Purpose
The purpose of the investigation is to establish the likely technical cause or causes of the building failure that led to a high number of casualties. All technical aspects will be documented, including the conditions of the building prior to the fire, the fire spread through the building following ignition, the response of the structure to the fire, the performance of installed fire protection systems, the behavior of the occupants in the evacuation process, and the activities of the emergency responders. The Team will recommend, as necessary, specific improvements to building standards, codes and practices based upon the findings, and will recommend any research and other appropriate actions needed to improve the structural fire safety of buildings and evacuation procedures.
Guiding Principles
The technical investigation will be conducted independently and objectively, with consideration of the concerns and issues of all interested parties, and within the limits of available resources. It will be coordinated with Federal, State and local entities that are conducting investigations or sponsoring research into this building failure. Investigative priority will be relinquished to law enforcement agencies conducting ongoing criminal investigations. Actions will be taken to ensure that evidence is preserved. No findings of fault nor negligence will be assigned to any individual or organization.
General Approach
The investigation consists of the following major elements:
Specific Tasks
The investigation is organized into the following specific tasks:
1. Establishment of initial conditions
2. Materials testing
3. Reconstruction of thermal and tenability environment
4. Determination of occupant behavior and egress
5. Documentation of emergency response
6. Examination of the impact of sprinklers on survivability
7. Identification of building and fire codes that warrant revision
1. Establishment of initial conditions
The conditions in the nightclub prior to the fire will be determined by examining construction plans, maintenance records, and building inspections; through videos, photographs, news articles, and measurements/observations of the site after the fact; and through discussions with contractors, the building owner, employees, survivors, and witnesses familiar with the operation of the building on similar occasions. Information will be collected on the materials of construction and contents; the location, size and conditions of doors, windows, and ventilation; the installed fire protection systems; and the number of occupants and their approximate locations. From this information we will
2. Materials Testing
Small-scale experiments will be conducted to provide additional data on materials of construction and contents that affect the growth of the fire. These may include
3. Reconstruction of thermal and tenability environment
The fire spread and survivability within the building will be reconstructed using computer models. Information on the location and cause of fatalities for each victim (as provided in the medical examiner's report) will help determine the tenability and thermal conditions in the room at their time of death. The following steps will be used for the reconstruction:
4. Determination of occupant behavior and egress
The emergency evacuation and occupant responses will be analyzed to better understand the impediments to safe egress encountered by the occupants. The analysis will include
An expert in human behavior and egress modeling will be contracted for aspects of this task.
5. Documentation of emergency response (USFA to lead)
Collect emergency response data in cooperation with the local fire department to document procedures and operation of equipment. Identify successful operations and technical difficulties.
Records of interest include dispatch logs, recorded radio communications, run logs, 911 records, data recorded by the Fire Department operations and the Police Department , and fire ground positioning of emergency apparatus. Information will also be sought on operations and function of communications systems, on-site emergency information systems, fire alarm panels, standpipes and fire hoses, and other emergency equipment. Data will be collected from witnesses, those in control of emergency operations, and first responders.
6. Examination of the impact of sprinklers on survivability
The impact on survivability will be examined had a sprinkler system been installed, all other conditions being the same.
7. Identification of building and fire codes that warrant revision
Identify specific areas in building and fire codes, standards and practices that warrant revision based upon findings. Recommendations for revisions will be made when they are justified based upon the technical findings from the other tasks.
NCST Members and Liaisons
The NCST Act requires that at least one member of the Team be from NIST, and that experts who are not employees of NIST shall also be appointed to the Team by the NIST Director. The members from NIST are listed below. Additional Team members will be appointed from among the primary federal agency liaisons and key private sector experts, as deemed appropriate.
NIST members
Primary Federal agency liaisons
State/local agencies and liaisons
Secondary Federal agency liaisons
Private sector contracts
The assistance of private sector experts may be solicited to supplement internal expertise and to accelerate the publication of the final report. Contracts are contemplated in the following areas:
Task | Title | Area of Expertise |
---|---|---|
2 | Standard Flammability Tests | Fire Test Laboratory |
4 | Analysis of Emergency Egress | Human Behavior and Egress |
5 | Documentation of Emergency Response* | Fire Department Operations |
6 | Parametric Study of Sprinkler Impact | Fire Dynamics Simulations |
7 | Building Code Review | Building Codes |
*US Fire Administration contract
Budget and timeframe
NIST appropriated funds will be used for the salaries of NIST staff, Team travel, materials, testing, contracts, report dissemination, and administrative expenses. The US Fire Administration will cover contracting expenses for task 5. The investigation will operate within the charter of the NCST Act. The goal is to complete the technical investigation in as timely a manner as possible, consistent with the relinquishment of priority to state and local authorities conducting criminal investigations. A review copy of the final report will be provided to these same state and local authorities.
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1 The NCST Act requires that the Team relinquish investigative priority in the event of a criminal investigation. We are assessing how this will affect the Rhode Island investigation and its schedule. The information in this plan represents our best present thinking but is subject to change.