On March 4, 1991 a fire of accidental origin occurred at a board and care facility in Colorado Springs, Colorado, leaving 9 residents dead. Eight other residents and five firefighters were injured. An electric motor in a ventilation fan apparently malfunctioned and ignited combustible materials in the attic. The fire burned for an undetermined amount of time, spreading above several rooms before causing a ceiling collapse in a residents’ lounge. It was at that point that the corridor smoke detection system was activated, and staff began their emergency procedures.
According to the investigation, the following factors appear to have significantly contributed to the loss of life:
- Heat detector system in the attic did not provide early warning
- Fire separations did not prevent the spread of smoke and fire
- Combustible ceiling in the dining room
- Lack of adequate fire safety training for staff and residents