand why there wasn't a search right there on that same stairwell to make sure that any citizens were out of harm's way," she said.

Others, too, testified they had told building security or firefighters that co-workers were trapped or missing in the southeast stairwell, but the information was apparently not relayed.

Runk said she escaped down the northwest stairwell and found a firefighter. "I said: `There are people in that other stairwell,'" she testified.

She said she repeated the message to another firefighter outside at the command van.

"And he said: `No, everyone's out of the building.'"

Boatner said he eventually ordered three men to go up looking for Zajac but did not hear back from them. It wasn't until about 6:50 p.m., after a full search of the building had been ordered, that Boatner heard victims, including Zajac, were found in the southeast stairwell.

Boatner said Enright radioed down and said, simply, "Joe, we've got problems."

[Illustration]

PHOTOS 4 GRAPHIC; Caption: PHOTO (color): Earl Strayhorn, vice chairman of the commission reviewing the county building fire (the name and title as published have been corrected in this caption), and Abner Mikva listen to testimony about the fatal Loop high-rise fire. Tribune photo by Charles Cherney. PHOTO (color): `I saw a firefighter standing in front of the door . . . and he said, "You can't pass right now. Go back up." ' --Jill Runk, employee in Cook County public guardian's office. Tribune photo by Phil Velasquez. PHOTO: Erica Yngve, a building management firm employee, said she told a fire chief several times that a cleaning woman was missing. Each time, she said, the chief said everything was taken care of. Tribune photo by Charles Cherney. PHOTO: Fire Capt. Michael Gubricky decided to fight the fire from the smoke tower. Tribune photo by Chris Walker. GRAPHIC: Problems at the scene. Witnesses' testimony about the Oct. 17, 2003, fire reveal that personnel responding to the fire made questionable decisions on the scene. - Building engineer ordered an evacuation, a decision the building safety plan says the Fire Department is authorized to make. The plan does say a building official could order "additional floors" to be evacuated. - Acting against fire protocol, officials failed to take over the building's public-address system upon arriving on scene. - Firefighters began fighting the blaze from the southeast stairwell, which was the building's smoke tower. Firefighting protocol states that fighting a fire from the smoke tower should be a last resort. - Emergency dispatchers directed rescuers to the northwest stairwell. The southeast stairwell, where many were trapped, was not completely searched until after the fire was extinguished. Source: Testimony in Mikva commission hearings, documents Chicago Tribune