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#TBT From The NFPA Archives: The Cleveland Clinic Disaster - May 15, 1929

Blog Post created by jrodowicz Employee on May 11, 2017

One hundred and twenty-five people died as a result of a fire originating in nitrocellulose X-ray films in one of the buildings of the Cleveland Clinic Foundation in Ohio on May 15, 1929.

 

Where the fire started

Pictured here: Location where the fire started. Electric light bulb and steam pipes present.

 

The Cleveland Clinic Foundation, established at the end of World War I, included a hospital, laboratory, and a clinic. The clinic building, well separated from the rest of the foundation's buildings, was used for examining, diagnosing, and treating patients. There were no bed patients in the clinic, so most people in the building at the time of the fire were adults able to walk. A fire and two explosions broke out around 11:30 a.m., during the clinic's busiest time of day, when about 225-250 patients and employees were inside. Three tons of X-ray films in the basement decomposed and ignited, spreading toxic fumes throughout the building.

 

A steam pipe leak had been reported earlier that day in the film storage room. A workman sent to repair the leak shut off the steam supply upon seeing the room filled with steam, and about 20 minutes later, he "heard a 'sputtering hiss' and saw a cloud of yellow smoke 4 or 5 feet in diameter at the ceiling of the film room." He had sprayed most of a fire extinguisher into the discolored smoke when there was an explosion. He was able to make his way to a window as a second explosion blew him outside through the window. The explosions "forced these fumes at considerable pressure into the pipe tunnel and up the pipe ducts," causing the fumes to permeate nearly every room in the building.

 

Though "safety" film was available at the time, and it had "no more hazard than paper or cardboard," the Cleveland Clinic still used nitrocellulose film, known to be extremely flammable and produce toxic fumes when burning. Nitrocellulose film becomes chemically unstable and begins to decompose and ignite when exposed to elevated temperatures. Investigations determined three probable reasons why film decomposition was ignited at the Cleveland Clinic: 1) a light bulb hanging just above a shelf used for film storage came in contact with the film; 2) steam escaping from a pipe that passed close to the storage shelves caused the film to get hot enough to ignite; or 3) a discarded match or cigarette came in contact with the film.

 

But whatever the cause of ignition, the carbon monoxide and nitrogen peroxide fumes from the burning X-ray films killed about half the people inside the clinic. Most were caught unaware and died almost instantly, while others collapsed on their way to a door or stairway. Some were able to escape only to succumb to the poisonous fumes in their lungs in the subsequent hours or days. In all, 125 people died as a result of the fire, though none of the deaths or injuries were from burns.

 

 

For more information regarding this or other historic fires, please feel free to reach out to the NFPA Library

The NFPA Archives houses all of NFPA's publications, both current and historic. Library staff are available to answer reference questions from members and the general public.

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