This incident of the 43, Green Wood Road took place on the 19th of December. There was a block of 4 flats, 2 flats on each floor and each consisted of two bedrooms. These flats had no smoke detection installed in them. At the time of fire the occupier an old lady was accompanied by her daughter and her three children. They lived on the ground floor. A call was received by the fire brigade and they attended the call with three appliances, they used six breathing apparatus sets, 2 high range jets and a large jet.
At 2100 hours on 19th December the daughter and her children retired to bed in the front bedroom. The children were of 8, 6 and 4 years in age. At 6:30 AM the mother woke up feeling hot. She was sleeping with 2 children while the third was near the front window. When she woke up she noticed a fire on the carpet between the door and her bed and one child stood there. The fire was on her duvet, she immediately jumped out of her bed and started searching for the keys to the front door and at the same time she was shouting to the old lady to awaken her. In the meantime the smoke kept accumulating in the house. As she found the keys she ran into the street shouting for help. The fire brigade attended the fire call soon from Morley and Hunslet. The team used 2 breathing apparatus crews to find the seat of the fire and fight it down. During this the two children were rescued from the rear bedroom, while one was found in the front bedroom. But due to the severity of his injuries, it was obvious that he died and hence was left behind till the Investigation Officer arrived.
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An accelerant detection dog was used at the fire scene, but the dog showed no signs of accelerants being used. The scene was also excavated by forensic department from the Wetherby to know the cause. This revealed a spalling pattern and hence indicating the places that maximum to heat or fire.
It was concluded that fire was put down as a naked flame exposed to clothing located on the carpet adjacent to the bed. As a result the bedding material lit and led to a rapid fire development in the horse hair mattress (it was approved also confirmed by the fire test of the horse mattress at the scene) which resulted in the loss of two of children.
Notes of Richard Hagger, The effects of fire fighting operations on fire investigation.
The occupier of this property was an 87 year old lady. The fire service had been informed by the police referring to a fire that had occurred 2 days back at 12, Manor Street. As the occupier was too old it seemed that she would not survive and needed to speak to the Fire investigator. The fire crew that attended the call did not ask an Investigator to attend the scene of fire, whilst the police asked him to do so.
The first thing that was done was that a copy of the FDR-1 form was filled which showed that the cause of the fire was a washing machine. According to the new bill, the investigators had power of entry if a 24 hours notice was given in writing. Till then they could not enter the premises. But as the Investigator was about to leave the son of the old woman arrived for some cleaning and granted the Investigator the permission to gain access to the fire scene. The son stated that the fire was initiated by the washing machine and that it was supplied by a charity shop and he was going to sue them for providing a faulty machine.
The Investigators decided to reconstruct the kitchen in the background and first inspected the washing machine. Doing so they found that the soap tray was intact, inner agitators were relatively undamaged and most of the wirings were insulated. Looking at this it appeared that there was only an external damage and there was no fault within the machine. Hence they decided to put back the remaining items like cupboard, worktop and the remaining kitchen assemblies and items. It was then noticed that the main seat of fire was around the cupboard and not the washing machine. And the burnt part in there was perfect enough to accommodate a bread toaster and hence they needed to talk to the lady to find out more. Unfortunately they were not able to talk with the lady, but her daughter contacted the investigators and said that her mother had done some silly job.
It was found that the toasters pop up mechanism was not functioning and the lady had been toasting tea cakes and as they started to burn the lady tried to take them out with a knife. Even though some bread bits had been setting of the smoke alarm, the lady had placed a cloth or towel over the toaster. This eventually led to the fire that had burnt the kitchen and the lady, severely enough to cause her death after 4 days of her hospitalization.
Notes of Richard Hagger, The effects of fire fighting operations on fire investigation.
This incident occurred on the 7th of May 1993, on the second floor of a department store that was not protected by sprinklers. This floor mainly consisted of clothing and a restaurant was also present on this floor. The fire had occurred on the morning of a busy day and hence the store was very busy. It was found that the fire was deliberately started by a young boy (he had been found to have problem at school which led him to starting fires at the school and library).
The building was on a sloping site and the front side of the floor contained a restaurant while the remaining areas were covered by clothing sales. The rear of the building lead to an exit at the street level, of the ‘Knifesmiths Gate’. Escalators were in the bottom left of the building while the stairs located at the top right. At the time of fire there was no automatic fire detection and neither was sprinklers installed, but the staff had some training of handling situations in case of fire. The restaurant had a slightly lower floor and ceiling levels and due to this it was separated from sales area by a barrier, even though a view was possible over the top, it would not be sufficient to draw the attention of the public present there.
The main source of fuel in the shop was clothing. It was hung in several tiers on racking along the walls which was near the point of origin of fire. There were also vertical stands which had clothes on the hangers slightly above waist level throughout the floor. During the fire the clothing mostly involved was of polyester, which is flammable and produced large amounts of smoke and CO on burning.
The fire was started in a clothing rack near a wall, and as the material involved was clothing the fire grew large but it was still in a small place. As the place was large enough the temperature did not rise enough to make a flashover occur, but it was sufficient to melt down all the hangers and stands of the clothes on the racks. Within 2-2.5 minutes of the discovery of the fire the whole floor had become smoke logged.
Most of the people on the second floor were in the restaurant and some were shopping.
It was revealed that two middle-aged women who were shopping had discovered the fire as they were near the point of origin of the fire. At the time she discovered the fire it was around 1 foot high and she then shouted “fire-fire” and hence caught the attention of the sales women on the billing machine. The sales women, who was trained in fire situations made the fire alarm go off and called the office to notify the fire brigade. She then advised people to evacuate the floor while she held the door open to the stairs.
It was then that an ex -Royal Air Force warrant officer happened to be present on the sales floor and demanded for a fire extinguisher from the manageress. They had the option of both an extinguisher and a fire hose, but they took the extinguisher. The extinguisher was not sufficient in extinguishing the fire as it had now become large enough and was spreading in both horizontal and vertical directions. The officer’s wife suggested them to leave the floor and hence did so by taking the rear exit. And at the same time the remaining staff quickly left the building taking the rear exit from the third floor.
There was not much to investigate in this fire as there were many eyewitnesses and the boy was found guilty for setting the store on fire. Due to this several people suffered mainly due to inhalation of smoke while they were escaping from the store. Although the majority remained uninjured, a few suffered from long term illness.
This fire resulted in death of an elderly couple who were trapped in the restaurant; they were a retired coal mine worker and his wife. Their blood had fatal levels of carbon monoxide.
Notes of Prof. David Purser, Fire investigation Case studies – Implications for fire safety design.
The King’s Cross underground fire was a very severe fire which occurred on 18th November 1987 at approximately 7:30 PM. 31 people were killed in this incident. The king’s Cross station consisted of two parts; the first was a subsurface station and a deep level tube station. The fire had started in an escalator that was used by the passengers of the Piccadily line, the escalator was completely burnt and also took along with it the entrances and the ticket counters of the tube station.
The fire had started on the escalator that was quiet old and was known to have been built just before the World War II began. Also some parts of the steps and the sides of the escalators were made of wood which made it easy to burn and quickly. Smoking in the subsurface stations was banned, but obviously not all followed the rules. One of the passengers threw away a matchstick without blowing it out, this matchstick fell down into the mechanism driving the escalator. This place had not been cleaned since some time and hence a lot of similar waste along with grease had accumulated there.
The fire had started immediately but the smoke that emerged was relatively clean and hence thought it was a false alarm. But later when the fire crew reached the scene as the flames emerged out of the escalator steps, they reported the fire to be of the size of a campfire. The people in the station did not notice the fire was growing rapidly and thought that it was not big enough the station had to be evacuated. Some of the passengers argued that the fire only spreads in the upward direction and hence the station below the fire need not be evacuated. But they were not aware that the intensity of the fire may liberate fuel vapours anywhere and hence the fire can spread in any direction. Also the emergency escape route was parallel to the escalator that was already on fire. Another major problem was ventilation as it was an underground station, hence it had no natural ventilation. The fire that was burning produced Carbon-dioxide and Carbon-monoxide as well, and this as it is heavier than air could cause a problem for the people on the lower end of the escalator.
The fire started underneath the escalator and gradually engulfed the whole escalator and as a flash over might later filled the whole ticket hall with smoke and fire. But the investigators later explained that the trains that left the station and the trains that came into the station caused heavy flow of air in and out of the stations, hence causing draughts, because the wind had a speed of about 19 km/hr (this is also known as the Piston effect and helps to ventilate the tube stations). The blowing of winds at this speed helped in increasing the spread of fire. The investigators calculated the wind was not enough to bring in the required amount of air needed to cause a flash over, that was otherwise assumed to have occurred.
During the investigation some parts of the escalator that were still left un-burnt were examined, the forensic department found that the wood had been charred in 18 different places, this depicted that such fires had occurred before but luckily they had blown out before they could expand to its full size. The investigators also noted another important fact that all these points where charring had taken place were on the right and stated that people who smoke usually stand on the right to let other people walk ahead from the left.
A large lump of grease was also found under the tracks that had collected over the period of time. But grease alone was difficult to ignite and if at all it was ignited it would burn slowly. As the investigation went on it was found that the tracks below the stairs had not been cleaned since when it was first bought into use, that was in 1940’s. Hence it was evident that a lot of small paper bits from the tickets, confectionary wrappers, hairs of humans and rats had been collected there.
The fire investigators then decided conduct a test to see what might happen if a lighted matchstick was dropped on the escalator, and it was much to the surprise of the investigators that the first matchstick that was dropped was sufficient to ignite a fire below and spread it further. The fire was then allowed to burn for seven minutes and was then extinguished. The fire was much similar to that of what the eye witnesses had seen. But this test did not provide any clues as to why a flash over occurred.
Oxford University was assigned a task to generate a computer simulation of the fire. The simulation showed that the fire in the early stages expanded downwards rather than expanding vertically, but surprisingly the end results were the same as the fire scene at the tube station. Later the investigators made a full scale model of the escalator and the nearby surroundings with the same type of materials to see what had actually happened. After seven and half minutes of normal burning the flames of the fire then laid down exactly in the same manner as shown in the simulation. At this time the wooden treads of the stairs reached a temperature as high as 500°C to 600°C even though they were almost 20 feet away from the fire. At this time when the flash over occurred the temperatures increased drastically and the fire then was converted into a jet flame aiming towards the ticket hall.
The angle of the escalator that was 300 was a crucial factor for the loss of several lives, this phenomenon was henceforth known as the trench effect.
Also the station had been painted several times since its construction, but the old coats of paint had not been removed, hence when the fire was raging on the escalator, during the flashover the ceiling also caught fire and gave off thick black and oily smoke.
Due this disastrous incident smoking was strictly banned in all the underground stations, and all the underground stations having wooden escalators were replaced with latest steel escalators. Also it was then made mandatory to install automatic fire detection and sprinklers in escalators and the type of paint to be used in underground stations become more typical.
The Bradford city’s football stadium was always a favourite for the football fans for the matches played there. It was in 1908 that the football clubs authorities decided to renovate the stadium, and the renovation work was completed in 1911. The changes made accommodated a main stand that could enable 5300 people to sit and could also have another 7000 of the audience stand and watch the match. It was almost about half time that a fire was noticed in the one of the stands. The fire spread quickly and engulfed the whole stand in no time. In this unfortunate incident 56 people lost their lives.
It was around 3:40 pm, just 5 minutes prior to the half time that signs of the fire were noticed like a glowing light(1). It seemed that the fire had been started accidentally when one of the spectators threw a lighted matchstick or a cigarette down and it ignited the waste papers that had collected under the seating stand. According to the “Inglis” one of the eye witnesses saw paper burn about nine inches below the floor boards and the audience began to feel hot near their feet, while one of the spectators searched for a fire extinguisher but failed to find one, so he informed a police officer and then it was reported to the fire brigade. The fire brigade had received a call at 3:43 pm(2). The fire then escalated vigorously and within a very short time, the flames could be seen and hence the police present at the scene began to evacuate the audience from their places. The fire then within no time involved the wooden stands and the roof also.
At this time when only three minutes were left for half time the match had to be stopped.
The heat radiated from the flames was so much that the commentator who was seated on the opposite stand of that engulfed in fire said that he could feel the heat. The audience was evacuated onto the field as the fire kept spreading.
Some of the spectators who tried to escape from the rear where they had entrance gates failed to do so, because the gates were locked soon after the match started. This was to prevent entry of those without tickets. Due to this those people got trapped and could not make it out of the fire.
The cause of the fire to spread so fast was because firstly the roof was made of wood and above that, they were coated with tarpaulin and were also sealed with asphalt and bitumen(1). It was also found that the prevailing strong winds too helped in the spread of fire. The whole stand was engulfed in fire within four minutes(2).
After this unfortunate incident, Sir Oliver Popplewell was appointed to head the inquiry. The inquiry introduced better safety legislations for the football stadiums in the UK. This mainly pointed to the restriction of wooden stands at any of the sports stadiums throughout UK (3).
1) Inglis.The football grounds of Great Britain. Pg.361
2) Pithers, Malcolm, www.guardian.co.uk/theguardian/1985/may/13/ fromthearchive
Manchester Woolworth’s was the largest store of the company in Europe. It was reported that there were about 500 people in the store when the fire took place. It was 1:28 PM that the Greater Manchester fire brigade received a call from the taxi controller. The store did not have sprinklers installed which was a major drawback and allowed the fire to escalate.
After the fire grew the fire brigade received a total of 12 calls reporting the fire.
Around 500 customers were busy shopping in this store when the fire broke out. When the first fire vehicle arrived at the scene flames and smoke was gushing out of the windows of the second floor. The fire crew had three water pumps and a hydraulic platform made available at the scene within two minutes of the first call. A mobile station officer also reached the scene. As soon as they reached they found that most of the people were trapped on the second and third floors of the building, while some had already made their way to the terrace and were waiting for help.
Further help was requested as the fire seemed out of control and 10 more pumps were called for. Rescue work was started with the help of an extension ladder and the hydraulic platform. While in the meantime the people on the ground floor were evacuated safely. The building had many windows that were barred and hence to rescue the people trapped in those places the fire men tried to spread open those bars but did not succeed until they used a saw and were able to rescue six people.
In the mean time BA set crews were already inside the building to rescue the trapped people, but the heat and smoke was so intense that they too had to kneel down to move further. It was around 1:42 PM that the Divisional Fire Officer came in to handle the situation and ordered to make the pumps to 15. In the process twelve people were also brought down from the terrace with the help of a hydraulic platform. By around 1:45 PM all the people who were trapped in the building had been rescued to a safe place.
It was around 2:15 PM that there were eight water jets in action on the fire and finally the fire was under control. During the whole process two BA set crews also had to be rescued as they were out of oxygen. The fire had been completely extinguished but the building was completely smoke logged and hence the fire department decided to use high expansion foam generator for extracting smoke out of the building. The building was then called safe at 3:51 PM and a complete review was then undertaken.
It was found that 3 people died on their way to the exit only 6 feet from the exit while few others were quiet close but could not make it to the exit door because of the huge amounts of smoke in the building.
After the investigation it was believed that the fire had started due to a fault in the electrical cable. Apart from that the reason for fire to spread rapidly was that the furniture consisted of polyurethane foam, which burns rapidly but also generates huge amounts of smoke. Due to this thick smoke the people inside could not see the exit signs.
In this fire incident a total of 10 people lost their lives while 26 people were rescued, around 47 people needed medical attention and 6 firemen had minor injuries. The fire loss was only the second floor was the fire had started, whereas remaining floors above suffered damage due to smoke logging. Due to fire fighting water had collected in the basement and the ground and first floor, hence causing water damage to the stock stored therein.
It was on the night of 13th of February. The stardust Disco fire was one of the worst and most severe fires in the history of Dublin lately. There were 48 young people who lost their lives in this tragic incident. The fire had started in a closed balcony.
The fire had started in a closed balcony that was on the exterior of the building. The staff present there with their abilities tried to extinguish the fire but were unsuccessful. The staff knowing that the fire was to spread further, they advised the people in the nearby rooms to evacuate the place. Unfortunately the alarm did not go off and majority of the people in the club remained un-notified about the fire. The fire then spread towards the main club area. Within a very short time the main area of the club was filled with thick black smoke.
As soon as the word of fire spread people began to evacuate the building. But at the same time a trade Union function was being held in the same building, hence there were a lot of people in the building. To add to worsening the situation some of the fire exits had been locked chains and padlocks. Hence the exits became limited. Many people tried to make an exit from the toilets, but did not succeed because the windows in the toilets had metal sheets on the inside and metal bars on the other side.
The fire exaggerated in the main area because the staff personnel shut the screen that was actually dividing the club area in two parts. As soon as the screen was pushed up, fire spread further and the walls and the tiles on the ceiling that generated large volumes of smoke.
The panic had spread and people started rushing towards the exits. Many people were run over by the others in this rush, and those who stood back fell unconscious due to the toxic atmosphere.
The fire brigade responded immediately to fire with five fire tenders and two ambulances. But as they arrived at the fire scene, they recognised that the fire was severe and the Dublin’s Major Disaster Plan requested to be activated. Various services from the Police, hospitals, ambulances and the fire brigade co-operated to help and rescue those still alive in the incident. The casualties were immediately transported to the nearby hospitals. The cities mortuary was overcrowded and hence help was taken from army to erect tents to keep those dead in the incident.
Till date it has not been known whether this fire was arson or not. In this incident a total of 48 people lost their lives of which most were young. The majority died due to intoxication of smoke and burns from the fire. While many were lucky enough to escape outside but suffered from the burns and inhalation of the smoke.
The Dupont Hotel Fire occurred on the 31st of December 1986. The fire was ignited by three employees who were discontented with their employer. The fire was started in a store room near the Ballroom. This fire grew big enough to claim lives of 97 people and caused over 140 casualties.
The employees of the hotel were in a way not happy with the management and had decided to go on strike. It was around 3:30 PM on the new years eve of 1986. Three men kept open cans of a flammable liquid in a store room near the ballroom located on the ground floor. The store room was filled with the unused furniture of the hotel. The flamable liquid was then lit by three employees. The fire grew rapidly as there was lot of combustible substances present and soon the fire grew out of control. Soon a flash over in the ballroom. Due to this flash over the the very hot gases rushed through the main staircase of the ballroom, this staircase led to the main lobby of the hotel. Eventually fire spread to all the rooms with open doors.
A large casino had a window that opened inwards, and knowing this many people came into the casino to make an exit. But as the window opened inwards and the people pushing outwards the window could not be opened and hence could not make it out. As the smoke filled into the casino many failed to survive aginst the toxic smoke. Few of the guests jumped from the second floor of the casino to the pool below and survived. While others who tried to get to the ground floor from a lift on faced the blazing fire as the lift door opened.
By the time help from the fire brigade arrived it was too late. 97 people had already died of which 17 were employees of the same hotel, most of them due to inhalation of smoke. The bodies had been severly burned that some of them could not even be identified. There were claims of over $2 billion.
Of the three employees accused for the fire on is still in prison while the remaining two had been released in 2001 and 2002.
A report was presented by the NFPA and according the sequence of events the fire had been reported approximately twenty minutes later than it had been noticed. If the call to the fire brigade had been made immediately they would have reached in time to prevent fire from spreading from the ballroom to further areas of the casino. The fire could have been put to arson as the mangement was in a harsh negotiation with more that half of the hotels employees belonging to the International Broteherhood of Teamsters. Also a strike had been declared by the members of the union at midnight. Above all this the police had received a call two hours before the fire regarding a bomb at the hotel.
It was then in February 1988 that a worker at the hotel admitted to have set fire at the hotel.
As a result of this incident many people lost their lives and hence to prevent similar fires occuring in the future some significant modifications had been made to the fire codes. This included that sprinkler requirements were now stictly enforced in areas where fire risk exists, the staff had to be trained to fight initial fire situations and some changes on the engineering side were adopted to contain the fire to its point of origin.
The morning of 21st November 1980 was a bad day for the MGM Grand hotel. As a fire broke out in the hotel it claimed lives of 85 people and left more than 700 injured. It was the second largest fire in the US in terms of loss of life.
It was around 7:00 in the morning that a marble and tile fitting supervisor made a vist to the Deli and he found some unusual glare and flickering. He went closer to examine it and discovered that the flame from a counter were rising to the ceiling. He immediately alerted the security and rushed to control the fire with an extinguisher and a fire hose. The supervisor tried a lot to contain the fire to the point of origin but failed evrytime. Eventually as the fire was out of his control he moved to a safe place. Many other employees who noticed the fire spread tried to extinguish it but none of their efforts succeded.
It was in less than six minutes that the entire casino was engulfed in fire and was spreading at a rate of around 4.6 – 5.7 m/s.
The fire department received their fire call 17 minutes after the fire was initially discovered, and the arrived at the scene in two minutes of the fire call. The fire crew started pouring water into the North entarnace of the casino at 1500 gallons per minute. On enterin into the casino the fire crew noticed black smoke coming out from the Deli. They had hardly travelled 13 meters when a huge fireball emerged from the Deli and came across the Casino, the crew immediately made their way out as flame came out of the front entrance. Most of the people dead were found in the staircase. As the fire sprinklers operated well in time the fire was contained only to the Casino and the restaurant.
On investigating the fire it was found that there was a grounding fault in the electrical system. The refrigerator used for a display cabin in the Deli caused vibrations due to which the damaged wires produced sparks that led to a fire. They also found the reason for the fire to spread very fast across the lobby, it was because the walls were covered with wallpaper, the glue used, there were also PVC pipings and other combustible materials present. The material that burnt in the fire generated toxic smoke and the major reason for the death of the people involved. It was also found that the smoke dampers did not function as required during the fire and hemce enabled the toxic smoke to spread throught the hotel.
The restaurant and the casino were areas that would be occupied almost 24 hours and hence were exempted from the installation of sprinklers. But when the fire began the restaurant was closed and hence the fire spread before anyone could notice it. The alarm system in the hotel was manually ridden and there were no manual call points in the restaurant and in the casino due to which no alarms were raised.
Eventually in this incident 85 people lost their lives and to prevent this from happening again the entire hotel was installed with sprinkler systems. And the hotel suffered a loss of $223 million to settle for the fire incident.
11th of April 1996 was like any other day for the Dusseldorf airport until 3:31 PM, when a person reported that some sparks had been falling from the ceiling down onto a flower shop. Soon the fire grew and ultimately in this incident 17 people died and about 62 people were injured.
When sparks were noticed falling from the ceiling, two fire fighters of the airport fire brigade responded within two minutes to the fire. They could smell smoke in the terminal building, as problems had previously been associated with the mechanism of the automatic doors they requested an electrician to have a look at the motors. At around 7 minutes after the fire was reported smoke was noticed to be coming from the vents in the flower shop. And soon the ceiling was on fire and small debris from the false ceiling began to come down. Seeing the fire grow, at 3:40 PM the all of the fire crews and their equipment were made available at the scene. The first floor of the terminal building was burning very quickly and about 4:07 PM the first floor was almost smoke logged as smoke could be seen coming out of the doors on the first floor. At this time the fire was attended by one water tanker and two fire tenders. At 4:15 as the situation worsened and seemed to getting out of control help was requested from all the fire brigade units across the city.
After hours of hard work the fire was declared under control at 7:20 PM. Eventually 701 people from the various fire brigades, search and rescue teams were in action when the fire was extinguished. As a result of this mishap the Dusseldorf fire brigade reported death of 7 people in two lifts. Eight other passengers were found dead in the VIP lounge on the third floor, one more person was found dead in a lavatory. Another person had been rescued in the fire but he lived only a few weeks and died.
The investigation was carried out by the German authorities. According to them, a welding work was being carried out by a worker in the terminal, and during this process the polystyrene insulation that was used to cover gaps in the ceiling caught fire. Hence the fire spread all over the first floor and then fire to the second floor through the staircase and the lift shaft. The main dame due to the fire was caused in the staircase while the damage on the first and second floors was caused mainly by the smoke. They also found that the reason for fire to spread over a large area was because no automatic sprinkler was installed in the area of fire. Also the dry risers were not connected to the municipal water supply line. The vertical openings were not adequately protected to cope up with the spread of smoke. Also the insulation material used in the ceiling was combustible.
As a result of this fire the airport was completely out of service for 84 hours and was brought back into service on the 1st of July 1996. According to NFPA this fire was the worst in terms of loss of life due to a structural fire in the airport throughout the world. Due to lack of communication and chain of command over manpower, 17 people lost their lives and 62 were injured.
The Summerland leisure center fire occure on the 2nd of August 1973. The leisure center was located in Douglas on the Isle of Man. In the fire 50 people died and 80 people had severe injuries.
The fire had started around 7:40 PM in a stall. When the stall could not limit the fire to itself it collapsed towards the exterior of the building. The part of the building facing the fire had scladding of steel that was coated with bitumen, and it could not resist the fire for a long time. After some time the on the inside of the building where sound proof material had been fitted cought fire and the fire started to spread. As the fire spread it caused an explosion. The remaining part of the building had been covered with acrylic sheets that were flamabale. Due to this explosion the acrylic sheets were soon engulfed in fire. As the fire developed the acrylic that was on fire melted and dripped down that set fire below and also injured the people. As the acrylic melted away more air was available to the fire and this worsened the conditions.
No one present in there informed the fire department about the fire for almost half an hour. Ultimately when the fire brigade was informed it was by a ship’s captain almost 2 miles into the sea. He contacted the HM Coast guards and said “It looks as if the whole of the Isle of Man is on fire” (https://en.wikipedia.org/wiki/Summerland_disaster). The coast guards then informed the fire brigade.
At the time of fire 3000 people were present in the building. Many people rushed towards the Fire Exits, but they were locked, hence there was a great rush to get out of the building from the main entrance. As a result there were many people who got crushed and crumpled in this commotion. As the first fire crew reached the fire scene they realised that additional aid would be required to handle the situation and hence all the help at the Isle of Man was made available at the fire as soon as possible. The large loss of human life was because no power was available and the ventilation inside became inadequate for those who were trapped by locked fire exits.
In this disaster at the Summerland leisure center 50 people lost their lives. As most of the building was damaged by fire another building was constructed at the same place but smaller than the previous one. Due to such a high number of deaths, Lieutenant Governor ordered a public inquiry which ran in September 1973 and it concluded in February 1974. Although no one was found guilty, the reason for high number of deaths was put to the delay in the evacuation of the people and the combustible materials used for construction. Some changes were immediately introduced in the Theatre Regulations to improve the safety standards.
On the 22nd of August 1985, a British Airtours flight from Manchester (England) to Corfu (Greek island) was on the runway and ready to takeoff, when an engine cought fire and caused death of 55 passengers and left 15 seriously injured.
The plane was on the runway of the Manchester International Airport with 131 passengers and 6 crew members on board Boeing 737. Just before take off the pilot heard a loud bang and thought that one of the tires had been punctured. Hence he slowed down the plane and diverted it on to the taxiway where slight winds prevailed. As the plane haulted the crew noticed that the engine 1 was on fire. Before anything could be done fuel had already leaked in sufficient amounts that the fire from the engine spread to the passenger cabin as the light winds aided it. The fire in the passenger cabin generated a lot of toxic fumes and smoke. 55 passengers died including two crew members. About 48 of them had died due to inhalation of toxic smoke. The remaining 78 passengers and 4 crew members were able to evacuate to safety, although 15 of them had severe injuries.
Investigation carried on showed that the reason for the fire to break out in the engine was beacause a crack had developed in the No. 9 combustor can because of thermal stress. As the exhaust was now not directed outside the engine but the hot gases hit the casing. It caused damage to the engine structure and rupture in the fuel tank and causing the fire.
The can had been repaired once before by a welding, but the welding was not upto the safety standards and had failed again causing the disaster.
If the pilot had known that the tire had not burst but an engine fire had started the aircraft could have been stopped in a shorter time and the time of evacuation would be more.
All of the cabin crew including the two dead and two employees of the Manchester Airport Fire department were awarded the Queen’s Gallantry Medal in recognition of their brave work that helped save lives of 78 passengers. There were recommendations of installing systems like the smoke hoods and the mist system, but as both were very expensive they were ruled out.
On the night when the fire took place, an arabian tent had been set up on the outer side of the restaurant of the hotel. The fire had somehow started in this tent and as it was made of fabric it spread fast, as the winds were strong it aided the fire and set the decorative panels made of aluminium on fire. Within a short time one side of the hotel was completely on fire, and then it spread into the hotel throught the kitchen and the floors above the kitchen. The construction of the hotel was such that it was divided into three wings that were connected at a place where the lifts and the staircase were present. The hotel was damaged on the exterior adn in the corridors from where the fire spread. In some places the building sustained serious structural damages. In such places smoke was able to get into the room and some people died due to smoke inhalation, while those on the rear end had been safe in their rooms as the smoke was not able to enter their rooms. One person tried to escape through the corridor, on opening the door she faced fire, hence she ran towrds the window but forgot to close the door behind her, by the time she could open the sliding window and escape to safety she was overcome by the smoke and collapsed to death.
In this accidental fire 16 people died and around 70 people were injured. As there was no legal binding for installation of sprinklers in hotels in Egypt, this hotel also had no sprinkler or alarm system installed causing the fire to spread faster and over a greater area. The brigade took nine hours to extinguish the fire in the six floored hotel.
Reference: David Purser’s notes on Fire Investigation Case studies.
The fire on Tooley street had started on the eend of June 1861 and is the known as the biggest fire after the Great Fire of London.
The fire started in a warehouse that stored jute and hemp, in almost half an hour the fire grew large and spread to the neighbouring buildings, the main reson for this was because the workers had left the fire doors open. By the time the fire brigade arrived the fire was far out of control. In the attempts to extinguish the fire the head of the London Fire Engine Establishment died when a wall fell over him and killed him on the spot. The fire kept burning till 14 days until it was finally extinguished. The estimated loss of property was to be 2 million pounds.
On the 11th of November ’00, the Kaprun disaster (Austria) took place. A fire lighted in a moving train in a tunnel and claimed 155 lives and left only 12 alive. These passengers were mainly skiers who were headed to the Kitzsteinhorn Glacier to enjoy the skiing season.
It was just after 9:00 AM when the train had entered the tunnel, when the electric heater in the conductors cabin (that was unattended) cought fire. It was due to a fault in the design. The electric heaters that were installed were meant only for domestic use and not mobile properties. The fire was sufficient enough to melt the pipes that carried the hydraulic fuel which was flammable. As the hydraulic fluid from the brake system leaked the pressure drop caused the train to stop due to its inbuilt safety features. The conductor who was at the front end of the train configured that a fire had started in the rear conductor cabin. He reported to the fire to the contol room and tried to open the doors with the controls, but as the hydraulic system was down the doors did not open. As the fire grew it burned the power cable and hence left the conductor with no pwer to contact the control room. The passengers in the train then became aware of the condition and attempted to break the glass windows, but they were break- resistant. While on the rear of the train eleven passengers had succeded in braking the window and with advice of another passengers who was an experienced fire fighter escaped out of the train. As the fire expande toxic gases were produced and spread through the train. The conductor some how managed to unlock the doors, so the passengers could open them manually, but by this time most of the passengers had fainted due to inhalation of the toxic smoke. Those of the passengers who managed to get out of the train along with the conductor were asphyxiated due to the smoke and later burned to death as the fire spread. This actually happened because the tunnel was ascending and hence it acted like a chimney wherein oxygen from the rear was consumed and helped fire to spread further upwards.
In the meantime another train was decending from the same tunneland had only one passenger and a conductor on board. These wo also died from inhalation of smoke as a lot of smoke had accumulated in the tunnel.
Later it was found that people in the Alpine center were evacuated almost 2.5 Kms from the burning train, but four people were unable to get out and only one of them had been rescued by a fire fighter while the remaining three died due to lack of oxygen in the smoke before they were rescued.
There were only tweleve survivors in this incident because they headed downwards of the train i.e. in the direction opposite to that of the fire spread and hence were safe.
It took almost one year for the inquiry that determined that the fire had started due to the over heating of the electric heater, and the leak in the hydraulic fluid line only added to the blaze. The leak also caused the train to stop and prevented the doors from opening.
Eventually 155 passengers in the train, 2 on the other train and three others in the Alpine center died in the disaster, while only 12 escaped the safely and one rescued by the fire fighter.
The investigators were shocked to find out that there was no means the passengers could contact the conductor, neither were smoke detectors installed and nor were there emregency braking mechanism in the passenger cabins. The train had extinguishers but they were out of reach of the passengers in the sealed conductors cabin. Later on all the trains running in the Alps were improvised in the safety measures that lacked in the Funicular train.
The fire in the Windsor Castle took place on November the 20th, 1992. The fire had originally started in The Queen’s Private Chapel at around 11:33 AM. The cause of the fire was the excessive heat of a spotlight that had been beaming on a curtain and caused its ignition. Shortly after the curtain was on fire the fire alarm went off and alerted the Castle’s fire brigade. Initially the grid map of the castle showed that the fire was in the Brunswick Tower, but soon the fire spread to other nearby rooms. The main part of the castle – The State Apartments were also engulfed in the fire within a short time.
The firemen on patrol rounds were alerted by pagers autom automatically. The Chief Fire Officer Marshall Smith activated the public fire alarm and called the Royal Berkshire Fire and Rescue Service. The Chief then immediately made his way to the fire scene to observe the scenario and to guide the fire fighting and salvage operations.
The first fire vehicles to respond arrived about 7 minutes after the fire call from the Royal Berkshire Fire and Rescue Service. At around 11:48 AM 10 fire tenders had been involved in fighting the fire. But as the fire worsened there were 10 more engines joined by 12:12 PM and at 12:20 PM there were 35 fire vehicles and more than 200 firemen involved in fire fighting and salvage operations from Surrey, London, Oxfordshire and Buckingham shire and Berkshire.
The St. Georges’s Hall was also on blaze at 12:20 PM and hence four other fire vehicles were called on which included two hydraulic platforms. At 1:30 PM fire barriers had been constructed to prevent the futher spread of the fire. The firemen were now gaining control over the fire but the celing of the State Apartments had started to fall down.
By 3:30 PM the fire seemed to have been brought under control, but as the Brunswick Tower collapsed the fire had been the center of fire.
The firemen had been the called back to their reporting stations as it was reported that two firemen were missing, but on reporting all were sound. The firemen had been temporarily asked to step back for a second time when the roof fell in. But at quarter past 4 the fire had re ignited in the Brunswick Tower. At around 6:30 PM the entire tower was on fire and flames upto 50 feet high had been reported, after 30 minutes the ceiling of the St. George’s Hall eventually gave way in the fire.
It was around 8:00 PM that the fire was completely under control after burning for 9 hours. The fire was said to be completely extinguished by 2:30 AM. But as a precaution 60 Firemen and 8 fire vehicles were kept on standby duty for many days after the fire.
The main reason for the fire to spread swiftly was because there were no fire barriers in the voids above the false ceiling. It was estiated that more than 1 million gallons had been used in the fire fighting operation taken from the mains of the Castle and the Thames river.
The restoration cost of the Castle was firstly thought to reach around 60 million Pounds, but the actual cost came upto 36.5 million Pounds. The Queen herself contributed 2 million Pounds for the reconstruction of the Windsor Castle.
The reconstruction of the damaged structure was completed by May in 1966, but the final finishing that was due on spring 1998 was completed by 17th November 1997
Purkiss, John.Fire safety engineering: design of structures.Butterworth-Heinemann, 2007, Pg-12
McDonald, Roxanna.Introduction to natural and man-made disasters and their effects on buildings.Elsevier, 2003
The cold store had one floor and had offices attached with it. The consytruction of the buikding was such that it was 70 m in length, 40 m wide and 16 m in height. The offices were 11 m long, 9 m wide and 3 m high. The building was mainly constructed with steel columns and concrete slabs, it had galvanised cladding sheets and polyisocyanurate sandwhiches for the roof. Sandwhich panels installed as they provided good insulation to maitain low temperatures in the cold store.
On the 10th of October ’97 at around 9 in the morning some welding workers had been completing some of the welding works in the safety barrier of the gantry. It was then at 11:35 AM that one of the welders noticed something on fire some 2.5 m below him. The worker tried to put out the fire with his hand gloves and asked another worker to get an extinguisher. The fire grew rapidly and before the worker escaped the flames had become 4-5 feet high.
Within a few more minutes the entire building was engulfed in fire and the foam panels from the ceiling collapsed and added to the fire.
Investigation was started the very next on the 11th of October and was carried out by the Fire Department and the Private Fire Investigators. On examining the building externally it was found that the steel structure had been severely buckled and in some places collapsed. The eye witnesses available agreed that the fire had started in the place where the welding work was being done.
There were only two ways by which the fire might have originated:
1) Electrical fault: this was ruled out because the electricity suply had been cut off in the building untill all the electrical work was not completed.
2) Welding Machine: the welding machine was supplied power from a vehicle outside the building and the welding was done by the lead taken to the point. The earthing was done at the lower most point on the steel structure and generally on the exterior of the building.
After considering all the possible factors for the fire to ignite, the most likely cause for the fire seemed to be that the spark during the welding operation having to fall down and igniting the hardboard below. According to the investigators, this fire then must have seeped below into the sandwhich panel and ignited the polystyrene, and hence spreading the fire further.
A test was done to verify the assumption they had made. In the test the harboard did ignite due to the welding sparks, but the polystyrene in the panels below did not. And hence futher investigation was done.
It was later found from the eye witnesse that the gap between the panels was sealed with a polyurathene foam spray which was then left to dry before it was covered with a metal tape.
Repating the test again it was seen that the uncovered polyurathene foam ignited and spread the fire to the polystyrene in the sandwhich panels.
Notes of Phil Reed, Case Studies with application of fire science and fire investigation.
A church hall that had been out of service for almost 18 months had been put on small fires and small thefts took place many times. On the 9th of November 2002 at 11:55 PM a fire started. The fire brigade had been alerted and reached the fire scene at 7 minutes past 12 at night. The fire crews set into the church from the front and the back to find out the seat of fire and extinguish it.By the time the fire crews could get the fire under control the fire had started to spread from the voids in the roof and spread horizontally. The intensity of the fire made the roof of the church to collapse and now the flames spread to an adjacent hotel through the open fire exit, hence endangering lives of the people in the hotel.
As the fire brigade became aware of the fire spread to the hotel, they evacuated all the people in the hotel and finaly extibguished the fire.
On initial examination of the fire scene the investigators said that the fire had been delibrately started in the kitchen on the ground floor. The police inquired many people in concern with the fire and many stated that four youngsters were responsible for the fire as they were many time found within the church premises.
On the 11th a deeper and more carefull investigation was carried out and the outcome was that the fire had been started in two different places, one the toilet, and second in the office, which completely contradicted the initial investigation.The four youngsters were interrogated and based on their answers it was likely that a naked flame had been used to set alight the furniture in the office. The four youngsters were then finally charged for deliberatly setting fire or setting the fire without considering the results.
Notes of Phil Reed, Case studies with application of fire science and fire investigation.
A fire began in a builing that was under contruction on the 23rd of June in ’90. From the information avalable it was known that the fire had begun in the contractors cabin, that was located on the first floor of the 14 floor building. As the sprinklers were not not fully functional, the smoke spread throughout the building without being noticed.
Upon investigation the investigators found that the fire had burnt for almost four and half hours and out of which the flame temperature crossed 1000 0C for two hours. The total fire loss was reported to be more than 25 million Pounds, where as the damage to the structure was approximated to be only 2 million Pounds.
The majority of the damage had been caused to the materials used for fabrications and the services installed. The damage to the structure was repaired in only a month. The construction of the building was of steel frame and concrete floorings with steel mesh. As the builiding was under constrution there was no functional fire system. The investigators noticed that eventhough the fire had been so severe and there were deflections in the steel structure, none of the floors, beams or columns collapsed.
Having found the some evidence from the Broadgate fire , BRE decided to build a 8 floor steel structure with composite concrete frame at their testing center – Cardington. After the structure was setup it was exposed to six fire tests in full scale.
The study of the Broadgate fire and of the Cardington test showed that how the fire in a structure would behave. Now the structures are modelled for the worst case fire scenarios considering the fire load present, duration of the fire and the ventilation available. This modelling is done withe finite softwares and it helps to understand the areas that have to be protected and hence is cost effective in terms of the fire systems installed.
Notes of Paul Jenkins & Nick Troth, Fire Investigation as a source of data for safety design.
It was on the 29th July ’03 that a fire broke out in a 12 storeyed builing – Telstar, Paddington. The two basement had offices. The rooms on the above floor were approximately of the dimensions of 15 m wide by 51 m in length, and the floor area was 765 m2.
During the investiagtion the iformation of the fire was obtained from the statements of the eyewitnesses, video footages, fire reports and from burnt debris. To calculate the rate of fire spread and growth engineering calculations were used but to use them three important factors are to be known. They are :
1) The time when the fire started and when it flashed over and the condition of the room during the flashover.
2) What might have been the maximum temperature in the room during the fire.
3) The ventilation that was available in the room when the fire began.
After the investigators had observed the debris at the fire scene the concluded that the flashover had occured 10 minutes after fire was detected. And the detection systems would have activated latest after 5 minutes of the fire initiation. Hence the flashover occured 15 minutes after the fire began.
After gathering all the information available it was concluded that:
1) The fire was very severe as the temperatures reached to almost 850 0C.
2) The fire had spread faster than thought, because of the ventilation windows.
3) The fire lasted for almost two and half hours and flashed over after 15 minutes of the begining of the fire.
Notes of Paul Jenkins & Nick Troth, Fire Investigation as a source of data for safety design.
The west one project had three builing blocks for residential purpose and had a common linked car park in the basement. On the 5th of May ’03 at about 4 in the morning someone discovered a fire in the basement car park at the construction site when the construction was still being carried out. The fuel to the fire was mainly the construction material and the cables. When the investigators observed the fire scene they concluded that the temperatures might have varied from 760 0C to 1093 0C at the seat of the fire by looking at the extent of damage to the steel and copper fittings.
After the initial investiagtion had been completed it was stated that in the remaining two blocks there was not much damage due to fire except from the smoke damage. And the investigations to be carried out further would mainly concentrate on third block of the podium structure. A Schmitt hammer was used to know the extent of damage in the concrete where ever it made a hallow sound, but this method was difficult to assess the total structural damage that might have occured. Futher tests were carried out with help of a Petrographand a microscope. This test showed that there were micro cracks that had developed but no other structural damage was reported.
The following were concluded from the West-One fire with regards to the structural analysis:
The main damage to the structure was suffered by the slab of the podium structure and the beams therein. But eventhen the overall strength of the three blocks was not affected by the fire.
The damaged beams and columns were then rectified by using additional concrete and mesh over the damaged areas also known as the gunite method.
The fire had started in the area where all the construction materials were stored. In some areas there was contamination of chlorine. The contamination in some areas was removed by hydro cleaning and demolition services. But in areas where there was more contamination the concrete was remaoved and then constructed again.
After all the repairs had been made the tensile strength of the damaged areas was calculated and found that it was slightly less than the designed tensile strength but was within the acceptable limits.
Notes of Paul Jenkins & Nick Troth, Fire Investigation as a source of data for safety design.
In 2001 on the 9th of September when two hijacked planes crashed into the Twin Towers or the World Trade Center and made them to collapse, the disaster claimed 2750 lives (1) which includes people who worked in the World Trade Center, fire fighters from the various fire departments of New York, officers from the Police departments.
After this disaster occured, it changed the way in which the sky crapers were previously looked at. Due to this disaster many of the codes and standards had to looked over again and revised so that such and incident does naot happen again.
The main area where work had to be done was on the fire resistance of the material used for construction, its rigidness, the evacuation plans for high rise buildings and risk identification and management.
The National Institute of Standards and Technology carried out the deepest examinations for the failure of the WTC structure. Many agencies and authorities looking after the safety of the personnels in the buildings were requested to make some changes in the safety procedures.
The NIST made 30 major changes that were recommended and to be follwed for increasing the safety standars in the high rise buildings. These recommendations were classified into 8 categories.
1) Increased integrity of the structure: in the worst case scenarios like strong winds or a collapse of the building the structure was degigned accordingly to prevent the collapse of the entire structure due to the hazard.
2) Increase in the fire resistance of the structure: according to this the material of the construction used must be fire resistant according to the rating of the hazard present. The method of fire testing of the structural components was made mor stringent.
3) New methods of testing of fire resistance structure design was implied.
4) There were improvements in the active fire protection systems installed such as sprinkler system, hydrant system, alrm system and the smoke sxtraction system.
5) The evacuation plans for the buildings were improved: the evacuation of the people inside the building was a prime focus to get them to a place of safety in the safest way and in the shortest time and in an orderly fashion.
6) The emergency response mechanisms were to be improved: the technologies used must provide a better acces of the buildings facilities and the communication ao-ordination between agencies and response was improved for emergencies on a greater scale.
7) Improvement in the procedures for the maintenance of existing buildings and installing of safe escape routes with sprinklers in the new buildings.
8) Training and educating the professional: the architects, fire protection personnel and structural engineers should be given tarining and eduaction at a national level.
From the analysis of structures after the fire many things are learnt that are later rectified by introducing changes in the codes and regulations and hence more accurate conclusions can be drawn.
(2) Notes of Paul Jenkins & Nick Troth, Fire Investigation as a source of data for safety design.
The Bethnal Green road fire took place on the 20th of July, 2004. According to the London fire brigade a fire call was received from the Bethnal Green road and by 4:00 AM it was responded by 50 fire officers as the fire had transformed into a blaze.
The fire brigade was successfull in rescuing two people from their terrace as the fire was still raging. The fire was at its worst in the basement of the building. As two fire fighters were fighting fire there and had some problem with their hose line they were severely injured and burnt in the fire. But they died within a short time after they were transported to the Royal London Hospital.
Malcolm Kelly, the Assisstant Commisioner of the London Fire Brigade said that as soon as they reached the fire scene the they saw a “serious fire in the clothes shop and in he basement” (1) he also said that the smoke had spread to all levels in the building and was seen coming out of the windows.
On the 22nd of March, 1975 fire broke out at the Browns Ferry Nuclear Plant. The fire started when a worker was searching for air leaks with the help of a candle, and accidentally ignited a cable and burnt the cable seal (that was not fire proof) and hence the fire spread to the reactor building. This fire spread also caused intense damage to the control cables of the reactor chamber.
The fire was ablaze for almost seven hours and burnt over 1600 cables including 628 cables that were for the safety purpose. The power supply was disrupted and hence the controls sytems and mechanisms could not function properly because the instrumentation cables were damaged. The cooling systems for the reactor including the standby cooling systems had failed. Many emergency repair works were undertaken to enable the reactor to shutdown safely.
Lateron when an investigation was carried out as to what caused the fire to be so severe in nature, it was found that there were many drawback in the design of the power plant as well as in the fire protection systems installed. The investigators finally said that safety of the people and the infrastructure with regards to a fire scenario in a nuclear power plant was not complied to the standard by the insurance companies. And specially in regards to the proper and safe shutdown of the nuclear reactor in case of a fire.
After the Browns Ferry fire incident the Nuclear Regulatory Commision revised its rules and regulations where it had lacked behind in the Browns ferry incident.
From the investigation carried NRC recommended that there must be sufficient distance between blocks, fire ressistant walls or barriers must be constructed and sprinkler systems must be installed.
NRC introduced Section 50.48 in 1980 to describe the requirements of the fire protection systems. Paragraph III.G describes the fire protection facilities needed for a safe shutdown of the Nuclear reactor facilties. According to Paragraph III.G.2 in Appendix R, cables and equipment must comply with one of the following:
1) Seperated be seperated by a three hour rating fire wall or barrier.
2) Seperated by a distance of more than twenty feet and must have no flamable or combustible materials in between and should also have fire detectors and automated systems to extinguish the fire.
3) Have one hour rted fire barrier along with fire detectors and automatic fire suppression facilities.
Notes of Keith Murray, Passive Fire Protection in process and building fires (failure and testing)
Hunterson steel plant was located in Scotland. It had a conveyor belt that carried iron ore over a distance of several kilometers. Before it reched the steel plant it crossed over a road. Due to the fire all the panels on the side of the conveyor were blown outwords. The fire was ignited by some workers who were performing repair and welding work. The spread of fire is much faster in conveyors because it acts like a tunnel and specially in cases where the conveyor belt is at a slope. Every 70 meters a vent had been provided to prevent the fire from spreadind further but this did not work. The entire conveyor tunnel was completely destroyed.
Notes of Prof. Gordon Andrews, Fire and Explosion experience in industrial and commercial fires.
On the 10th of July, 1976, a highly poisonous Dioxin spread in the nearby areas of Seveso, near Milan for about twenty minutes. Almost 250 people affected by this suffered from a dermital disease called chloracne and about 450 people suffered burns from caustic soda. The contamination had spread over an area of 17 square kilometers and an area of 4 square kilometers was left inhabitable.
Although so many people suffered from diseases none were killed in this incident. This deadly chemical was released by the rupturing of the safety disc due to over pressurisation of the plant where 2,4,5 – trichlorophenol from 1,2,4,5 – terachlorobenzene and caustic soda in presence of ethylene glycol(1). During the process the rector became over heated and a thermal runaway rection occured, producing dioxin and hence causing overpressurisation and hence rupturing the disc.
There was no arrangement to contain the contents in such a situation and hence 6 tonnes of the chemical which included 1 kg of dioxin was released into the surounding areas of upto 17 square kilometers.
A forman who was working nearby heard the sound of the leakage from the ruptured disc and immediately started to cool the rector. If this step had not been taken by the foreman the contamination would have spread over a larger area.
The chemical process that was to take place had been designed to safety by keeping a margin of 40 oC and so that a thermal runaway rection would not start . the steam temperature was maintained at 192 oC where as the thermal runaway reaction was supposed to start at 230 oC. But they had not considered the lowest temperature it could start i.e. at 180 oC. As a slow exothermic reaction started on the top surface of the liquid the temperature raised gradually and finally leading to a full thermal runaway rection. In case of the Seveso the management that such a reaction would never happen and hence did not install a catchpot to contain the chemicals in case of leakage.
(1) T. Kletz, Learning from accidents, 2nd edition 1994, Chapter 9, Butterworth.
(2) Notes of Prof. Gordon Andrews, Spontaneous Ignition.
Bhopal gas tragedy is remembered as the worst industrial accident that has ever occured till date. It claimed the lives of over 2100 people while they were sleeping and left many more seriously ill. On the night of the 3rd of December 1984, a very toxic gas MIC – methyl isocyanate used for the production insecticides came in contact with water and led to a runaway rection. A cooling system for safety had been provided to prevent a runaway rection to occur but it was shut down. Apart from this the scrubbers used for the absorption of excess gas was not functional and the flare was not used to burn any gas that came from the scrubbers. Hence all the safety features that were installed had failed to prevent the leakage from occuring.
It is not known that how water came in contact with MIC, but it was later known that about 1000 kg of water and 1500 kg of chloroform entered the tank in which MIC was stored and hence the runaway reaction occured. Small pieces of metal came into the MIC tank from the Nitrogen pressurization pipe which acted as catalysts and made the runaway rection to occur with less quantity which otherwise would have been greater.
The line for ventilation was cleaned with water, but a blank cap was not installed in the line to prevent water entering the tank. The flushing of the line with water was continued without checking it flow into the tank.
The decision about flushing the pipe with water was taken by a new employee who had been on duty for only about a month and did not know the consequences of a runaway reaction that would occur when water comes in contact with MIC. This was due to lack of training and knowledge.
Notes of Prof. Gordon Andrews, Spontaneous ignition.
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