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Volume 32, Issue 1

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A recent fatal fire at a Chicago office building demonstrates the need for established evacuation plans and clear communication with emergency personnel. The fire, which occurred at the Cook County Administration Building on Oct. 17, 2003, killed six people and injured 15 who were trapped in a smoke-filled stairwell.

Questions surround the rescue procedures used by the fire department and the methods of evacuating the buildings’ occupants, according to published reports.

“I wish I could tell you that every aspect of this event went as well as we liked,” Cortez Trotter, Chicago’s emergency management director, told the Chicago Herald. “That is simply not the case.”

Edward S. Devlin, a leading contingency planning consultant, said, “From reading the newspaper reports it appears a lot of mistakes were made. We don’t know all the details of what went on, but it sounds like there was a breakdown in communications.”

Despite numerous 911 calls from the trapped employees and on-scene reports from other employees, the fire victims were not found for nearly 90 minutes after firefighters arrived on the scene.


Chicago Fire Commissioner James Joyce told the Chicago Tribune the deaths were concentrated in one small section of the 22nd floor. “The people who passed away appear to be, for the most part, in one area of one stairwell,” he told reporters. That stairwell was located on the southeast side of the building. Another stairwell on the northwest side of the high-rise structure remained relatively smoke free during the evacuation.

The fire started on the 12th floor of the 35-story building at around 5 p.m. Though many of the 2,500 employees who worked in the building had left for the day, hundreds were still in the building when the fire began.

When an announcement was made over the building’s public address system ordering the evacuation, employees headed for the stairwells. Those in the building at the time of the fire said alarms failed to sound and they were unsure about the reason for the evacuation.

“We had no idea what was going to come,” said victim Mary Russell Gardner in a Chicago Sun-Times newspaper article. “By the time we got to the 18th floor, [the smoke] was thick. And we knew that we had a problem.”

Gardner and others in the stairway were trapped because doors leading to the stairway automatically locked as people exited. Some were able to escape through an open door on the 27th floor; others were overcome by smoke before they reached that level.
“We were banging on the doors trying to see if we could get people to open up,” Gardner said.

Officials initially believed that the building had been completely evacuated, but Joyce told a Chicago newspaper that victims trapped on floors 16 to 22 continued to call 911.
Joyce later told Chicago Tribune reporters, “A floor-by-floor sweep after the fire was contained turned up several people in distress.” He said the sweep was ongoing as the fire was being fought, but it was unclear why the victims weren’t found until well after the flames were extinguished.

“My impression has always been that the first priority for firefighters is to rescue potential victims, the second phase is the fire containment and the third step is extinguishing the fire,” said Devlin about the fire department’s handling of the situation.
He explained that the occupants of the building should have been given clear instructions on when and how to evacuate.

“Why weren’t they told to use the stairwell that wasn’t contaminated?” asked Devlin. “I don’t know what exact instructions were given, but it doesn’t seem like the employees knew how to safely evacuate.

“I’ve been onsite with clients when we are doing fire drills. The employees are always told that no one is to enter the stairwell until they know which one will be used by the fire department. That will be the contaminated one.”

Devlin emphasized that proper training is essential in teaching employees what to do in a crisis situation. That training is especially important when a high-rise building is involved.
Business continuity planners need to reinforce the procedures for evacuation. High rise buildings are the most dangerous because fire can be on the lower floors, leaving employees trapped above. People tend to panic. Extra attention must be paid to the evacuation procedures,” said Devlin.

Dr. Thomas Phelan, president of Strategic Teaching Associates, Inc., agrees with the importance of drills. “In some cases, hindsight is 20/20, but in this case, the fundamentals were unrehearsed. Businesses must have an occupant emergency plan, and they must drill it. If they had conducted one drill where employees had to reverse direction and re-enter a higher floor, it would have pointed out that the doors from the stairwells automatically locked.”

Devlin questioned the use of the self-locking doors. The doors are commonplace in most buildings because of security reasons, but as this situation proved, the doors can be detrimental during an evacuation, he said.

“Shouldn’t there be a releasing mechanism available for use in this type of situation? No one seems to have that. In my research, it is common to hear of people being trapped in stairwells,” said Devlin. “An electronic or manual release that could be activated by fire alarms or by security personnel could be a solution.”

Chicago Mayor Richard Daley has proposed the locked stairwell doors be banned or altered. He is also calling for sprinklers in all new commercial high-rise buildings with more than four stories.

The Cook County Administration Building was not equipped with sprinklers because current fire codes in Chicago do not require sprinklers above the ground floor in buildings built before 1975. The administration building was built in the early 1960s.
Under the mayor’s plan, building owners also would have to leave the stairwell doors open, install a system that unlocks the doors when the fire alarm goes off or a release is triggered, or leave the door unlocked at every fifth floor.
The proposals are currently before the Chicago City Council.
“There is a lesson here for all business continuity planning professionals,” said Devlin. “Business continuity includes protection, emergency response and resumption. Planners need to consider all three of these when writing their plans.”

Janette Ballman has served as an editor with Disaster Recovery Journal since 1991. She has reported on numerous disasters and business continuity issues during that time. Ballman received a journalism degree from Mississippi University for Women in 1989.