1991 — March 4, Crystal Springs Estates Boarding Home Fire, Colorado Springs, CO– 10

lornajarrettblanchard March 4, 1991

–10 USFA. Ten Elderly Victims from Intermediate Care Facility Fire Col. Springs, CO. 1999

— 9 NFPA. NFPA Today. “Today in fire history: 9 dead…”[1]

Narrative Information

USFA: “An accidental fire determined to have originated above ceiling level occurred in the early morning hours of March 4, 199l to the Crystal Springs Estates personal care boarding home in Colorado Springs, Colorado. All indicators point to this fire as having been burning in the attic undetected for some period of time, perhaps as much as an hour or more before breaking through the ceiling sheetrock and having smoke detectors react.

“Heat detectors were found in the attic but had not functioned. A pull station’s use and a 911 call alerted the fire department, but upon arrival they found a fire already ventilated through roof turbines. Nine elderly occupants perished, all as a result of carbon monoxide poisoning, in this fire. A tenth victim died months later of smoke aggravated lung problems. (USFA 1999, 2-3)

“A total of 25 residents were in the structure at the time of the fire along with two staff members. Nine fire fatality victims were removed during the suppression of the fire. The victims ranged in aged from 77 to 97. The El Paso County Coroner’s Office has determined that all the victims died from asphyxia due to carbon monoxide inhalation. All victims but one were found in their rooms; the one outside of her room was found in the dining area. One woman, Lois Mitchell, age 82, died in December 1991 of smoke aggravated lung problems.” (USFA 1999, 4)

“This tragic fire, like many other similar fires in care facilities, illustrates common, preventable problems that continue to occur.

“The first and foremost question deals with the inspection force and who is ultimately responsible for the well-being of the occupants in this type of facility. Colorado labeled this facility as an “intermediate or personal care facility’ instead of calling it a “nursing home.” For this category there is supposed to be a lesser degree of care needed, i.e., less nursing staff. However, as shown in this scenario, this group of residents who averaged 85 years of age, many with limited mobility, were put at a serious disadvantage by this categorization when an emergency situation arose. Other states, like Colorado, need to review their criteria and practices in this important area.

“Adequacy of inspections is another problem area spotlighted by this incident. Colorado currently has two inspectors for the entire state and 281 operating personal care homes. They range in size from three beds to several hundred, but most are twenty beds or smaller. The State Health Department Director is currently trying to arrange contracts with local county inspectors to maintain inspections on these facilities, but in the interim two inspectors are charged with the major portion of inspections in the state. The Director indicates these are not trained building inspectors and have only a cursory amount of training in this area. The State Health Department Director makes the point that the bulk of these facilities are not in line for any federal aid and if forced to go with more stringent safety features, they would be forced to close. By comparison, numerous states, such as Virginia and Alabama have made sprinklering of this type of facility mandatory, and it does not appear that financial constraints have hampered them.

“The Colorado Springs Fire Department is to be commended for their openness during USFA’s investigation of this fire and their willingness to learn from this loss. They indicated they will implement into their plan a program of more stringent code enforcement as a result of lessons learned from this fire. (USFA 1999, pp. 5-6)

Lessons Learned:

Inspection for these types of care facilities must be conducted by fully qualified building inspectors as well as by health inspectors. or joint inspections should be conducted….
Properly working heat and smoke detection equipment is a must….
Adequate staff must be assigned for the number of occupants….
Care facilities should be sprinklered in patient rooms and halls….
Evacuation planning and regular drills are particularly important in facilities for the elderly….” (USFA 1999, 7)

NFPA: “On, March 4, 1991 a fire of accidental origin occurred at Crystal Springs Estate, a board and care facility, in Colorado Springs, Colorado. Nine of the building’s 25 elderly residents died during the fire. In addition, eight other residents and five firefighters were injured.

“The single-story masonry and wood structure, with two separate partial basements, was divided into three fire compartments by noncombustible walls, and the corridor openings in these walls were protected with fire doors. A fire alarm system using heat detectors as the primary initiating device protected all rooms, closets, and attic spaces. Manual pull stations and smoke detectors located next to the fire doors were also connected to this fire alarm system. The activation of any device in the fire alarm system would initiate alarm chimes throughout the building and would send a signal to a central monitoring station. A separate alarm system of interconnected corridor smoke detectors was also provided and only initiated a local alarm upon the activation of any detector on the system.

“An electric motor in a ventilation fan apparently malfunctioned, overheated, and ignited combustible materials in the attic above the east wing. The fire burned for an undetermined period of time, spreading in the attic space above several rooms before causing the ceiling to collapse in a residents’ lounge. At approximately 12:35 a.m., smoke entering the occupied space activated the corridor smoke detection system, and staff began their emergency procedures.

“The fire also breached a wall between the wing of origin and a dining room and spread across the combustible ceiling in the dining room. Because there was no fire door between the dining room and the corridor in the west wing, smoke and fire extended to that corridor.

“The first firefighters on the scene found the dining room fully involved in fire with heavy smoke and some fire extension in corridors of both wings. They started simultaneous rescue and suppression operations. All survivors were rescued during the first half hour, and fire suppression operations continued for approximately 4 1/2 hours. In addition to the nine fatalities and eight injured residents, the fire destroyed two of the building’s three wings.

“The following factors appear to have significantly contributed to the loss of life:

Heat detector system in the attic did not provide early warning,
Fire separations did not prevent the spread of smoke and fire,
Combustible ceiling in the dining room,
Lack of adequate fire safety training for staff and residents.”

(NFPA. Today. “3-4-2016. Today in fire history: 9 dead, eight residents and five firefighters were injured in a board and care facility.”)

Sources

National Fire Protection Association. Today. Your online NFPA community. “3-4-2016. Today in fire history: 9 dead, eight residents and five firefighters were injured in a board and care facility.” Quincy, MA: NFPA. Accessed 4-28-2016 at: http://nfpatoday.blog.nfpa.org/historic-fires/page/2/

United States Fire Administration. Ten Elderly Victims from Intermediate Care Facility Fire, Colorado Springs, Colorado. Emmitsburg, MD: National Fire Data Center, USFA, FEMA, 1999, 50 pages. Accessed at: http://www.interfire.org/res_file/pdf/Tr-050.pdf

[1] As the USFA notes, one of the injured survivors died months later due to “smoke aggravated lung problems.”