On October 5, l989, a nursing home fire in Norfolk, Virginia, resulted in the death of 12 patients and required hospital treatment or relocation of 96 others. The building, built in 1969, is a four-story, nonsprinklered, fire resistive structure housing 161 elderly patients at the time of the fire. The first floor contained general administrative offices and support facilities and patient rooms were located on floors two through four. The fire was discovered just after 10:00 p.m. by the nursing staff who immediately began to evacuate patients, activate the fire alarm system, close patient room doors, notify the fire department, and extinguish the fire. However, during this process, the fire grew within the patient room of origin and extended into the exit corridor, forcing the staff to abandon their emergency procedures on the fire floor.
Norfolk Fire Department received notice of the fire at 10:l8 p.m., and fire fighters arrived on the scene within four minutes of the notification. Upon arrival, they observed fire extending from a second floor window and lapping to the floor above. An interior fire attack was begun utilizing the building standpipe system while other fire fighters laddered the building, extended a handline and “knocked down” the majority of the fire. Severe heat and smoke conditions existed on the fire floor and fire fighters began to realize many of the patients remained in their rooms. Because of these severe conditions, fire fighters began to evacuate patients from the fire floor.
Other arriving fire fighters, summoned by additional alarms, found moderate to heavy smoke conditions existing on the third and fourth floors. Eventually the entire nursing home was evacuated.
Local investigators have listed the probable cause of the fire as careless disposal of smoking materials. An open flame ignition source ignited bedding materials on a patient’s bed which soon involved a polyurethane decubitus pad, and the bed’s mattress. Investigators believe that the fire grew very rapidly while the staff was attempting to complete their emergency procedures. Within an estimated three to four minutes of discovery, flashover conditions were reached in the room of origin and the fire extended into the corridor.
The following are significant factors in this fatal fire incident:
• The rapid growth and development of the fire within the patient room;
• The absence of automatic sprinklers that could have prevented full room involvement or
• The absence of automatic early detection and fire warning in the room of origin;
• The lack of compartmentation due to the open door to the room of fire origin;
• Failure of the fire alarm system to function properly.