LESSONS LEARNED
It is not enough that we look at a pre-incident survey or a building and think of how we would operate at an incident when things are going as they usually do. We must think outside the box and plan for how to operate at that same building when our water supply is insufficient, we experience a Mayday, or we arrive late due to delayed notification.
On February 23, 1991, at 20:40 EST, the Philadelphia Fire Department responded to One Meridian Plaza, the Meridian Bank Building, for a building fire at which they lost three of their own. The Meridian Bank building is a 38 story steel frame building with concrete floors poured over metal decks which measures 243 feet in length by 92 feet in width. The building is surrounded by other high rises and the front of the building faces City Hall. The fire originated on the 22nd floor as a result of linseed oil soaked rags left by a contractor performing renovations
The 22nd floor had incomplete smoke detector coverage, which greatly delayed initial detection and allowed the fire to become well advanced before the alarm activated. The alarm monitoring company called the building and was advised by security personnel that the alarm was being investigated; the fire department was not notified. Once the alarm activated, another security guard on a floor above the fire took an elevator to the 22nd floor and when the doors open, fire entered the elevator. This guard was rescued by the guard in the lobby who recalled the elevator to the lobby floor. The guards and one maintenance person evacuated the building to the front pad only to realize that no one has summoned the fire department as of yet.
The guards returned to the building and called the alarm company to advise them that there was a fire in the building. The first call received by 9-1-1 was from a passerby using a pay telephone near the building who reported smoke coming from a large building. While this call was in progress, the alarm company contacted 9-1-1.
The primary and secondary power risers for this building had been installed in the same unprotected enclosure. As fire burned through the enclosure and the insulation for both risers, they made contact and shorted to the ground. The natural gas fired emergency generator on the 12th floor failed to function. This all transpired just as first-in units arrived at the scene.
As firefighters entered the lobby of the Meridian Bank Building, the building went completely dark, no lights, no elevator use, no fire pumps. Pressure Reducing Valves on the standpipe system had been improperly set, as the numbers on the valve itself did not directly correspond to actual pressures. This resulted in the inability to produce effective fire streams, many of which would have only allowed approximately 40 psi nozzle pressure (this is insufficient for solid stream nozzles and dangerously inadequate for fog streams).
Virtually every stairway door encountered by firefighters was locked, requiring exhaustive forcible entry just to access the fire floors. The ineffective fire streams made it impossible for firefighters to even enter the fire floor from the stairwells. There was also limited pre-incident survey information available regarding the building. Unprotected openings in the fire resistive barriers and auto-exposure resulted in lateral and vertical fire spreading up two floors to the 24th floor. Due to the continued ineffectiveness of fire streams from the standpipe system, the command staff ordered that five inch hose be stretched up three separate stairwells to the 24th floor to combat the fire which has now spread to the 26th floor.
As crews are working without lights in the stairwells, the smoke begins to take hold of all the upper floors, making it difficult to connect hose lines. Engine 11’s crew of three is sent to the 38th floor via the center stairwell in an attempt to open a door or hatch to ventilate the stairwell and improve visibility. Engine 11 subsequently reported that they had left the stairwell on the 30th floor and were disoriented in heavy smoke. Attempts to redirect the crew to another stairwell failed. The captain of Engine 11 requested permission to break a window on 30 and did so followed by a radio report from an Engine 11 firefighter that the “captain is down.”
A RIT team of eight personnel was sent up from the 22nd floor and another team was deployed to the roof via helicopter. The eight person RIT team reached the 30th floor and searched without locating the missing firefighters. Several floors above the 30th were searched and the RIT team became disoriented and reported being out of air and lost in a mechanical area on the 38th floor. They were rescued by the crew that landed on the roof and were evacuated via helicopter to the ground.
Shortly thereafter, air operations were suspended due to low visibility and thermal updrafts although helicopters continued to circle the building and provide information to the command staff. One of the helicopters later identified a broken window on the 28th floor. Another search crew was sent from below and found all three of the Engine 11 crew just inside the broken window. They were evacuated to the staging area on the 20th floor where resuscitation efforts were unsuccessful.
After 11 hours of uncontrolled fire growth, the building was evacuated due to risk of structural collapse. An exterior attack was initiated; however, the command staff was faced with additional issues.
The accumulation of water in the basement of the Meridian Bank Building required the power company to turn off the transformers for fear of short-circuits. These transformers powered neighboring buildings. Firefighters trying to take advantage of elevators in neighboring buildings to deploy elevated streams via standpipes reported to the command staff that they were once again taking the stairs and in the dark.
The fire continued to burn for 19 hours until 10 sprinkler heads on the 30th floor extinguished the fire. The 30th floor was the first fully sprinklered floor above the 22nd floor. The Philadelphia Fire Department responded with 12 alarms, 51 engines, 15 ladders, and over 300 firefighters. There were 24 firefighter injuries. Tragically, Engine 11 Captain David P. Holcombe, Firefighter Phyllis McAllister and Firefighter James A. Chappell died in the line of duty at this incident.
While reviewing this case, one is left with the question, what else could have gone wrong there? Short of having more firefighter injuries or fatalities, a fair guess would be, not much. Your author here can almost not get his head wrapped around how much of an uphill battle these guys had when they arrived at the scene. When you examine the sequence of events, it is easy to pull one event out that could significantly change the outcome of this fire. Certainly, if the linseed oil soaked rags were disposed of properly, your author would be writing about something else.
There are a myriad of construction problems from the breaks in the fire resistive construction to the design of the primary and secondary power risers in the same unprotected enclosure. The backup generator had been documented as not starting under load conditions but was not fixed as it was not required by code. The secondary power feed was from an exterior power source which would have worked properly had it not contacted and shorted to the primary feed.
The incomplete detector coverage and reactions by the guards and alarm monitoring company led to a well advanced fire by the time the fire department found out about it. The lack of lights, limited pre-incident survey information, and locked doors requiring forcible entry hindered offensive operations. This was greatly complicated by the presence of pressure reducing valves that were improperly set and did not allow for effective fire streams. This also required a labor intensive lay of five inch hose up 22 floors through three separate stairwells.
When Engine 11’s crew got disoriented and lost, this should have fundamentally changed the entire incident, but it didn’t and couldn’t. While deploying search teams, the command staff was still faced with over 22,000 square feet of fire multiplied by floors 22 through 26 at the time the crew was located.
Even after Engine 11’s crew was removed and a decision to evacuate and go defensive was made, Philadelphia FD still couldn’t catch a break. Their intent to use elevated streams from neighboring buildings was hindered by the power outage caused by the deactivation of the transformers in the basement of the Meridian Bank Building. This required firefighters to haul equipment to the upper floors of neighboring buildings without the benefit of elevators and in the dark.
For the sprinkler proponents, it is interesting to see that 10 sprinkler heads put out a fire that was thought to have been capable of bringing down a 38 story building.
One Meridian Plaza was not just another high rise in Philadelphia. Hidden behind all the fire resistive construction, which was later cut through to make plumbing, utility and HVAC chases, was a worst case scenario building. Unfortunately, the late detection, lack of lighting, inadequate fire streams, locked doors, lost engine crew, etc. all converged to form the perfect storm of worst case circumstances. One would assume if we were all faced with the worst case circumstances inside the worst case building that we would have been dealt the same results. However, it’s not hard to see that the results of the fire in Philadelphia on the night of February 23, 1991 could have been much, much worse.
How do we learn from this? It is not enough that we look at a pre-incident survey or a building and think of how we would operate at an incident when things are going as they usually do. We must think outside the box and plan for how to operate at that same building when our water supply is insufficient, we experience a Mayday, or we arrive late due to delayed notification. In short, we also need to consider how we would operate at that same incident when everything goes wrong.
We also must all take responsibility to report code violations to the fire marshal, code enforcement division or fire chief when they are discovered during pre-incident survey updates. For the Fire Marshals, code enforcement folks and fire chiefs, there is a sign this author gave to the fire marshal in his department. It reads, “You protect the lives of our citizens. The rest of us are only here for whenever you screw up.”
Keep in mind that many of the prevention, education and code enforcement activities not only protect the lives of our citizens but also all of our lives. These activities are often treated as an unimportant part of the modern fire-rescue service; however, they serve to interrupt one event in the chain that can help prevent the worst case circumstances and the worst case building from showing up at the same fire.
Be safe and do good.