The+Station+nightclub

The Station nightclub fire (February 20, 2003) // Tyler E. Graybill, BAE/MAE, Penn State, 2010 //

toc =Absract=

On the night of February 20th 2003, The Station nightclub in West Warwick, Rhode Island caught fire leaving 100 dead and more than 200 injured, making it the fourth deadliest nightclub fire in U.S. history. Over 400 patrons had gathered in the club to hear the music act Great White perform, when a pyrotechnic set off by the band’s manager ignited the walls of the stage, triggering a blaze that took just six minutes to engulf the entire facility (NFPA, 2006). The staggering number of fatalities can be attributed mainly to the proximity of the pyrotechnics to flammable sound-insulating foam, overcrowding of the facility, and the lack of a sprinkler system (Reese 2004). The high loss of life resulting from the fire spurred a number of changes to life safety codes.

=Key Words=

Fire, nightclub fire, the station, great white, pyrotechnics, NFPA, polyurethane foam, overcrowding

=Building Description=



General Information
The Station was a popular nightclub located in West Warwick, Rhode Island. Only a single story with a wood structural system, the building had a footprint of 4,484 square feet (NIST 2005). Walls and exterior shingles were of wood construction; wood paneling and paint made up the interior finish. Built in approximately 1946, the facility had seen a variety of uses as a tavern, restaurant, and nightclub under a number of owners. In 1991, the building’s use was changed for a last time from a pub to a nightclub (NFPA 2006).

Layout of Interior
The two primary areas of The Station’s interior were the bar and the club, as seen in Figure 2. As a patron entered from the front entrance, the bar opened up to their left and the club to their right. Included in the bar area was the adjacent kitchen and dart room. In the club area, a raised platform was located in the south-west corner with an alcove at the platform’s rear. Of particular importance was the use of exposed expanded polyurethane foam plastic as a finish on the alcove, platform, and nearby surfaces to control sound to the outside as a result of bands performing at the club. Small tables, chairs, and billiard tables were found on the club area’s floor but could be removed or rearranged to allow for a larger crowd, as they were during the night of the fire (NFPA 2006).

The facility had a total of four exits: > The front doors were comprised of two outward-swinging 36” wide doors that opened onto an entrance ramp. Six feet in from the main entrance was a single 36” wide, outward swinging door. The bar exit and kitchen exit also had single 36” wide, outward swinging doors, though it is important to note that the kitchen exit may be considered inaccessible to customers, under normal circumstances (NFPA 2006, NIST 2005). Two 36” doors mounted in series – the inner door swinging inwards and the outer door swinging outwards - made up the platform exit. (NFPA 2006).
 * Front (main) doors
 * Bar side exit door
 * Platform exit door
 * Kitchen exit door



Life Preservation Systems
All exits were marked by illuminated exit signs above the doorway. All exits except for the front doors were equipped with panic hardware. The building was also equipped with a fire alarm consisting of pull boxes, heat sensors, and horn/strobe notification units (NFPA 2006).

The building was not sprinklered, nor was sprinklering required for an existing building of its size under the 2003 editions of model codes (NIST 2005). Active fire protection consisted of portable fire extinguishers located throughout the facility (NFPA 2006).

=The Fire=

Only three days earlier, a fatal crowd crush incident claimed the lives of 21 people at E2, a nightclub in Chicago (NFPA 2006). As a result, a local television reporter and cameraman were on scene at The Station nightclub the night of the fire, taking video footage for a story on nightclub safety (Keith 2008). This video, along with the accounts given by survivors of the blaze, was used to piece together the first moments of the blaze before local authorities arrived.

Origin (First 6 Minutes)
On Thursday, February 20, 2003, The Station nightclub was hosting a show with several bands, including a headlining act, the popular rock act Great White. The show was promoted heavily and a large crowd was expected.

At approximately 11:07 p.m., the headlining act took the stage (NFPA 2006). A few seconds into the act, pyrotechnic “gerbs” – which are designed to emit a fountain of sparks – were ignited by a stagehand (NFPA 2004). The sparks emanating from the gerbs ignited the highly combustible polyurethane sound-proofing foam covering the platform’s walls (Keith 2008).

Within 9 seconds, flames were visible on the walls on either side of the platform. For the following several seconds, the band seemed unaware of the open flames and the crowd assumed the flames were part of the performance. The fire quickly spread to engulf much of the platform’s walls, prompting the crowd to start reacting. Approximately 30 seconds after ignition, flames had reached the ceiling, the band had stopped playing and left the platform, and the crowd began its frantic attempt to exit the building (NFPA 2006).

The majority of the club’s patrons attempted to exit the building where they entered – the front doors. Fire alarms were audible at 48 seconds after ignition. After just 75 seconds, smoke reached the ceiling throughout the room and began drifting out the entrances. Widespread panic was not yet evident but egress through the front doors had slowed considerably (NFPA 2006).

At this point in the video, the cameraman exited through the front doors and began circling the building. After 1 minute and 40 seconds had elapsed from time of ignition, heavy black smoke billows out all openings of the building, as patrons use both windows and doors to escape. Seconds later, with heavy smoke now pouring out of the building and fire alarms no longer audible from the outside, patrons desperately attempting to escape began to pile up inside the front doors (NFPA 2006).

At 4 minutes and 30 seconds from ignition, bright orange flames were seen deep within the building, as sirens sounded in the background. Approximately 1 minute and 30 seconds later, flames as tall as the building rose out every window and door. In the 6 minutes from time of ignition, the entire facility was engulfed in flames (NFPA 2006).

Immediate Rescue Response (6 Minutes - 2 Hours)
The first 9-1-1 call was received less than 40 seconds after the time of ignition. Dozens of fire crews from both Rhode Island and Massachusetts responded (NFPA 2004), the first of these arriving about 4 minutes after the first 9-1-1 call was received (NIST 2005). A triage center was set up in a restaurant across the street. Over 200 victims were treated on scene and transported to a total of 15 nearby medical centers in under 2 hours (NFPA 2006, NFPA 2004).

Final Toll (2 Hours - 70 Days)
The day after, 96 people had died from the tragic blaze and over 200 were injured. This number rose to 100, as four hospitalized people died from severe injuries in the following days, making it the fourth deadliest nightclub fire in U.S. history. The task of recovering victims from within the building was completed late on February 21 by the State Fire Marshal, State Medical Examiner’s Office, and a task force of local, state, and federal law enforcement agencies (NFPA 2006).

= = =Investigation & Findings: What Went Wrong?=

The significant loss of life associated with The Station nightclub fire prompted several investigations by a number of local, state, and federal agencies. The State Attorney General’s office and State Fire Marshal put together an investigative team to conduct a detailed examination of the fire. Additionally, NIST (National Institute of Standards and Technology) composed a detailed investigation on the incident to determine the cause of the building failure and any recommendations necessary to improve the safety of buildings (NFPA 2006).

The elements contributing to the severity of The Station nightclub disaster are generally agreed upon to be the following and are discussed in more detail in the sections below (NIST 2005): > It is important to note that The Station nightclub was governed by state and local building regulations and //not// model codes, such as those published by NFPA (National Fire Protection Association) and ICC (International Code Council). These model codes have provisions that address the above contributors.
 * Hazardous mix of building contents
 * Fire protection systems
 * Occupant load & egress

Hazardous Mix of Building Contents
The close proximity of a high temperature source (pyrotechnic device) to a substantial amount of material with a low ignition energy and high flame spread rate (polyurethane foam) served as the trigger for the fire. It is important to note that there was no fire-proofing covering on the foam (NIST 2005).

Pyrotechnics
Pyrotechnics were permitted in nightclubs under model codes if certain precautions were taken and with the approval of the Authority Having Jurisdiction (AHJ) (NIST 2005). Under NFPA 101, //Life Safety Code//, a pyrotechnic operator must submit, within 24 hours of the event, a written plan including exact date, location, and time of event, qualifications of operator, and diagrams detailing device location and fallout radius (NFPA 2003).

Though the facility was not under a model code, there were apparent protocols to be followed. A day after the fire, the West Warwick fire chief stated that neither the club nor the band appeared to have obtained the necessary town or state fire permits for a pyrotechnics display. The band’s lead singer claimed that the club had been informed of their intent to use pyrotechnics. The club’s owners, brothers Michael and Jeffrey Derderian, denied this claim, stating, ''At no time did either owner have prior knowledge that pyrotechnics were going to be used by the band Great White. No permission was ever requested by the band or its agents to use pyrotechnics at the Station, and no permission was ever given.” Several nightclubs that Great White had played recently also claimed they had not received notification that a pyrotechnic display was planned (Belluck 2003).

Building Materials
As stated above, The Station nightclub employed the highly combustible polyurethane foam as a soundproofing tactic. The video record of the incident shows the foam igniting almost immediately and the subsequent rapid spread of flames. NIST estimates that 95% of the fuel load was found in the building’s wood structure and paneling. The flames generated enough heat and growth from this foam to ignite the wood paneling underneath and eventually the wood structure, quickly transitioning to a more traditional, oxygen-limited fire (NIST 2005).

NIST also tested both a piece of non-fire retarded foam and a piece of fire retarded foam against a pyrotechnic gerb in a set-up similar to that used in The Station nightclub. The result was that the non-fire retarded sample caught fire within 15 seconds while the fire retarded foam sample would not ignite (NIST 2005).

Model codes require that foamed plastic materials used on interiors such as that used in The Station nightclub are subject to large-scale fire tests, ensuring their safe performance relative to end use (NIST 2005).

Fire Protection System
The fire suppression system in place at the nightclub did not allow occupants sufficient time to exit the facility.

The Station nightclub’s active fire protection consisted of portable fire extinguishers located throughout the facility, though they were not located at a convenient location relative to the fire, nor was there any indication of the presence of personnel trained in their use (NFPA 2006). As previously mentioned, the building was not sprinklered, nor was sprinklering required for a building of its size under the 2003 editions of the model code (NIST 2005). The existing model codes required similar buildings of new construction to be sprinklered, but not for existing structures such as The Station (NIST 2005). However, according to Gary Keith (NFPA Vice President of Field Operations and Education), the state building inspector at the time testified that the building should have been treated as a change-of-use facility, which would have exempted it from the "grandfathering" process and thus requiring the building to be sprinklered (Keith 2008).

An experiment on a recreation of the club area of The Station showed that a water sprinkler system was able to suppress the fire enough to maintain tenable conditions at head level throughout the duration of the experiment (5 minutes). This is contrasted with the estimated duration of tenable conditions in the non-sprinklered space that night of 1 ½ minutes (NIST 2005).

Occupant Load
Overcrowding of the facility and the patrons’ rush towards a single exit were major contributors to the large loss of life (NIST 2005).

The number of building occupants present at the time of the fire varies according to a number of sources. The Providence Journal as of 2007 reported 462 documented people present. Evidence released by Attorney General Patrick C. Lynch listed 458 people believed to be in attendance (Parker 2007).

It is also evident that the nightclub’s management was not closely monitoring whether the club’s capacity had been reached. Co-owner Jeffrey A. Derderian reported a headcount of 250 - 260 at 10 p.m. Club manager Kevin J. Beese Sr. reported a count of 310 – 320 between the times of 10:00 and 10:30 p.m. Management was also unsure as to the actual legal capacity of the club. West Warwick Fire Marshal Denis P. Larocque had set the normal capacity of the club to 258, but allowed 404 people with the removal of tables, chairs, and the billiard tables (Parker 2007). The occupant load according to model codes at the time would have been approximately 420 (NIST 2005).

Egress
According to NIST’s official report on the incident, 2/3 of the crowd attempted to exit the building through the front doors, just one of the four exits in the facility. For over a minute, patrons exited at an orderly rate of a little over one occupant / second. Within 90 seconds of the ignition time however, a crowd crush occurred at this exit, almost entirely halting the flow of patrons. At this time, it appears the large windows at the front of the building became a secondary route of escape, as a reported 1/3 of those who successfully exited the building exited through these windows. A fire test conducted showed temperatures and combustion gases to be well in excess of survivability limits within the club area at the 90 second mark. The reason for the crowd crush was likely a combination of 1) the panic induced by the rapidly worsening conditions, and 2) the poor egress path to the front doors, requiring merging streams of traffic to pass through a single interior door, as shown in Figure 2 (NIST 2005).

Summary of Contributing Factors
It seems that the presence of only one of any of the contributing factors discussed would have caused little or no loss of life. In particular, the use of a fire retarded sound-insulating foam would never have ignited. Likewise, the implementation of a water sprinkler system would have suppressed the fire enough to allow the building’s occupants sufficient time to exit.

Indeed, a task force convened by the Commonwealth of Massachusetts’ Department of Public Safety to study building and fire codes in light of this tragedy commented on these elements, saying, “Individually, they presented a danger. Together, they formed a ‘perfect storm’ of events that precipitated the catastrophe” (NFPA 2004).

Additionally, had The Station been governed by a model code and had the code been enforced, some – but not all – of the contributing factors would have been addressed.

=Aftermath=

Prosecution
Daniel Biechele, the band’s tour manager who was responsible for activating the pyrotechnics, pleaded guilty in 2006 to 100 counts of involuntary manslaughter. He was sentenced to four years, of which he served less than half before being released in 2008. Club owners Jeffrey and Michael Derderian were each charged with 200 counts of involuntary manslaughter. Michael Derderian, who plead no contest for involuntary manslaughter for installation of the combustible foam, was sentenced to four years. Jeffrey Derderian was sentenced to probation and 500 hours of community service (Tucker 2008).

Resulting Changes in Code & Industry
The Station nightclub disaster, similar to significant disasters in the past, prompted the codes and standards development process to incorporate lessons learned from the disaster into the code.

NFPA & Rhode Island's Response
Three weeks after The Station nightclub fire, the NFPA Technical Committee on Assembly Occupancies and Membrane Structures held a special meeting at which a number of Tentative Amendment Agreements (TIAs) were proposed. Considered tentative because they have not gone through the NFPA Standards Council’s official process, the TIAs are effective only between successive code publications and must be independently adopted by jurisdictions. All TIA’s officially became part of the 2006 edition of NFPA 101, //Life Safety Code//. The TIAs proposed and accepted included the following (NFPA 2006):
 * A requirement that fire sprinklers be installed in all new nightclub-like assembly occupancies, as well as existing nightclub-like assembly facilities that accommodate more than 100 people
 * A requirement that building owners inspect all means of egress to ensure they are free of obstructions before opening, and to maintain records of each inspection
 * A requirement that at least one trained crowd manager be present for all gatherings, except religious services
 * A prohibition on the use of festival seating for crowds of more than 250 without a life-safety evaluation approved by authorities

An additional requirement added to NFPA 101, //Life Safety Code// that wasn’t a part of the TIAs was as follows (NFPA 2006):
 * A requirement for the width of the main entrance/exit for new nightclub assembly occupancies to be increased from ½ to 2/3 of the total occupant load, while remaining exits must each accommodate ½ of the total occupant load

Additionally, the state of Rhode Island included an amendment eliminating the “grandfather” clause which exempted older buildings from meeting current building code requirements (NFPA 2006).

NIST's Recommendations
In addition to presenting the key findings of the investigation, NIST's official 2005 report made 12 recommendations for improving the structural safety of buildings and improving evacuation and emergency response procedures. Items addressed included the requirement of sprinkler systems, stricter provisions for pyrotechnic use, an increase of the factor of safety for the time of egress, and various areas of needed research. The recommendations, as well as key findings from the report, can be found here (NIST 2005). = = =Other Notable Nightclub Tragedies=

E2 nightclub - Chicago, Illinois (February 2003)
On February 17, 2003, just 3 days before The Station nightclub tragedy, pepper spray was used to break up a fight in the E2 nightclub. After shouts of poisonous gas were heard and several individuals began vomiting due to the pepper spray, a crowd crush occurred at the main entrance as hundreds attempted to exit via a steep staircase with inward-opening doors. The stampede created a pile of bodies at the entrance six feet high; 21 patrons died and over 50 were injured. In July of the previous year, a court order had forbid the use of portions of the club, citing 11 building code violations, most of which dealt with egress requirements (CNN 2003).

Fine Line Music Cafe - Minneapolis, Minnesota (February 2003)
On the same day, just hours after the E2 nightclub incident, the Fine Line Music Cafe caught fire when a band's pyrotechnics ignited a fire in the ceiling. There were zero casualties as 120 patrons escaped the building unharmed within two minutes.Two major reasons account for the differing outcomes between this and The Station nightclub tragedy. The first is that the Fine Line Music Cafe was a sprinklered building. Second, and just as important, was the avoidance of a crowd crush. Fine Line staff were trained in evacuating the facility in a safe and efficient manner. They had attended monthly meetings coordinated by the Minneapolis fire and police departments and had even attended one earlier that day. (NFPA 2003).

Lame Horse nightclub - Perm, Russia (December 2009)
Lame Horse, a nightclub in Russia, caught fire in much the same fashion as The Station nightclub - fireworks ignited a highly flammable interior finish/decoration. The highly flammable material led to a rapid spread of the fire, killing more than 150 patrons.

= = =Conclusions=

The high loss of life resulting from The Station nightclub fire was a result of many compounding factors. The use of pyrotechnics in a facility constructed with highly combustible materials proved a fatal combination. The legal system ruled negligence on the part of the band manager for activating pyrotechnic gerbs in such a flammable environment and on the part of the club owner for installing the highly combustible sound proofing foam in and around the club platform (Tucker 2008). Because the nightclub was an existing building, model codes existing in 2003 would not have required it to be sprinklered (NIST 2005). However, local building officials have testified that, because the facility went through a change of occupancy, it should have been required to meet all current codes, which would have required the installation of water sprinklers (Keith 2008). This was missed by local authorities. The building was also overcrowded at the time of the fire. Some estimate the number of people present at over 460, well beyond the legal capacity of 404 (Parker 2007).

Code changes resulting from this fire have attempted to account for many of the problems evident in The Station nightclub building, including restricting the use of both pyrotechnics and combustible interior finishes in clubs and increasing the occupant load paths of egress are required to accommodate. However, code modifications can only do so much. In the case of The Station nightclub, the existing model codes were not adopted by governing authorities. Many of the deficiencies contributing to such a high loss of life would have been addressed in these model codes (NIST 2005). Also, enforcement of the building codes in place is extremely important. The Station nightclub was well over its legal capacity at the time of the fire, despite having club employees monitoring the number of patrons and a West Warwick police officer stationed on scene. Also worrisome is the fact that the club’s change of occupancy should have required the building to be brought up to date with current governing codes, necessitating the use of water sprinklers. This was missed by authorities. Finally, The Station tragedy shows a need for education and awareness of the public. Had the crowd at The Station nightclub on the night of the fire known or been made aware of the locations of all exits, the fatal crowd crush would likely have been avoided, as patrons would have exited the building through the nearest exit, rather than flooding toward the doors through which they entered.

As stated before, the combination of deficiencies present in The Station nightclub building served as a “perfect storm”, resulting in 100 deaths and over 200 injuries. If any one of these contributing factors had been addressed, the fire and/or high loss of life would have been significantly reduced, if not entirely averted.

=Annotated Bibliography=

Belluck, P. and Zielbauer, P. (February 22, 2003). “96 Dead in Fire Ignited at Rhode Island Club.” //The New York Times//.  (Sept 24, 2010). New York Times article reporting the number of immediate casualties resulting from the fire.

CNN. (February 19, 2003). "Judge Blocks Charges Against E2 Owners." //CNN.//  (Dec 14, 2010). CNN article describing the potential causes of the E2 crowd-crush incident.

CNN. (December 5, 2009). "Five Detained as Investigators Probe Deadly Russian Nightclub Fire." //CNN.//  (Dec 14, 2010). CNN article describing early reports for the Lame Horse nightclub fire.

Duval, R. (2007). “The Legacy of Nightclub Fires,” //NFPA Journal//, May/June 2007,  (Sept 24, 2010). Article based on the featured presentation at the World Conference and Safety Exposition (WSC&E). It provides a review of the nightclub fire, reaction and investigation results of NIST, and the resulting fire code changes in the states of Rhode Island and Massachusetts.

Keith, G. “Audio: Gary Keith, NFPA Vice President of Field Operations and Education, on the fifth anniversary of The Station tragedy.”  (Sept 24, 2010). Audio of expert Gary Keith directly answering questions related to the origins of the fire, why it was so deadly, and why the nightclub did not have sprinklers.

National Fire Protection Association (NFPA). “NFPA Case Study: Nightclub Fires.” 2006. Report from 2006 reviews historic fires in assembly occupancies as well as The Station nightclub fire and the response of NFPA to this tragedy. In addition, code changes made in Rhode Island and Massachusetts, as well as an investigation completed by the National Institute of Standards and Technology are summarized.

National Fire Protection Association. “Public Assembly and Nightclub Fires.”  (Sept 24, 2010). Page of the National Fire Protection Association’s website lists the ten deadliest public assembly and nightclub fires in U.S. history and the ten deadliest foreign nightclub fires since 1970.

National Institute of Standards and Technology (NIST). “Key Findings and Recommendations for Improvement, NIST Investigation of the Station Nightclub Fire.”  (Sept 24, 2010). Page off the NIST website summarizes the key findings and recommendations found in the NIST investigative report.

National Institute of Standards and Technology (NIST). “Report of the Technical Investigation of The Station Nightclub Fire.” NIST NCSTAR 2: Volume I. June, 2005. Final investigative report addresses NIST’s findings on the causes of the fire, why it was so deadly, and recommendations for the future. Report includes results from computer simulations and physical mock-ups of the fire.

Madrzykowski, D., Bryner, N., and Kerber, S. (2006). “The NIST Station Nightclub Fire Investigation: Physical Simulation of the Fire,” //Fire Protection Engineering//, 3rd Quarter 2006,  (Sept 24, 2010). Trade article provides overview of the physical mock-up and computational model developed by NIST for its investigative report. Paker, P. (December 3, 2007). “Talley of a Tragedy: 462 were in The Station on night of fire.” //The Providence Journal//.  (Sept 24, 2010). News article updating the total number of people present in the club the night of the fire to 462 after the release of tens of thousands of pages of evidence.

Perry, J. (May 10, 2006). “Biechele gets 4 years to serve.” //The Providence Journal//.  (Sept 24, 2010). News article covering the sentencing of the band’s tour manager, who was responsible for setting off the pyrotechnics that started the blaze.

Reese, S. (2004). “If Only Becomes Never Again,” //NFPA Journal//, January/February 2004,  (Sept 24 2010). Author Shelly Reese describes the code changes made by NFPA as a result of The Station nightclub fire.

Tucker, E. (March 18, 2008). "RI Club Fire Figure Released from Prison." //USA Today//.  (November 11, 2010). News article covering sentencing of the band's tour manager and club co-owners.

Wolf, A. and Nicholson, J. (2003). “Nightclub Safety Equals Life Safety.”  (Sept 24, 2010). Authors discuss the major factors contributing to the Station nightclub fire’s high death toll.