The Iroquois Theater. The Triangle Shirtwaist Factory Fire. The Cocoanut Grove. The Beverly Hills Nightclub. The DuPont Plaza. The World Trade Center. The Station Nightclub.

To those in fire protection engineering, these names represent major fire losses that have caused significant changes in code requirements, building design, enforcement and education. With many of those events, there were repetitive failures in the design, enforcement and operation of buildings. Although the fire protection principles have been well-known for many years, an analysis of these losses shows repeated violations of many of the same fire protection principles.


The following examples illustrate this point:

  • The fire at the absolutely fireproof Iroquois Theater (1903) resulted in 602 fatalities: mostly attributable to blocked exits; a confusing egress path; inward-swinging doors; inadequate exit signage; combustible interior finish; and a lack of fire suppression.1
  • The Triangle Shirtwaist Factory fire (1911) resulted in 146 fatalities: attributed to locked exits; inadequate exit capacity; combustible contents; and a lack of fire suppression.2
  • The Cocoanut Grove nightclub fire (1942) caused 492 fatalities: owing to inadequate exit capacity and arrangement; inward swinging doors; inadequate exit signage; combustible interior finish; vertical openings; and a lack of fire suppression.3, 4
  • The Beverly Hills nightclub fire (1977) resulted in 165 fatalities: due to inadequate exit capacity and arrangement; combustible concealed spaces; and a lack of fire suppression.5
  • The DuPont Plaza hotel fire (1986) caused 97 deaths: attributed to locked exits; vertical openings; an unusual fire load; and a lack of fire suppression.6
  • The Station nightclub fire (2003) resulted in 100 fatalities: Major factors leading to those deaths included inadequate exit arrangement; combustible interior finish; and a lack of fire suppression.7

It is not surprising that there were many violations of the same fire protection principles in these major losses of life. Yet, those in the fire protection community should be in a position to recognize buildings with these deficiencies and act before the next event occurs.

Regulations are often enacted following such tragedies typically on a local basis and often in an emotionally charged atmosphere. It is human nature to act so that tragedies are not repeated, but it is also human nature not to act unless faced with a recent or imminent threat.


Fire safety regulations reflect the needs of society, particularly for public buildings. They seek to balance the perceived risks with the reality of economics, and they sometimes wane when fire tragedies fade into the history books.


Not all fire safety improvements are borne from tragedy. In the early 1970s, a number of technical committees were formed to develop criteria for two types of buildings that were growing in popularity: covered mall shopping centers and atrium buildings. Today, all model codes have comprehensive provisions for these building types, employing technical knowledge and experience with fundamental fire protection principles all developed before any major loss-of-life event. These provisions have been effective for more than 35 years.

Over the years, events such as those described above have prompted research into areas involving fire growth, people movement and human behavior. These activities have led to improved codes, improved analytical techniques for complex building designs and models for complex egress scenarios. Building and fire codes have significantly evolved to require improved fire protection features, including active systems such as automatic fire sprinkler systems and fire detection systems. The safety of products, such as heating equipment and electrical appliances, has improved. The level of code enforcement and the qualifications of those involved in it have improved. Public education and public awareness have also improved.


Since 1977, the number of reported fires has dropped by 52%, reflecting better building design, construction methods, product safety, fire prevention and enforcement. At the same time, the number of fatalities has dropped 47%, again reflecting those same measures, plus improved regulations for fire detection and fire control through automatic sprinklers and construction features. During the last 25 years, the fire death rate in the United States has fallen by about one-third. Although direct property losses due to fire have increased over the last 25 years, there has been a 25% reduction in property damage when measured as a percentage of the nations GNP. In addition, during the last 55 years, there have been only five U.S. incidents, each having more than 100 fatalities; there were 44 such incidents in the previous 55-year period, reducing the frequency of those incidents from roughly once per year to once per decade.4

Nevertheless, concerns remain. The World Trade Center event of Sept. 11, 2001, showed the potential of extreme events affecting tall buildings and how to reasonably safeguard them. The relatively simple and effective philosophy of defend in place was challenged and strategies are being explored that could more effectively protect the building and its occupants to allow for a complete building evacuation.


In addition, threats other than fire, e.g., chemical attacks, gun wielding terrorists and similar threats, directly challenged the time-based people movement assumptions. Risk assessments are now per formed on major public and iconic buildings and additional, non-traditional measures are considered to meet their safety needs.


One new technology resulting from this event is the use of elevators as part of the means of egress. Provisions have been adopted into the IBC8 and NFPA 1019 to allow, if not encourage, the use of hardened elevators as a component of the buildings overall egress design. This technology also provides a solution for safely moving disabled building occupants in the same manner as able-bodied occupants, rather than sending them to areas of refuge to wait for rescue. The same technology also provides firefighters a means of reaching the fire scene on the upper floors of a building.


Certain other building features resulting from the 9/11 tragedy, such as the hardening, number and separation of stairway shafts, will continue to be reviewed and debated. Fundamental to this, of course, are the design basis events to be considered and the risk of such events. This work is on-going.


Larger, taller and more complex buildings are being built. Society demands new methods and new materials to build more energy efficient and sustainable buildings. These are worthy endeavors that benefit society in many ways, but fire protection engineers cannot forget or disregard the knowledge of fundamental fire protection principles while doing so.


Perhaps the single greatest challenge to the fire protection community is dealing with the existing building stock, especially buildings built before code provisions for new construction began to require significantly more in the way of built-in fire protection. There are perhaps thousands of these existing buildings, which should be identified to determine their fire risk.


In addition, fire prevention activities should be emphasized as an important element in preventing future large-loss fires. Fire prevention includes: code enforcement through plan review and facility inspections; education and training; fire investigation and fire data management. The balance of this article will focus on the value of facility inspections.


The Value of Fire Inspections
Fire inspections of major facilities are often conducted by the fire department, insurance representatives, owner representatives and private sector organizations on behalf of one of the previously mentioned entities.


In some cases, the frequencies of such inspections are specified for various types of public buildings considered to have high-risk factors, such as schools, hospitals, theaters and other places of public assembly. Typically, for those communities that perform such inspections, annual inspections are conducted, but they may be more frequent at large public assembly facilities.


Inspection activities involve reviewing the overall facility to determine whether:

  • changes have occurred since the last inspection or since original construction without those changes being reviewed for code compliance;
  • all means of egress are maintained in a usable and operable condition;
  • no unusual fire hazards have been introduced;
  • routine hazards are being properly controlled;
  • pre-fire incident plans are updated;
  • all fire protection systems are in an operable condition and have been properly serviced;
  • the facilitys emergency plan (if any) is current and necessary drills have been conducted.

The inspections usually include either witnessing actual operational tests of fire protection systems, such as flowing water from a sprinkler systems test connection or fire pump or activating occupant notification systems and alarm system connections to notify the fire department. This is more important today than ever, as the number of buildings required to have active fire protection systems by building and fire codes has increased substantially over the last 25 years. Active systems tend to make up for deficiencies that may exist in the construction or operation of the building. An operational system is also important for that reason.


The inspections conducted by the fire department under the jurisdiction of a code or ordinance has a legal basis, providing for the publics health, safety and welfare, and may bring with it legal action and fines if significant or repetitive violations are found. Nevertheless, for even the code-compliant facilities, the time spent on site with the facility representative is more valuable than what simply appears in the written report. Periodic visits by a good fire inspector will provide a level of education and interest in maintaining a fire-safe facility on a year round basis, often providing technical information about the operation and testing of the fire protection systems to building operating and management staff. They will likely maintain an awareness and interest in good fire protection practices, such as keeping egress facilities usable, long after the fire inspector has left the premises. A number of private sector organizations, such as insurance carriers and owners, invest considerable resources as part of an effective loss prevention program.


Fire Inspector Qualifications
A knowledgeable and effective fire inspector is a key component in a loss prevention program. Although reports suggest that fire safety concerns were raised at the new Iroquois Theater when it was inspected shortly after construction and one month before the fatal fire, fire department supervisors ignored the concerns of the inspector and the nations largest public assembly fire life loss occurred.1 The investigation into the Beverly Hills Supper Club fire criticized the efforts of the fire inspector who visited the facility four months prior to the fatal fire and said the exit facilities were adequate, calling the work a myopic inspection effort.9 Tragically, The Station nightclub was inspected prior to the fire.7 Not only did the inspection not identify that a change of use had occurred (which would have required significant fire safety features be provided), but the inspector either did not see or did not appreciate the imminent danger to life associated with the exposed foam material applied to the walls and ceiling in stage area.


In order to meet the challenges associated with preventing the next major life-loss fire, persons performing these activities must be qualified. NFPA has several professional qualifications standards for fire service personnel, including NFPA 103111 and NF PA 1037.12 Certification to these standards is accomplished through third-party accredited agencies.


As fire department budget s have been subject to pressure, citizens need to keep in mind that the less-exciting, less-glitzy work in fire prevention is an important element in community safety and that those efforts should receive their support. Fire protection engineers can play a role as citizens as well as practitioners when the opportunity exists to help identify and correct substandard buildings.


Carl Baldassarra is with Rolf Jensen & Associates, Inc.



  1. Foy, E. A Tragedy Remembered, NFPA Journal, July/August, 1995, pp. 75-79.
  2. Grant, C. Triangle Fire Stirs Outrage and Reform, NFPA Journal, May/June, 1993, pp. 72-82.
  3. Grant, C. Last Dance at the Cocoanut Grove, NFPA Journal, November/December, 2007, pp. 46-71.
  4. Hall, J. & Cote, A. "An Overview of the Fire Problem and Fire Protection," Fire Protection Handbook, 20th edition. National Fire Protection Association; Quincy, MA, 2008.
  5. Wolf, A. (ed.) Date Night Turns Deadly, NFPA Journal, March/April, 1996, p.64.
  6. Fruin, J. "Techniques of Crowd Management," Fire Protection Handbook, 20th edition. National Fire Protection Association; Quincy, MA, 2008.
  7. Duval, R. The Legacy of Nightclub Fires, NFPA Journal, May/June, 2007, pp. 90-97.
  8. International Building Code, International Code Council, Washington, DC, 2009.
  9. NFPA 101, Life Safety Code, National Fire Protection Association, Quincy, MA, 2009.
  10. The Fire that Still Rages, Cincinnati Enquirer, May 28, 1997.
  11. NFPA 1031, Standard for Professional Qualifications for Fire Inspector and Plan Examiner, National Fire Protection Association, Quincy, MA, 2009.
  12. NFPA 1037, Standard for Professional Qualifications for Fire Marshal, National Fire Protection Association, Quincy, MA, 2007.