1989 — Oct 5, Fire, Hillhaven Rehabilitation and Convalescent Center, Norfolk, VA — 12

— 13  NIST. Engineering Analysis of…Fire Development in…Hillhaven Nursing Home Fire.[1]

— 12  National Fire Sprinkler Association.  F.Y.I. 1999, 6.

— 12  NFPA. Nursing Home Fire, Norfolk, VA, October 5, 1989. 1989, p. 2.

— 12  USFA. Twelve-Fatality Nursing Home Fire, Norfolk, Virginia.  2007, 1.

— 12  Winchester Star, VA. “Marshal:  Hospitals Flunked Fire Test,” Sep 26, 1990, A3.

 

Narrative Information

 

NFPA: “On October 5, 1989, a nursing home fire in Norfolk, Virginia, resulted in the death of 12 patients and required hospital treatment or relocation of 96 others. The building, built in 1969, is a four-story, nonsprinklered, fire resistive structure housing 161 elderly patients at the time of the fire.  The first floor contained general administrative offices and support facilities and patient rooms were located on floors two through four. The fire was discovered sometime after 10:00 p.m. by the nursing staff who immediately began to evacuate patients, activate the fire alarm system, close patient room doors, and notify the fire department. However, during this process, the fire grew within the patient room of origin and extended into the exit access corridor, forcing the staff to take refuge from the fire.

 

“Norfolk Fire Department received notice of the fire at l0:18 p.m. and fire fighters arrived on the scene within four minutes of the notification.  Upon arrival, they observed fire extending from a second floor window and lapping to the floor above. An interior fire attack was begun utilizing the building standpipe system while other fire fighters laddered the building, extended a handline and “knocked down” the majority of the fire.  Severe heat and smoke conditions existed on the fire floor and fire fighters began to realize many of the patients remained in their rooms.  Because of these severe conditions, fire fighters began to evacuate patients from the fire floor.

 

“Other arriving fire fighters, summoned by additional alarms, found moderate smoke conditions existing on the third and fourth floors.  Eventually, the entire nursing home was evacuated.  Nine patients on the second floor died during the fire, eight were within the smoke zone of origin.

 

“Local investigators have listed the probable cause of the fire as careless disposal of smoking materials.  An open flame ignition source ignited bedding materials on a patient’s bed which soon involved a polyurethane decubitus pad, and the bed’s mattress.  The fire grew very rapidly while the staff was attempting to complete their emergency procedures. Within an estimated three to four minutes of discovery, flashover conditions were reached in the room of origin and the fire extended into the corridor.

 

“The following are significant factors in this fatal fire incident:

 

  • The rapid growth and development of the fire within the patient room;
  • The absence of automatic sprinklers that could have prevented full room involvement or flashover;
  • The lack of compartmentation due to the open door to the room of fire origin;
  • The lack of automatic detection and failure of the fire alarm system to function properly.”

 

(NFPA. Nursing Home Fire, Norfolk, VA, October 5, 1989, 1989, pp. 2-3.)

 

USFA: “On October 5, 1989, at 2218 hours, a fire in Norfolk, Virginia, was reported from the Hillhaven Rehabilitation and Convalescent Home, 1005 Hampton Boulevard. This was a 4-story masonry building, housing 161 elderly patients, most of whom were bedridden.

 

“First arriving firefighting units discovered fire coming out of the window of a second floor patient room located on the front of the building. The fire was lapping up to the third floor window. The second floor was completely filled with heavy smoke, and some flame at the ceiling level was observed. No alarms were heard and there was no apparent commotion.

 

“Second and third alarms were sounded immediately to assist in rescue efforts. Some patients were removed from their rooms by the use of ground ladders set up on the outside. Bedridden patients, trapped in their rooms, had to be carried by firefighters through heavy smoke and heat conditions. Rescue efforts on the second floor required approximately 35 minutes….

 

“Approximately 55 patients were removed from the second floor, and eventually, the entire building was evacuated. Heavy smoke conditions claimed the lives of 12 residents and injured 98. In addi­tion, four firefighters were injured.

 

“One hundred thirty-eight fire and rescue services personnel were required to bring the scene under control, officially declared at 0100 hours….

 

“The fire originated in Room 226, believed to be as a result of patient accidentally discarding a lighted match onto his bed (after missing the waste can) and igniting the bed linen and the polyurethane mattress pad, which is a highly combustible and smoke-generating material when subjected to open flame. The fire intensified very rapidly, generating tremendous heat and smoke buildup. It was known that the patient was a smoker. The night before the fire he had been caught with cigarettes in his room, which was against the facility’s rules.

 

“The room was not equipped with smoke detectors or an automatic fire suppression system, and it appears that the fire burned unabated for a few minutes before it was discovered. A nurse’s assistant had checked the patients in Room 226, the room of origin, and then proceeded down the hall to look in on other patients. Originally she stated she was only two rooms away when she smelled smoke and began checking for the source of fire. Later, however, she recalled she was several rooms away from Room 226 and that she checked back into each of these rooms for the fire before finally discovering the blaze in 226.

 

“Once the floor nurse detected the fire she assisted the two occupants from the room. The door remained open, allowing the fire and smoke to penetrate the second floor hall.

 

“Smoke barrier doors, located in the hall and within 20 feet of the room of origin, failed to close, allowing smoke to completely penetrate the second floor. The interior fire alarm system was pulled. Due to a blown fuse in the main fire alarm control panel, that system also failed to operate and no alarm was sounded.

 

“The nurse yelled to other second floor staff that there was a fire. The nurses began to open and close stairwell doors as they attempted to evacuate patients. This allowed smoke to penetrate the upper floors.

 

“It is believed that the fire burned approximately 12-15 minutes before the fire department arrived.”  (USFA 2007, “Twelve…” pp. 1-4)

 

“Firefighters…[experienced] difficulty releasing restrained patients from beds, as the restraining devices had to be cut or untied, requiring additional time. Difficulty was also experienced when removing life support systems and body fluid tubes, which were connected to bed and patient. Because it took so long to remove the bed straps and to disconnect patients from medical equipment, and because rescuers had to move cautiously down the stairwell carrying elderly, infirm patients, a traffic jam developed in the hall outside the stairwell. This further compli­cated rescue operations.”  (USFA 2007, “Twelve…” p. 5)

 

“Twelve elderly patients, most of whom were bedridden, died as a result of smoke inhalation or other complications directly related to exposure from heat and smoke. The nine women, ranging in age from 71 to 97 years, and three men (including the patient who started the fire) ranging in age from 65 to 92 years, died either at the scene or in the hospital sometime later. All the victims resided on the second floor in the immediate vicinity of the fire origin. Of the original seven fatalities at the scene, all were reported to have carboxyhemoglobin rates of 54-59 percent, according to doctors at the hospital.”  (USFA 2007, “Twelve…” p. 5)

 

Lessons Learned:

 

  • Institutional buildings, regardless of when they were built, need full built-in protection….
  • Frequent testing of fire protection and alarm systems is critical….
  • Flammable furnishings contribute to rapid fire growth and flashover….
  • Commonly used patient restraints seriously hamper evacuation efforts during emergencies….
  • It is important to remember to rotate personnel at the scene….
  • Employee training and practice drills pay off when an emergency does happen….”

 

(USFA 2007, “Twelve…” pp. 6-7)

 

Sources

 

National Fire Protection Association. Nursing Home Fire, Norfolk, VA, October 5, 1989.  Quincy, MA:  NFPA, 1989. At: http://www.nfpa.org/assets/files/MbrSecurePDF/FInorfolk.pdf

 

National Fire Sprinkler Association, Inc. F.Y.I. – Fire Sprinkler Facts. Patterson, NY: NFSA, November 1999, 8 pages. Accessed at: http://www.firemarshals.org/data/File/docs/College%20Dorm/Administrators/F1%20-%20FIRE%20SPRINKLER%20FACTS.pdf   (Checked on 5-16-2016 and URL was not functional.)

 

National Institute of Standards and Technology (Harold E. Nelson and King Mon Tu). Engineering Analysis of the Fire Development in the Hillhaven Nursing Home Fire, October 5, 1989 (NISTIR 4665). Gaithersburg, MD: NIST, U.S. Department of Commerce, September 1991. Accessed at: http://fire.nist.gov/bfrlpubs/fire91/PDF/f91015.pdf  (Was not operable when checked on 5-16-2016.)

 

United States Fire Administration. Twelve Fatality Nursing Home Fire, Norfolk, Virginia (USFA-TR-034). Emmitsburg, MD: National Fire Data Center, USFA, FEMA, 2007, 39 pages.  Accessed 5-16-2016 at: http://www.usfa.dhs.gov/downloads/pdf/publications/tr-034.pdf

 

Winchester Star, VA. “Marshal:  Hospitals Flunked Fire Test,” 9-26-1990, A3. Accessed at:  http://www.newspaperarchive.com/FullPagePdfViewer.aspx?img=158692264

 

 

 

 

[1] We believe the notation of 13 deaths on page 2 of this report is either a mistake or reflects a very late fire-related death. We have checked Newspaper Archives through September 26, 1990 and find all of the numerous references to this fire note 12 fatalities.  In addition, Figure 16, “Location of Victims” (page 20) reflects only 12 fatalities.