On February 8, 1996, a fire occurred in a board and care facility in Shelby County, Tennessee, which caused the deaths of four residents. The fire was caused most likely by improperly disposed smoking materials. Smoke from the apartment of fire origin spread to other apartments through open doors. The facility was 20 years old, and all areas of the building were of wood-frame construction. All areas in the building had various fire protection provisions including smoke detectors, fire alarms, fire doors, and door self-closing devices. However, self-closing devices for many apartments, including the apartment of fire origin, had been removed or deactivated allowing doors to remain open. Based on NFPA’s investigation and analysis of the fire, the following factors were considered as having contributed to the loss of life in the incident:
- Improperly disposed smoking materials
- Lack of automatic sprinkler protection
- Ineffective response of some staff members
- Failure of occupants to respond effectively to operating fire alarms
- Room doors that remained open due to the deactivation of door self-closing devices and chocks
NFPA members can download the full investigation report.