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–11  Donahue, Bill. “The Tragedy of Tillamook Bay.” Field & Stream, 1-12-2004.

–11  Dresbeck. “Fatal Error: The Sinking of the Taki-Tooo 2003.” Oregon: True Stories… p185.

–11  NTSB. MAR. Capsizing of U.S. Small Passenger Vessel Taki-Tooo… 6-28-2005, v.

–11  Oregonian (J. Killen). “Previous stories about boating accidents involving bar crossings.”

 

Narrative Information

 

NTSB Executive Summary:  “On June 14, 2003, the small passenger vessel Taki-Tooo, a U.S. charter fishing vessel with 2 crewmen and 17 passengers on board, was enroute from the marina at Garibaldi, Oregon, to the Pacific Ocean for a day of fishing. A small craft advisory was in effect for the northern Oregon and southern Washington coasts, and personnel at U.S. Coast Guard Station Tillamook Bay had activated the rough bar warning signs based on their assessments of existing hazardous conditions. At the Tillamook Bay inlet, the Taki-Tooo operator waited in the channel for an opening in the ocean swells so that he could cross the bar. After the Taki-Tooo exited the inlet and turned northward around the north jetty, a wave struck and capsized the vessel. As a result of this accident, the master and 10 passengers died; the deckhand and 7 passengers sustained minor injuries….

 

“The National Transportation Safety Board determines that the probable cause of the capsizing of the Taki-Tooo was the decision of the master to attempt to cross Tillamook Bay bar despite the hazardous sea state that existed at the time. Contributing to the severity of the accident was the failure of the Taki-Tooo master to ensure that he, the deckhand, and the passengers donned lifejackets before crossing the bar. Also contributing to the severity of the accident was the failure of the U.S. Coast Guard to enforce the regulatory requirement at 46 Code of Federal Regulations 185.508, which stipulates that vessel masters shall require passengers to wear lifejackets when transiting a hazardous bar….” (NTSB. MAR. Capsizing of U.S. Small Passenger Vessel Taki-TOOO, Tillamook Bay Inlet, Oregon, June 14, 2003. 2005, p. vi.)

 

Source

 

Donahue, Bill. “The Tragedy of Tillamook Bay.” Field & Stream, 1-12-2004. Accessed 5-25-2016 at: http://www.fieldandstream.com/articles/fishing/saltwater/2004/01/tragedy-tillamook-bay

 

Dresbeck, Rachel. Oregon: True Stories of Tragedy and Survival. Chapter 20, “Fatal Error: The Sinking of the Taki-Tooo, 2003.” Globe Pequot Press, 2006.

 

National Transportation Safety Board. Marine Accident Report. Capsizing of U.S. Small Passenger Vessel Taki-TOOO, Tillamook Bay Inlet, Oregon, June 14, 2003 (NTSB/MAR-05/02, Notation 7582B). Washington, DC: NTSB, adopted 6-28-2005, 76 pages. Accessed 10-16-2015 at: http://www.ntsb.gov/investigations/AccidentReports/Reports/MAR0502.pdf

 

Oregonian (John Killen). “Previous stories about boating accidents involving bar crossings.” 11-28-2008, updated 11-5-2010. Accessed 10-16-2015 at: http://blog.oregonlive.com/oregonianextra/2008/11/previous_stories_about_boating.html

 

–19  Blumenthal. “Truck driver found guilty in deaths of 19…immigrants…” NYT, 11-5-2006.

–19  US Attorney’s Office, Southern Dist. of TX. “Tyrone Williams Re-sentenced.” 1-24-2011.

 

Narrative Information

 

May 14, CNN: “Victoria, Texas (CNN) — Eighteen suspected illegal immigrants, including an infant, suffocated Wednesday after they rode in the back of a semi-trailer with dozens others from Mexico to south Texas, federal officials said. Federal authorities leading the investigation believe the migrants were locked inside the truck. All the deaths were due to asphyxiation, dehydration or heat-related conditions, officials said….

 

“The scope of the tragedy became clear after officers from the Victoria County Sheriff’s office responded to a 911 call reporting a disturbance outside a convenience store shortly after 2 a.m. Wednesday [May 14].[1] They found the trailer parked nearby. “When the deputies opened the door, they didn’t expect that there was gonna be people inside,” Shelby said, “and when they opened this door they were flooded by human beings that were pouring out of there.” Thirteen bodies were found inside the trailer and another four were found on the ground nearby, Victoria County Sheriff Michael Ratcliff said. Another person died after arriving at Citizens Medical Center in full cardiac arrest, a hospital spokeswoman said.

 

“As many as 100 people or more fled the back of the truck, he said, as sheriff’s deputies tried to administer first aid to those left behind. By Wednesday afternoon, 32 of the people, including eight juveniles, were in federal custody, Shelby said. As many as 80 remained at large….

 

“Federal authorities now leading the investigation suspect the migrants were locked inside the trailer….

 

“Four of the survivors remained in local hospitals Wednesday night and two of them were in critical condition….”  (Frieden, Terry (CNN). “18 human cargo deaths in Texas.” 5-14-2003.”)

 

May 14, LA Times: “Authorities said 17 suspected illegal immigrants were found dead today at a truck stop near the south Texas town of Victoria, and one more died at a hospital, in what is believed to be one of the worst cases of human smuggling near the U.S.-Mexican border in more than a decade. The big rig truck carried more than 100 people, jammed into the trailer like cargo. At least 44 survivors, including a 15-year-old girl, were being treated at nearby hospitals or housed at a community center.

 

“It is unclear whether those inside the trailer were illegal immigrants, but officials said while most came from Mexico, others were from El Salvador, Guatemala and Honduras. “This case involves the greatest loss of life in recent history in what appears to be an alien smuggling case,”
said Asa Hutchinson, undersecretary for border and transportation security at the Department of Homeland Security. He spoke at a press conference in Washington, D.C. ….

 

“A man believed to be one of the smugglers was arrested today in Houston, about 115 miles away, but had not been charged today. The trailer, with New York state license plates, had been registered in the suspect’s name to an address in Schenectady, N.Y., U.S. Attorney
Michael Shelby told the Associated Press. Left behind in the trailer along Highway 77, about 230 miles north of the Mexico border, were dozens of people.

 

“Responding to an emergency call, authorities opened the trailer’s door about 2 a.m. and “a flood of human beings” spilled out. Some dashed off, but others were too weak to run away, Shelby said. Authorities found 13 bodies inside and four outside the unhitched tractor-trailer. The victims were believed to have died from suffocation, heatstroke and other heat-related illnesses, Sheriff Michael Ratcliff said at a news conference today. The victims apparently tried to get fresh air by scraping away insulation that clogged small holes in the trailer’s back door. Reports ranged as high as 140 people were left in the trailer, but authorities late today were still trying to determine the exact figure. It remained unclear where the truck and trailer were headed.

 

“Six men, ranging in age from 20 to 47, had been taken to Detar Hospital Navarro, with at least one in critical condition. Ratcliff declined to say whether water containers had been found inside the rig. He also declined to say how long he believed the victims had been inside the tractor-trailer, even as outside temperatures soared. The high Tuesday was 91, three degrees short of a record for that day set in 1980. Factoring in humidity, the temperature felt like 99 degrees, the National Weather Service said….”  (Strickland and Gold. “17 Found Dead at Texas Truck Stop.” Los Angeles Times, 5-14-2003.)

 

May 15, 2003: “Victoria, Texas — On a desolate stretch of south Texas highway, sheriff’s deputies responding to a routine disturbance call discovered a tableau of horror early Wednesday morning [May 14]: the bodies of 17 people, most of them believed to be illegal Mexican immigrants, sprawled in and around a trailer at a roadside truck stop. An 18th person recovered from the trailer died later in the day, making it the most lethal incident involving suspected illegal immigrants in at least 16 years. Wednesday afternoon, federal authorities arrested a man suspected to have been the driver of the tractor-trailer rig, which he had apparently abandoned about 175 miles north of the Mexican border on U.S. Highway 77.

 

“Authorities said the dead — among at least 62 people packed into the locked trailer of an 18-wheeler — had apparently suffocated in the nearly airless, heat-baked container, despite the efforts of some who tried to claw two holes through the foam insulation to admit fresh air. Most of the trailer’s human cargo was male. The youngest of the dead was a small boy, perhaps 5 years old, who died in his father’s arms.” (Hockstader, Lee and Karin Brulliard. “Trapped in scorching trailer – 18 die/Immigrants abandoned at Texas truck stop.” Washington Post, 5-15-2003.)

 

Nov 5, 2006: “Houston — A truck driver was found guilty of all charges and faces possible execution in the deaths of 19 illegal immigrants who suffocated in his airless trailer in South Texas in 2003. In a retrial of the nation’s deadliest human trafficking case, the federal jury that on Monday convicted the driver, Tyrone Williams, 35, of Schenectady, New York, begins hearing testimony on Wednesday on whether to give Williams the first death sentence under a 12- year-old “alien smuggling” statute or a lesser term of up to life in prison.

 

“The milk trailer, piled with bodies and 55 survivors, was found abandoned at a truck stop near Victoria, Texas, in the early hours of May 14, 2003.

 

“Williams, a legal immigrant from Jamaica, sat impassively through 58 recitations of “Guilty” as the verdict form was read, then embraced his lawyer, Craig Washington…Washington, whose trial defense conceded Williams’s role as a smuggler but challenged his awareness of the victims’ suffering, said he planned to put on about 20 witnesses to testify about mitigating factors in Williams’s history.

 

“The lead prosecutor, Daniel Rodriguez, an assistant U.S. attorney, who had painted Williams as “vile and heartless,” declined to comment until the punishment phase was concluded.

 

“Williams’s first trial had ended in March 2005 with an incomplete verdict later thrown out by the 5th U.S. Circuit Court of Appeals. Jurors had found Williams guilty on 38 of the 58 counts but deadlocked on the others, including conspiracy resulting in death, a charge carrying possible capital punishment. Jurors also could not agree on how to answer questions assessing Williams’s degree of culpability. The Monday verdict, on the fifth day of deliberations, found him guilty of all 58 counts: conspiracy plus counts of harboring, transporting and transporting resulting in death for each of the 19 victims. The jurors also found him culpable as a principal offender, out for “private financial gain.”

 

“Evidence in the trials portrayed Williams as a milk trucker and sometime drug courier recruited by a smuggling ring to transport 60 illegal immigrants on a similar run from the border about a week earlier and who then took $7,500 to carry a group from Harlingen, Texas, past a Border Patrol checkpoint in Sarita to a waiting van and pickup truck. But the relief vehicles became stuck at the checkpoint, and Williams, with the truck’s refrigeration turned off, was directed by the smugglers to continue toward Houston. A companion in the cab, Fatima Holloway, testified that Williams ignored the banging of his passengers as they succumbed to airlessness, dehydration and temperatures as high as 173 degrees, or 78 degrees Celsius, finally clawing out a taillight in a desperate bid for air.

 

“The first to die, a survivor testified in English, was a 5-year-old Mexican boy who expired in his father’s arms, crying, “Daddy, Daddy, I’m dying.” Sixteen more suffocated before Williams halted the truck, and two more died in the hospital.” (Blumenthal, Ralph. “Truck driver found guilty in deaths of 19 illegal immigrants in Texas in 2003.” New York Times, 11-5-2006.)

 

US Attorney’s Office, So. Dis. TX: “(Houston) – The driver of the insulated tractor trailer used in a smuggling operation which left a total of 19 aliens dead in the deadliest smuggling operation ever in the district has been sentenced to more than 30 years imprisonment without the possibility of parole, United States Attorney José Angel Moreno announced today. U.S. District Judge Lee H. Rosenthal today sentenced Tyrone Mapletoft Williams, 40, to 405 months imprisonment on each of 19 counts of conviction – counts 40 through 58 of the indictment – relating to the 19 deceased victims of the ill-fated smuggling operation in May 2003. Williams was the driver of a tractor trailer discovered abandoned at a truck stop in Victoria, Texas, during the early hours of May 14, 2003. Victoria law enforcement officers who arrived at the location came upon the bodies of 17 smuggled foreign nationals in and around the trailer who had died as a result of being transported inside Williams’ insulated trailer. Two additional trailer occupants subsequently died of their injuries at Victoria area hospitals. The resulting 19 deaths associated with this smuggling operation establishes it as the deadliest in the district.

 

“Williams was originally sentenced to life imprisonment on each of these 19 counts of conviction by a jury’s verdict; however, the case was remanded to the District Court for re-sentencing after the Fifth Circuit Court of Appeals issued an opinion finding that Williams’ punishment on these counts of conviction should have been assessed by the court and not the jury.

 

“Williams was convicted by a jury of conspiring with others to transport and harbor illegal aliens for commercial advantage and financial gain in a manner that caused serious bodily injury, placed a life in jeopardy or caused death as alleged in count one of the indictment and further found his conduct placed a life in jeopardy. Judge Rosenthal previously sentenced Williams to 405 months imprisonment for this count of conviction which was upheld by the appellate court.

 

“In counts 21-39, Williams was charged with unlawfully transporting 19 of the 55 surviving aliens. Judge Rosenthal had previously sentenced Williams to the statutory maximum sentence of 20 years imprisonment on each of these counts. These sentences were also upheld on appeal.

 

“The sentences on all counts of conviction are to be served concurrently. Williams has been in federal custody since his May 2003. Williams will remain in custody to serve out his sentences. There is no parole in the federal system.

 

“This case was prosecuted by Assistant U.S. Attorneys Daniel C. Rodriguez, Jeffery Vaden and Tony R. Roberts and is the result of an extensive investigation conducted by the Houston, San Antonio, Harlingen, Brownsville and McAllen, Texas, offices of the United States Immigration and Customs Enforcement – Homeland Security Investigations, the United States Department of Housing and Urban Development-Office of the Inspector General, the Texas Department of Public Safety including the Texas Rangers, the Victoria County Sheriff’s Department and police departments in McAllen, Harlingen and Victoria.”  (United States Attorney’s Office, Southern District of Texas. “Tyrone Williams Re-sentenced (press release).” 1-24-2011.)

 

Sources

 

Blumenthal, Ralph. “Truck driver found guilty in deaths of 19 illegal immigrants in Texas in 2003.” New York Times, 11-5-2006. Accessed 3-28-2014 at: http://www.nytimes.com/2006/12/05/world/americas/05iht-smuggle.3787320.html?_r=0

 

Frieden, Terry (CNN). “18 human cargo deaths in Texas.” 5-14-2003.” Accessed 3-30-2014 at: http://www.cnn.com/2003/US/Southwest/05/14/truck.bodies/index.html?_s=PM:US

 

Hockstader, Lee and Karin Brulliard. “Trapped in scorching trailer – 18 die/Immigrants abandoned at Texas truck stop.” Washington Post, 5-15-2003. Accessed 3-30-2014 at: http://www.sfgate.com/news/article/Trapped-in-scorching-trailer-18-die-2648170.php

 

Strickland, Daryl and Scott Gold. “17 Found Dead at Texas Truck Stop.” Los Angeles Times, 5-14-2003. Accessed at: http://www.latinamericanstudies.org/immigration/immigrants-dead.htm

 

United States Attorney’s Office, Southern District of Texas. “Tyrone Williams Re-sentenced (press release).” 1-24-2011. Accessed 3-30-2014 at: http://www.justice.gov/usao/txs/1News/Releases/2011%20January/110124%20Williams.htm

 

 

 

 

[1] Given that the discovery was at 2am on May 14 in a vehicle that had been abandoned for hours, it appears that the deaths started on May 13, and perhaps were still continuing into May 14, when discovered.

— 38  NCDC. Storm Events Database. Search results for all U.S. States and Areas. Tornado. 5-4-2003.

— 37  NWS, NOAA. Service Assessment. Record Tornado Outbreaks of May 4-10, 2003, p. ii.[1]

— 24  NWS WFO, Springfield MO. Natural Haz. Risk Assess. Info…: Vernon Co. MO. 2009, 9.

 

Kansas            (  8)

–8  NCDC. Storm Events Database.

–2  Wyandotte County, 15:18-15:35 CST, 15 miles long, 500 yards wide.[2]

–1  Victim was a female, 46, who died of injuries Oct 10.

– 1  Kansas City, 15:18-15:35 CST. Male, 82, in home.

–3  Crawford County, 15:35-16:15, 27 miles long.[3]

— 1  Sharon Lasbrook, 48, thrown from mobile home into field.

— 1  George Boyle, 68, killed by debris on floor of manufactured home.

— 1  Josephine Maghe, 87, swept from frame home into the ground.

–3  Cherokee County, May 4, 16:45-17:50, F3, 20 miles long, 880 yards wide.[4]

–1  Julie Green, 50, thrown from home about quarter-mile, where she died.

–2  Crestline area; Charles Ross, Jr., 80 and Phyllis Ross, 73; killed by debris at home.

–6  NOAA Magazine. “Cold Front Spawns Super-Cell Storms, Deadly Tornadoes…” 5-5-2003.

 

Missouri         (19)

–1  Barton County, Liberal area,. Rex Smith, 88; killed by flying debris in his frame house.[5]

–4  Camden County, Decaturville area, F3; 14 miles long, 400 yards wide; 18:36-19:08 CST.[6]

–1  Roy Wright, 53; tossed from his mobile home.

–2  George and Betty Jones, 75 and 76; sought cover in bath tub, but thrown into field.

–1  Grace Racy, 83, taking shelter in her frame home; back broken; died in ~6 weeks.

–3  Cedar County, Jerico Springs vicinity. F3, 25 miles long, 880 yards wide; 17:00-17:45.[7]

–1  Rob Hewitt, 40, taking cover in his frame home; hit by flying debris.

–1  Mark Wilcox, 34, leaving home to help neighbor, hit by flying debris outside.

–1  John Cassell, 86, handicapped; refused to go to basement with wife; hit by debris.

–1  Christian County, Billings area, F3, 13 miles long, 880 yards wide; 18:35-18:50 CST.[8]

–1  Ruth Little, 63; sought cover in frame home with husband and daughter; swept outside.

–2  Dallas County, Louisburg area, F3, 14 miles long, 880 yards wide, 18:20-18:42 CST.[9]

–2  Bob and Robin Moroni, 49 and 47; swept from modular home bed to outdoors.

–1  Greene County, Battlefield area. F3, 4 miles long, 500 yards wide, 18:50-19:03 CST.[10]

–1  Stephanie Allton, 40; outdoors caring for pets when hit by falling oak tree.

–2  Jasper County, Carl Junction, F3, 5 miles long, 880 yards wide; 17:15-17:25.[11]

–Kenneth LaNear, 71, and wife Ethel LaNear, 62; swept from closet shelter to outdoors.

–5  Lawrence County, Pierce City, F3, 25 miles long, 880 yards wide, 17:58-18:35 CST.[12]

–1  Dale Taunton, 52, taking cover in NG armory tornado shelter, but not in basement.

–1  Wanda Sue Handly, 46, in mobile home north of Monett; swept from trailer, hit by debris.

–1  Jacob Aldaba Rueda, 20-weeks; swept from mother in mobile home, thrown quarter mile.

–1  Janet Eskridge, 52; swept from modular home and tossed several yards away.

–1  Vicki Lynn Lawrence, 39, hit by debris when mobile home was destroyed.

 

Tennessee       (11)

–11  Madison County, Denmark area. F4, 26 miles long, 880 yards wide, 22:35-22:57 CST.[13]

Male, 1, permanent home.      Female, 22, permanent home.             Male 33 mobile home

Male, 7, mobile home.            Female, 23, mobile home.                  Male 39 mobile home

Male, 8, mobile home.            Female, 25, mobile home.                  Male 53 mobile home

Female, 40, mobile home.      Female, 44, mobile home.

–11  NOAA Magazine. “Cold Front Spawns Super-Cell Storms, Deadly Tornadoes…” 5-5-2003.

 

Narrative Information

 

NWS WFO, Springfield, MO: “May 4^th – 2003…Three tornadic supercell thunder-storms formed over southeast Kansas and moved across the Missouri Ozarks, spawning 13 tornadoes. This was a very rare event for this part of Missouri since many of the tornadoes experienced across this area are short lived small tornadoes. This event surpassed the December 17-18, 2002 tornado event in both loss of lives and property damage, and exceeded tornado events that occurred over the past 100 Years for this part of Missouri. The hardest hit locations included Battlefield, Stockton and Pierce City. 14 tornadoes resulted in extensive damage and 24 deaths. Several of the tornadoes tracked long distances ranging from 15 to 80 miles.” (NWS WFO, Springfield MO. Natural Haz. Risk Assess. Info…: Vernon Co. MO. 2009, 9.)

 

NCDC, Wyandotte, KS 15:18 CST: “A dry line moved into eastern Kansas and initiated severe thunderstorm development the afternoon of May 4th. Several of the thunderstorms became tornadic in Miami, Leavenworth and Wyandotte counties. The strongest tornado reached F4 intensity in Kansas City Kansas before moving into Missouri. This tornado killed an 82 year old man and injured 30 others. Wyandotte county also had $15.5 million dollars in damage, with 69 buildings destroyed, and 390 suffering damage. Leavenworth county had 9 homes destroyed, 8 with major damage and 17 with minor damage. Damage estimates for Leavenworth county are around $4 million dollars. This was the most significant tornado outbreak in the Kansas City Metropolitan areas, since the Pleasant Hill tornado outbreak of 1977. A 46 year old woman died from injuries received with this tornado on October 10th, 2003.” (NCDC, NOAA. Storm Events Database. Tornado, F4, Kansas, Wyandotte County, May 4, 2003, 15:18 CST.)

 

NCDC, Crawford, KS, 15:35-16-15 CST: “This storm is known to have initiated the unforgettable series of events of 4 May, 2003. This classic supercell rapidly developed over Montgomery County, Kansas, eventually moving into southwestern Crawford County, Kansas where it spawned a very large and destructive tornado. This tornado laid out a path of destruction for 27 miles of farm land and small communities through Crawford County. This event also claimed three lives and injured 20 in eastern sections of the county, where the tornado had strengthened to F-4 status. The tornado continued on the ground into Barton County, Missouri.

“Sharon Lasbrook age 48, was deceased from being thrown out of her mobile home and into a field. Her home was completely disintegrated by the twister.

“George Bolte age 68, was taking cover in his manufactured home and laying over his wife to protect her from flying debris. While saving her life, he was deceased from the debris.

“Josephine Maghe age 87, was taking cover within her frame home as the tornado arrived. She was deceased from being struck into the ground.” (NCDC. Storm Events Database. Tornado, F4, Kansas, Crawford County, May 4, 2003, 15:35-16:15, 27 miles long, 880 yards wide.)

 

NCDC, Barton, MO, 16:15-16:35 CST, 6 Miles long, 880 yards wide: “An F-4 tornado tracked over the Kansas-Missouri state line and into west central Barton County. The tornado destroyed several farm houses and outbuildings prior to dissipating one mile north of Liberal. Ten injuries and one fatality can be accounted for from this large tornado. Rex Smith age 88, was in his frame house two miles west of Liberal when the tornado approached. He was deceased from flying debris.

 

“While this tornado was dissipating, a second tornado had formed one mile east of Liberal. This feature then tracked 23 miles through mainly rural farm land of central and northeast Barton County, and eventually through Cedar, Polk, Hickory, and Dallas counties. Altogether there were approximately 50 homes and outbuildings that were destroyed from the twisters.” (NCDC. Storm Events Database. Tornado, F4, Missouri, Barton County, May 4, 2003.)

 

NCDC, MO, Cedar County, 17:00-17:45 CST: “A large tornado laid out a path of destruction across the entire county. During this time, it took a path through the center of Stockton, which is the most populated community in the county. 350 homes, businesses, and outbuildings were destroyed while 650 received major damage. 37 local residents sustained injuries as three individuals lost their lives. The tornado continued on the ground into northern Polk County.” (NCDC. Storm Events Database. Tornado, F3, Missouri, Cedar, May 4, 2003, 17:00-17:45 CST.)

 

NCDC, MO, Jasper County, Carl Junction, 17:15-17:25 CST: “This tornado is a continuation of the Cherokee County, Kansas tornado. This feature crossed the Kansas-Missouri state line near the community of Smithfield, and then wreaked havoc through the center of Carl Junction. Around 112 homes and outbuildings were destroyed while 487 were damaged. The tornado claimed the lives of two local residents and injuring 15.” (NCDC, NOAA. Storm Events Database. Tornado, F3, Missouri, Jasper County, May 4, 2003, 17:15-17:25 CST.)

 

NCDC, MO, Lawrence County, Pierce City, F3, 25M, 880 yards wide, 17:58-18:35 CST: This tornado is a continuation of the Newton County tornado. A large tornado laid out a half mile wide path of destruction across southwest, central, and east central Lawrence County. Several communities was affected, however, the community of Pierce City was hardest hit as the historic downtown of 100 plus year old buildings were completely destroyed. Around 229 homes, businesses, and outbuildings were destroyed while 320 were damaged. The tornado also claimed the lives of five local residents and injured 33. The tornado continued on the ground into the Christian County panhandle.” (NCDC, NOAA. Storm Events Database. Tornado, F3, Missouri, Lawrence Co., May 4, 2003, 17:58-18:35 CST.)

 

NCDC, MO, Dallas Co., Louisburg area, F3, 14M long, 880 yards wide, 18:20-18:42 CST: “This is a continuation of the Polk County tornado that entered the northwestern portion of Dallas County near the Polk-Hickory-Dallas County lines. The tornado then tracked through rural areas and small communities of northern Dallas County where it destroyed approximately 48 homes and outbuildings and claimed the lives of two local residents.” (NCDC, NOAA. Storm Events Database. Tornado, F3, MO, Dallas Co., Louisburg area, May 4, 2004., 18:20-18:42.)

 

NCDC, MO, Christian Co., Billings area, F3, 13M long, 880 yards wide; 18:35-18:50 CST: “This tornado is a continuation of the Lawrence County tornado that laid a half mile wide path of destruction across the Christian County panhandle. Populated areas between the communities of Billings and Clever were affected that resulted in one fatality and three injuries. 27 structures were destroyed while 150 were damaged that added up to around 5.1 million dollars of monetary losses. The tornado continued on the ground into southwestern Greene County.” (NCDC. Storm Events Database. Tornado, F3, MO, Christian Co., May 4, 2003, 18:35-18:50 CST.)

 

NCDC, MO, Camden Co., Decaturville area, F3; 14M long, 400 yards wide; 18:36-19:08:

“A long lived cyclic supercell that had a history of producing large and destructive tornadoes spawned another large tornado in rural south central Camden County. This tornado then tracked northeast into more populated areas south of Camdenton, where it claimed the lives of four local residents. Approximately 50 homes and outbuildings were destroyed along with significant agricultural loss.” (NCDC, NOAA. Storm Events Database. Tornado, F3, Missouri, Camden County, May 4, 2003, 18:36-19:08 CST.)

 

NCDC, MO, Greene Co., Battlefield area. F3, 4M long, 500 yards wide, 18:50-19:03 CST: “This tornado is a continuation of the Christian County tornado that entered southwestern Greene County and laid down a path of destruction into the city of Battlefield. 100 homes and outbuildings were destroyed while another 150 were damaged causing estimated monetary losses of 14.7 million dollars. The tornado also claimed the life of one local resident and injured 12.” (National Climatic Data Center, NOAA. Storm Events Database. Tornado, F3, Missouri, Greene County, Battlefield area, May 4, 2003, 18:30-19:03 CST.)

 

NCDC, TN, Madison Co., Denmark area. F4, 26M long, 880 yards wide, 22:35-22:57 CST: “The tornado touched down in the southwest part of Madison county near Denmark and tracked east through the downtown section of Jackson. The tornado continued to move east and eventually crossed into Henderson county. Nine people were killed in mobile homes between Denmark and Jackson and two other persons were killed in an apartment complex in Jackson. Numerous buildings were destroyed, particularly in downtown Jackson. St. Luke Episcopal Church, one of the oldest churches in Tennessee built in 1844, was destroyed. The Carl Perkins Civic Center, Tennessee Supreme Court Building, the downtown Jackson Post Office and National Guard Armory were damaged. Also damaged was the Proctor and Gamble factory where Pringles Potato Chips are made and a Coca-Cola bottling plant was also damaged. Denmark Elementary School and Jackson Middle School were destroyed and 24 other schools in the county were damaged. The tornado caused severe damage to the local power and water utilities across the county. One of eight stone balls that were set up to commemorate the eight fatalities from the Jackson tornado of January 17, 1999 was blown across a street.” (NCDC. Storm Events Database. Tornado, F4, TN, Madison Co., Denmark area, May 4, 22:35-22:57.)

 

Sources

 

Fitzgerald, Daniel C.  Sound and Fury: A History of Kansas Tornadoes, 1854-2008. Dan Fitzgerald Company, 2008-2009.

 

National Climatic Data Center, NOAA. Storm Events Database. Search results for all U.S. States and Areas. Tornado. 5-4-2003. Accessed 10-25-2015: http://www.ncdc.noaa.gov/stormevents/listevents.jsp?eventType=%28C%29+Tornado&beginDate_mm=05&beginDate_dd=04&beginDate_yyyy=2003&endDate_mm=05&endDate_dd=04&endDate_yyyy=2003&hailfilter=0.00&tornfilter=0&windfilter=000&sort=DT&submitbutton=Search&statefips=-999%2CALL

 

National Climatic Data Center, NOAA. Storm Events Database. Tornado, F3, Kansas, Cherokee County, May 4, 2003, 16:45-17:15 CST. Accessed 10-26-2015 at: http://www.ncdc.noaa.gov/stormevents/eventdetails.jsp?id=5358085

 

National Climatic Data Center, NOAA. Storm Events Database. Tornado, F4, Kansas, Crawford County, May 4, 2003, 15:35-16:15, 27 miles long, 880 yards wide. Accessed 10-26-2015 at: http://www.ncdc.noaa.gov/stormevents/eventdetails.jsp?id=5358086

 

National Climatic Data Center, NOAA. Storm Events Database. Tornado, F4, Kansas, Wyandotte County, May 4, 2003, 15:18 CST, 15 miles length, 500 yards wide. Accessed 10-26-2015 at: http://www.ncdc.noaa.gov/stormevents/eventdetails.jsp?id=5358918

 

National Climatic Data Center, NOAA. Storm Events Database. Tornado, F4, Missouri, Barton County, May 4, 2003, 16:15-16:35; 6M long, 880 yards wide. Accessed 10-26-2015 at: http://www.ncdc.noaa.gov/stormevents/eventdetails.jsp?id=5358087

 

National Climatic Data Center, NOAA. Storm Events Database. Tornado, F3, Missouri, Camden County, May 4, 2003, 18:36-19:08 CST. Accessed 10-26-2015 at: http://www.ncdc.noaa.gov/stormevents/eventdetails.jsp?id=5358164

 

National Climatic Data Center, NOAA. Storm Events Database. Tornado, F3, Missouri, Cedar County, May 4, 2003, 17:00-17:45 CST. Accessed 10-26-2015 at: http://www.ncdc.noaa.gov/stormevents/eventdetails.jsp?id=5358167

 

National Climatic Data Center, NOAA. Storm Events Database. Tornado, F3, Missouri, Christian County, May 4, 2003, 18:35-18:50 CST. Accessed 10-26-2015 at: http://www.ncdc.noaa.gov/stormevents/eventdetails.jsp?id=5358169

 

National Climatic Data Center, NOAA. Storm Events Database. Tornado, F3, Missouri, Dallas Co., Louisburg area, May 4, 2004., 18:20-18:42. Accessed 10-26-2015 at: http://www.ncdc.noaa.gov/stormevents/eventdetails.jsp?id=5358172

 

National Climatic Data Center, NOAA. Storm Events Database. Tornado, F3, Missouri, Greene County, Battlefield area, May 4, 2003, 18:30-19:03 CST. Accessed 10-26-2015 at: http://www.ncdc.noaa.gov/stormevents/eventdetails.jsp?id=5358175

 

National Climatic Data Center, NOAA. Storm Events Database. Tornado, F3, Missouri, Jasper County, May 4, 2003, 17:15-17:25 CST. Accessed 10-26-2015 at: http://www.ncdc.noaa.gov/stormevents/eventdetails.jsp?id=5358178

 

National Climatic Data Center, NOAA. Storm Events Database. Tornado, F3, Missouri, Lawrence Co., May 4, 2003, 17:58-18:35 CST. Accessed 10-26-2015 at: http://www.ncdc.noaa.gov/stormevents/eventdetails.jsp?id=5358181

 

National Climatic Data Center, NOAA. Storm Events Database. Tornado, F4, Tennessee, Madison County, Denmark area, May 4, 2003, 22:35-22:57 CST. Accessed 10-26-2015 at: http://www.ncdc.noaa.gov/stormevents/eventdetails.jsp?id=5356963

 

National Oceanic and Atmospheric Administration. “Cold Front Spawns Super-Cell Storms, Deadly Tornadoes in Central Plains States.” NOAA Magazine. 5-5-2003. Accessed 12-28-2017 at: http://www.noaanews.noaa.gov/stories/s1136.htm

 

National Weather Service, NOAA. Service Assessment. Record Tornado Outbreaks of May 4-10, 2003. Silver Spring, MD: NWS, December 2003, 58 pages. Accessed 10-25-2015 at: http://www.nws.noaa.gov/om/assessments/pdfs/record-may.pdf

 

National Weather Service, Weather Forecast Office, Springfield, MO. Natural Hazard Risk Assessment Information: Vernon County Missouri. 2009 Update. Accessed at:  http://www.crh.noaa.gov/images/sgf/hazard_book/Hazard_Book_Vernon.pdf

[1] Page ii notes 39 fatalities, which are also reflected in Appendix B: “Direct Fatalities in Each WFO’s CWA,” pp. B-1 through B-3, counting direct fatalities noted for May 4, 2003. However, Appendix C: “Event Statistics,” which notes fatalities per jurisdiction per day, totals 37 for May 4, and another two on May 6, reported by the Paducah, HY Weather Forecast Office.

[2] NCDC, NOAA. Storm Events Database. Tornado, F4, Kansas, Wyandotte, May 4, 15:18-15:35.

[3] NCDC, NOAA. Storm Events Database. Tornado, F4, Kansas, Crawford County, May 4, 2003, 15:35-16:15.

[4] NCDC, NOAA. Storm Events Database. Tornado, F3, Kansas, Cherokee County, May 4, 2003, 16:45-17:15 CST.

[5] NCDC. Storm Events Database. Tornado, F4, Missouri, Barton County, May 4, 2003, 16:15-16:35; 6M long. Fitzgerald notes that a tornado “killed a woman by throwing her from her mobile home while the home disintegrated.” (p. 337.)

[6] NCDC, NOAA. Storm Events Database. Tornado, F3, Missouri, Camden County, May 4, 2003, 18:36-19:08 CST.

[7] NCDC, NOAA. Storm Events Database. Tornado, F3, Missouri, Cedar County, May 4, 2003, 17:00-17:45 CST.

[8] NCDC, NOAA. Storm Events Database. Tornado, F3, Missouri, Christian County, May 4, 2003, 18:35-18:50 CST.

[9] NCDC, NOAA. Storm Events Database. Tornado, F3, Missouri, Dallas Co., Louisburg area, May 4, 2004., 18:20.

[10] NCDC. Storm Events Database. Tornado, F3, MO, Greene Co., Battlefield area, May 4, 18:30-19:03 CST.

[11] NCDC, NOAA. Storm Events Database. Tornado, F3, Missouri, Jasper County, May 4, 2003, 17:15-17:25 CST.

[12] NCDC, NOAA. Storm Events Database. Tornado, F3, Missouri, Lawrence Co., May 4, 2003, 17:58-18:35 CST.

[13] NCDC. Storm Events Database. Tornado, F4, TN, Madison Co., Denmark area, May 4, 2003, 22:35-22:57 CST.

—  11  Baugher, Joseph F.  1990 USAF Serial Numbers.  8-19-2011 revision.

—  11  CNN.  “Fort Drum mourns crash victims. 3-13-2003.

—  11  Post Standard, Syracuse, NY. “Investigators’ first report…two months.” 3-14-2003, A4.

—  11  The Robesonian, Lumberton, NC. “11 killed in copter crash.” 3-12-2003, p. 9.

—  11  Titusville Herald, PA. “Soldier killed in crash was from Oil City.” 3-13-2003, p. 3.

—  11  UH-60 Crews.  Armyaircrews.com. 3-14-2012 modification.

—  11  VFW Magazine.  “11 killed in Fort Drum crash.” May, 2003.

 

Narrative Information

 

Baugher: “Sikorksky UH-60L Blackhawk….26273 (B Company/2-10th AVN) crashed into wooded area on western edge of Fort Drum, NY Mar 11, 2003.  11 out of 13 occupants killed, 2 survivors seriously injured.  Pilot error was reportedly responsible.” (Baugher, Joseph F. 1990 USAF Serial Numbers.  8-19-2011 revision.)

 

March 12: “Fort Drum, N.Y. (AP) — The, military confirmed Wednesday [March 12] that 11 of the 13 soldiers aboard a Black Hawk helicopter died when their helicopter crashed during training in a remote, wooded area of a post in northern New York.

 

“One of the two survivors was in critical condition Wednesday, and the other was in serious condition, a Fort Drum spokesman said.

 

“The soldiers had just completed a “sling loading” exercise, loading and unloading equipment from a sling beneath the helicopter, and were on their way back to Wheeler-Sack Airfield when the helicopter crashed about three miles from the field, said Lt. Col. Bryan Hilferty.

 

“Crews aboard two other helicopters flying in the same training formation did not see the crash, Hilferty said.  “They came back here and that’s when they noticed the trail helicopter was missing,” Hilferty said.

 

“All 13 soldiers aboard the helicopter were active members of the 10th Mountain Division. The four crew members were from the division’s Aviation Brigade.  The infantrymen were from the Second Brigade….

 

“The accident will be investigated by a team from the Army Safety Center at Fort Rucker, Ala., and personnel from the Criminal Investigation Command, Hilferty said. The military’s criminal investigation unit reviews all accidents at military facilities, he said.  Investigators stayed at the scene through the night.  On Wednesday, heavy snow was falling, making their work more difficult.

 

“Hilferty said there were no indications of problems before the crash.  “The first call I got was that it was missing.  It just disappeared,” Hilferty said.  “The Black Hawk is a great helicopter. It is the workhorse of the Army.  It has a great safety record,” Hilferty said.

 

“Maj. Daniel Bohr at Fort Drum said the aircraft last made radio contact shortly before 2 p.m. Rescue crews located the crash site at about 3:30 p.m.  Hilferty said search crews were slowed getting to the scene by several feet of ice-covered snow in the crash area.  The crash occurred about 150 yards from a dirt road, he said.

 

“Hazel Seery said she was driving home from work about 2 p.m. when she saw two Army helicopters.  After living in the area for 33 years, she has become accustomed to the training flights, but this one was different.  “There was one on the bottom and another helicopter flying on top of it.  The one on the bottom’s nose was up and the one on the top was tipping down,” Seery said….”  (The Robesonian, Lumberton, NC. “11 killed in copter crash.” 3-12-2003, p. 9.)

 

March 13: “Pittsburgh (AP)…. Pfc. Shawn A. Mayerscik, 22, was among 11 killed when the UH-60 Black Hawk crashed during a training exercise in New York….Another Pennsylvania soldier, Sgt. John L. Eichenlaub Jr., 24, of South Williamsport, was killed in the crash…”  (Titusville Herald, PA. “Soldier killed in crash was from Oil City.” 3-13-2003, p. 3.)

 

March 13: “The Black Hawk disappeared from radar at about 1:50 p.m. EST Tuesday, and a search-and-rescue team found the wreckage in a snowy wooded area more than 1 1/2 hours later. One survivor was walking around the crash site when emergency teams arrived, said division spokesman Lt. Col. Bryan Hilferty….

 

“Fort Drum, about 70 miles north of Syracuse, has been a major staging ground for troops preparing for possible war on Iraq. About 1,000 soldiers from Fort Drum have been deployed to the Persian Gulf.”  (CNN. “Fort Drum mourns crash victims. 3-13-2003.)

 

March 14: “….The pilot on this flight was Chief Warrant Officer Kenneth L. Miller The copilot was Cpt. Christopher E. Britton.” (Post Standard, Syracuse, NY. “Investigators’ first report will take about two months.” 3-14-2003, A4.)

 

May: “…A Black Hawk helicopter crashed during a March 11 training mission at Fort Drum, N.Y., killing 11 soldiers and injuring two. At press time, the Army was still investigating the cause.

 

“Killed in the crash were: Capt. Christopher Britton of Headquarters and Headquarters Co., 1st Bn., 10th Aviation Regt.; Chief Warrant Officer 3 Kenneth Miller and Spec. Barry Stephens of B Co., 2nd Bn., 10th Aviation Regt.; Staff Sgt. Brian Pavlich, Sgt. John Eichenlaub, Sgt. Joshua Harapko, Spec. Lucas Tripp, Pfc. Shawn Mayerscik, Pfc. Tommy Young, Pfc. Stryder Stoutenburg and Pfc. Andrew Stevens of C Co., 4th Bn., 31st Inf. Regt.”  (VFW Magazine.  “11 killed in Fort Drum crash.” May, 2003.)

 

Armyaircrews.com: “A/C was conducting a day multi-ship infantry battle skills training and orientation flight. A/C was Chalk 3 in flight of 3 and were heading back to the airfield when it impacted flat, marshy terrain at approx 30-deg. nose-low left bank attitude on the western edge of Ft. Drum.  Cause of crash was undetermined.” (UH-60 Crews. Armyaircrews.com. 3-14-2012 modification.)

Sources

 

Baugher, Joseph F. 1990 USAF Serial Numbers. 8-19-2011 revision. Accessed 3-14-2012 at:  http://www.joebaugher.com/usaf_serials/1990.html

 

CNN. “Fort Drum mourns crash victims. 3-13-2003. Accessed 3-14-2012 at:

http://articles.cnn.com/2003-03-12/us/blackhawk.crash_1_helicopter-crash-crash-survivors-nighttime-training-mission?_s=PM:US

 

Post Standard, Syracuse, NY. “Investigators’ first report will take about two months.” 3-14-2003, A4. Accessed at: http://newspaperarchive.com/FullPagePdfViewer.aspx?img=27555130

 

The Robesonian, Lumberton, NC.  “11 killed in copter crash.” 3-12-2003, p. 9. Accessed at: http://newspaperarchive.com/FullPagePdfViewer.aspx?img=103832934

 

Titusville Herald, PA. “Soldier killed in crash was from Oil City.” 3-13-2003, p. 3. Accessed at:  http://newspaperarchive.com/FullPagePdfViewer.aspx?img=106008435

 

UH-60 Crews. Armyaircrews.com. 3-14-2012 modification. Accessed 3-14-2012 at: http://www.armyaircrews.com/blackhawk.html

 

VFW Magazine. “11 killed in Fort Drum crash.” May, 2003. Accessed 3-14-2012 at:  http://findarticles.com/p/articles/mi_m0LIY/is_9_90/ai_102025112/

 

 

 

 

— 16  Associated Press (Kathryn Masterson). “Nursing home fire leaves 10 dead.” 2-27-2002.

— 16  David Randolph Smith & Associates. NHC Fire Litigation, slide 10, October 15, 2004

— 16  Hartford Fire Department, CT. “Major Fires.”

— 16  Robinson, K. “Feature: Health Care Occupancies.” NFPA Fire Journal, Jan-Feb 2013.

— 16  U.S. Government Accountability Office. Nursing Home Fire Safety. July 2004, p. 1.

— 16  USA Today.  “Blind Oversight: Inspectors Miss Infractions,” October 6, 2005.

 

Narrative Information

 

CNN: “On February 26, 2003 16 nursing home patients died at the Greenwood Nursing Home in Hartford Connecticut. There were no sprinklers in this nursing home. There was a national call to install sprinklers in nursing homes. (CNN.  Feb 26, 2003).

 

“Fire broke out at about 2:30 in the morning. Some 148 patients were actually inside the residence there. Ten are reported dead, nine have been identified, 23 of them are hospitalized, 10 are in critical condition. Many of the patients were mobility (ph) impaired, so it was extremely difficult to get some of the residents out of the facility. Just a short while ago, we spoke to a representative from the chief State’s Attorney’s Office. He talked about the fact that because of what happened here, because of the fact that there were no sprinklers in this particular facility —

sprinklers not required — he says because of what happened here, laws are likely to be changed ….

 

“…an individual is in custody and is being questioned at this point. That individual described as a female patient here at the facility. The chief inspector here telling me that they’ve obtained some sort of a search warrant. What they are going to be doing is going through the facility, trying to secure any evidence for their case. This is a criminal investigation at this point. At this point, investigators are going to try and determine whether or not this was some sort of an accident or whether or not this fire was intentional.” (CNN. “Nursing Home Fire Leaves 10 Dead” Feb 26, 2003.)

 

USA Today: “As the fire spread at the Greenwood nursing home in 2003, three nurses on the midnight shift tried to save residents closest to the flames. The fire department in Hartford, Conn., later gave one nurse an award for heroism.

 

“But investigators from the Connecticut Department of Public Health later found that, despite the nurses’ “extraordinary” and “valiant efforts,” the facility’s emergency evacuation plans “were not properly followed during the fire” by others on duty.  The state report found “evidence that not all of the on-duty staff responded and … some of those that did had to be told what to do.”  For some of the 16 patients who died, mostly from smoke, those lapses may have been critical. If the staff had responded according to the emergency plan and gotten them out of the smoke, Hartford Fire Marshall Bill Abbott says, “I don’t think we would have lost so many people.”

 

“State investigators also said they learned that the staff hadn’t been doing required fire drills on the night shift. It was a violation of safety rules that had gone unnoticed during safety inspections by the state health department, including one just a month before the fire.

 

“Nationwide, three in five nursing homes are cited for violating fire safety codes. That percentage would be higher, but inspectors often miss problems.  In an audit last year by the Government Accountability Office, the investigative arm of Congress, spot checks of state inspections found that surveyors were missing an average of two fire safety violations at every nursing home they visited.  The inspections often are left to nurses or other health care workers with little fire safety training.

 

“The Centers for Medicare and Medicaid Services (CMS), the federal agency that contracts with states to check nursing homes’ compliance with federal standards, requires only that state inspectors have one 40-hour course in fire protection. Some states require more training or use fire marshals to do the work. But CMS does not track or monitor who is doing the inspections.  CMS is supposed to catch states’ mistakes during follow-up “monitoring surveys” each year at 5% of all nursing homes — about 800 facilities. In past years, the agency never has come close to that many.  “We had not pushed” to do the monitoring surveys, says Syrena Gatewood, who heads nursing home oversight at the Boston CMS office that monitors New England.

 

“After the Hartford fire and another disastrous nursing home blaze in Nashville in 2003, Gatewood says, CMS regional offices “were handed a new priority”: to meet the requirement of 800 monitoring checks a year. It’s a tough mandate. Six of the 10 CMS regional offices have no dedicated fire safety engineer to do the surveys.  To fill the gap, CMS has hired private fire safety consultants to do hundreds of monitoring surveys nationwide. And the agency is making progress: CMS has done 732 monitoring surveys for fire safety so far this year. In all of last year, it did 81; in 2003, it did 27.

 

“In Connecticut, the state’s investigation of the fire at Greenwood led the Department of Public Health to provide additional training for inspectors. The nursing home has new owners — and new sprinkler and fire alarm systems.”  (USA Today. “Blind Oversight…,” October 6, 2005.)

 

Hartford Fire Department: “Greenwood Health Center, 5 Greenwood St.  16 people lost their lives. As a result of this fire, laws governing the use of sprinklers in convalescent homes were changed so that all nursing homes in CT must have them.  This fire was the greatest disaster in the City’s History since the Niles Street Convalescent home fire of 1945. It was the nation’s deadliest nursing home fire in a half-century.”   (Hartford Fire Department, CT. Major Fires.)

 

Robinson: “By August 13 of this year, all new and existing nursing homes in the United States will be required to install automatic fire sprinklers, without waivers or exceptions, if they wish to continue to qualify for participation in the Medicare/Medicaid reimbursement program. The requirement was enacted by the Centers for Medicare & Medicaid Services (CMS), the federal agency that contracts with states to make sure nursing homes comply with federal standards.

 

“The requirement is a direct result of two deadly nursing home fires that occurred in 2003, as well as the culmination of a half-century of improvements in fire safety regulations aimed at reducing nursing home fires. From portable fire extinguishers to complete-coverage automatic sprinklers, fire and life safety code requirements have become stricter and more specific, and enforcement efforts more rigorous, making loss-of-life fires in these occupancies increasingly rare….

 

“The last straw. In 2003…in what can only be described as a setback, two deadly fires again focused attention on fire safety in nursing homes.

 

“The first occurred in February at the Greenwood Health Center in Hartford, Connecticut, when a mentally disturbed patient set her bedding on fire with a cigarette lighter. According to NFPA’s investigation report, the fire spread to adjacent rooms and entered the building’s eaves before firefighters extinguished it. Ten residents died at the scene, and six more died later.

 

“Unlike Golden Age[1] or Katie Jane,[2] the Greenwood Health Center largely complied with the state fire safety code. Interior walls of gypsum board provided a half-hour fire-resistance rating. Concrete block walls extending from the floor slab to the roof deck separated patient rooms, and the rooms’ solid-core wood doors, which opened directly onto the corridor, had positive latching hardware. Smoke barriers divided the facility into 11 smoke compartments, with corridor doors that closed automatically when the fire alarm system activated. The facility also had an emergency generator, a fire alarm system connected to the Hartford Fire Department, and smoke detectors in the corridors and common areas that were tested monthly by staff and twice a year by an outside contractor. A chemical extinguishing system in the kitchen protected the exhaust hood. It, too, was inspected and maintained by an outside contractor. In addition, a single automatic sprinkler protected the laundry chute between the first floor and the basement, and portable fire extinguishers had been installed throughout.

 

“But an important fire safety feature was missing: complete-coverage automatic sprinklers, which were not required by the state. (A discrepancy in how the staff responded to the fire — a key component in the “total concept” safety idea — was also noted as a contributing factor in the outcome of the fire.)….

 

“In 2004, the Government Accountability Office (GAO) issued a study that looked at the entire oversight program dealing with nursing home fire safety and recommended, among other things, that the CMS[3] explore the feasibility of requiring sprinklers in all nursing homes. A discussion was already underway with the NFPA Technical Committee about changing the Life Safety Code to require sprinklers in all existing nursing homes in the aftermath of the two fires in 2003, and NFPA’s review of the draft GAO report in May 2004 simply confirmed and reinforced the concept, says Robert Solomon, NFPA division manager for Building Fire Protection and Life Safety.

 

“Knowing there would be pressure to improve fire safety in its facilities, the nursing home industry decided to become proactive, asking itself which fire protection systems would provide the best protection for the money. The answer was sprinklers. As a result, the industry submitted a proposal to the Life Safety Code committee and to CMS to mandate sprinklers in all existing nursing homes. (The 1991 edition of NFPA 101 had been revised to require all new health care occupancies, including nursing homes, to be protected with automatic sprinklers.) NFPA accepted the proposed revisions to the 2006 edition of the Life Safety Code, requiring the installation of automatic sprinklers in all existing nursing homes. CMS issued its final rule on August 13, 2008, requiring nursing homes across the United States to install automatic fire sprinklers, without waivers or exceptions, by August 13, 2013, if they wish to continue to qualify for participation in the Medicare/Medicaid reimbursement program. If they do not, they will face financial penalties or even loss of their ability to participate in their reimbursement program altogether.

 

“Brave new sprinklered world.

 

“NFPA statistics for 2006–2010 showed that sprinklers were present in 70 percent of the reported fires in licensed nursing homes. Faced with nursing home fires large enough to activate an operational sprinkler system, sprinklers operated 89 percent of the time and operated effectively 87 percent of the time. Of the 13 percent of cases where there was not effective operation, roughly half were because the sprinklers were turned off before the fire began….” (Robinson, Kathleen. “Feature: Health Care Occupancies.” NFPA Fire Journal, Jan-Feb 2013.)

 

Sources

 

Associated Press (Kathryn Masterson). “Nursing home fire leaves 10 dead.” 2-27-2002, Collegiatetimes.com, Blacksburg, VA. Accessed 5-25-2016 at: http://www.collegiatetimes.com/news/nursing-home-fire-leaves-dead/article_d20befae-36be-5f1d-a35f-4c2ecad37627.html

 

CNN. “Nursing Home Fire Leaves 10 Dead.” 2-26-2003. Accessed at:  http://www.drslawfirm.com/nhcfire.pdf {slide 12} [Link inoperative when checked 5-25-2016.]

 

Hartford Fire Department. Major Fires. Hartford, CT. Accessed 5-5-2005 at:  http://www.hartford.gov/fire/MajorFires/major_fires.htm

 

Robinson, Kathleen. “Feature: Health Care Occupancies.” NFPA Fire Journal, Jan-Feb 2013. Accessed 5-31-2015 at: http://www.nfpa.org/newsandpublications/nfpa-journal/2013/january-february-2013/features/long-time-coming/?p=1

 

Smith, David Randolph & Associates. NHC Fire Litigation, slide 10, 10-15-2004. Accessed 5-25-2016 at:  http://www.drslawfirm.com/nhcfire.pdf

 

United States Government Accountability Office. Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal Standards and Oversight (Report to Congressional Requesters GAO-04-660). Washington, DC: US GAO, July 2004. Accessed 10-11-2015 at: http://www.gao.gov/products/GAO-04-660

 

USA Today. “Blind Oversight: Inspectors Miss Infractions.” 10-6-2005. Accessed 5-25-2016 at:  http://www.usatoday.com/news/nation/2005-10-06-nursing-homes-oversight_x.htm

 

[1] 11-23-1963 Nursing/Rest Home fire in Fitchville, OH, in which 63 died.

[2] 2-17-1957 Nursing Home fire in Warrington, MO, in which 72 died.

[3] Centers for Medicare & Medicaid Service, the federal agency that contracts with states to make sure nursing homes comply with federal standards. (Robinson)

 

— 100  Durso, Fred Jr. “Managing the Masses. NFPA Journal, July/August 2010, p. 71.

— 100  History.com. This Day in History, Disaster. “Feb 20, 2003, RI Nightclub Burns”

— 100  National Fire Protection Association. Key Dates in Fire History. 1996.

— 100  National Fire Protection Association. The Station Nightclub Fire (webpage).

— 100  NFPA. U.S. Unintentional Fire Death Rates by State. December 2008, p. 25.

— 100  NIST. Report of the Technical Investigation of The Station Nightclub Fire.  2005, iii.

— 100  Sutherland, Scott. “Panic debunked, again.” NFPA Journal, July/August 2009, p. 15.

 

Narrative Information

 

History.com: “A fire at a rock concert in a West Warwick, Rhode Island, nightclub kills 100 people and seriously injures almost 200 more on this day in 2003. It was the deadliest such fire in the United States since 165 people were killed at the Beverly Hill Supper Club in Southgate, Kentucky, in 1977.

 

“On the night of February 20, a local news crew was on hand at the Station nightclub to report on the issue of nightclub safety. (Four days earlier, 21 people had been killed during a stampede at a club in Chicago.) Helping out with the report was Jeffrey Derderian, who co-owned the Station with his brother Michael. That night, they were expecting a full house to see the heavy-metal band Great White.

 

“Just after 11 p.m., near the beginning of the show, Daniel Biechele, Great White’s tour manager, set off some pyrotechnics behind the performers, which set fire to the soundproofing foam on the ceiling. For a short time, no one realized the severity of the situation. As the fire spread rapidly, though, panic ensued. Most of the 400 people at the concert attempted to leave the club through the front entrance.

 

“As black smoke filled the club’s interior, the desperate rush of people to the front entrance caused a pile-up, trapping people where they stood. Though firefighters, who responded within minutes, worked hard to pull people to safety through the front door, 96 people died in the smoke and flames. Most of the bodies were found near the front entrance. Among the dead was Great White’s guitarist, Ty Longley. Another 35 people were left in critical condition, including four who would later die from their injuries.

 

“In the aftermath of the tragedy, Daniel Biechele was indicted for setting off the pyrotechnics without a permit. He pled guilty to 100 counts of involuntary manslaughter and received a sentence of four years in prison with 11 more years suspended. Michael Derderian pled guilty for his role in maintaining the Station and received a 15-year sentence (four years to serve, and 11 years suspended). His brother Jeffrey got a 10-year suspended sentence.” (History.com. This Day in History…February 20, 2003, “Rhode Island Nightclub Burns”)

 

NFPA, The Station Nightclub Fire (webpage): “The fourth deadliest nightclub fire in U.S. history,[1] a blaze at The Station nightclub in W. Warwick, RI, on February 20, 2003, claimed 100 lives. After the fire, NFPA enacted tough new code provisions for fire sprinklers and crowd management in nightclub-type venues. Those provisions mark sweeping changes to the codes and standards governing safety in assembly occupancies.” (National Fire Protection Association. The Station Nightclub Fire webpage.) [This NFPA webpage contains links to a number of other documents relating to the fire, its aftermath, and effects.]

 

NIST: “A fire occurred on the night of Feb. 20, 2003, in The Station nightclub at 211 Cowesett Avenue, West Warwick, Rhode Island. A band that was on the platform that night, during its performance, used pyrotechnics that ignited polyurethane foam insulation lining the walls and ceiling of the platform. The fire spread quickly along the walls and ceiling area over the dance floor. Smoke was visible in the exit doorways in a little more than one minute, and flames were observed breaking through a portion of the roof in less than five minutes. Egress from the nightclub, which was not equipped with sprinklers, was hampered by crowding at the main entrance to the building.  One hundred people lost their lives in the fire.  On Feb. 27, 2003, under the authority of the National Construction Safety Team (NCST) Act, the National Institute of Standards and Technology (NISI) established a National Construction Safety Team to determine the likely technical cause or causes of the building failure that led to the high number of casualties in that fire. This report documents the procedures, findings, and issues that were raised by the investigation….

 

“The investigation concluded that strict adherence to 2003 model codes available at the time of the fire would go a long way to preventing similar tragedies in the future. Changes to the codes subsequent to the fire made them stronger. By making some additional changes — and state and local agencies adopting and enforcing them — we can strengthen occupant safety even further.

 

“Ten recommendations to improve model building and fire codes, standards and practices (as they existed in February 2003) resulted from the investigation, including (i) urging state and local jurisdictions to (a) adopt and update building and fire codes covering nightclubs based on one of the model codes and (b) enforce those codes aggressively; (ii) strengthening the requirements for the installation of automatic fire sprinklers; (iii) increasing the factor of safety on the time for occupants to egress; (iv) tightening the restriction on the use of flexible polyurethane foam — and other materials that ignite as easily and propagate flames as rapidly as non-fire retarded foam — as an interior finish product; (v) further limiting the use of pyrotechnics; and (vi) conducting research in specific areas to underpin the recommended changes.” (NIST. Report…Technical Investigation…The Station Nightclub Fire. June 2005, iii.)

 

Durso: “….Crowd managers weren’t present at The Station. Nor had they been present at the E2 Nightclub in Chicago just days earlier, when a crowd crush killed 21 people. In the wake of those incidents, NFPA issued interim amendments to NFPA 101®, Life Safety Code®, and NFPA 5000®, Building Construction and Safety Code®, that took effect in 2003. The amendments addressed assembly occupancy main entrance egress width, sprinklers in certain assembly occupancies, and limitations on festival seating. The amendments also required the presence of a trained crowd manager for every 250 people in all assembly occupancies; previous editions of the codes required crowd managers only where the occupant load exceeded 1,000 persons….” (Durso, Fred Jr. “Managing the Masses. National Fire Protection Association, NFPA Journal, July/August 2010, p. 71 of 71-73.)

 

Sources

 

Durso, Fred Jr. “Managing the Masses. National Fire Protection Association, NFPA Journal, July/August 2010, pp. 71-73.

 

 

History.com. This Day in History, Disaster, February 20, 2003. “Rhode Island Nightclub Burns.” Accessed 12-07-2008 at:  http://www.history.com/this-day-in-history.do?action=tdihArticleCategory&displayDate=02/20&categoryId=disaster

 

National Fire Protection Association. Key Dates in Fire History. 1996, 2010. Accessed 5-25-2016 at:  http://www.nfpa.org/research/reports-and-statistics/key-dates-in-fire-history

 

National Fire Protection Association. The Station Nightclub Fire (webpage). Accessed 6-1-2015 at: http://www.nfpa.org/safety-information/for-consumers/occupancies/nightclubs-assembly-occupancies/the-station-nightclub-fire

 

National Fire Protection Association (John Hall, Jr.). U.S. Unintentional Fire Death Rates by State. Quincy, MA: NFPA, 31 pages, December 2008.

 

National Institute of Standards and Technology. Report of the Technical Investigation of The Station Nightclub Fire (NIST NCSTAR 2: Vol. I). Washington, DC:  Department of Commerce, NIST, June 2005. Accessed 6-1-2015 at: http://fire.nist.gov/bfrlpubs/fire05/PDF/f05032.pdf

 

Sutherland, Scott. “Panic debunked, again.” NFPA Journal, July/August 2009, p. 15.

 

 

 

 

 

[1] See our files on: (1) Nov 28, 1942 Cocoanut Grove Night Club Fire in Boston with 492 lives lost; (2) April 23, 1940 Rhythm Club Dane Hall Fire in Natchez, MS with 207 deaths; (3) May 28, 1977 Beverly Hills Supper Club Fire in Southgate, KY, with 165 lives lost.

–7  CSB. CTA Acoustics Dust Explosion and Fire (webpage). 2-15-2005.

–7  CSB. Investigation Report: Combustible Dust Hazard Study.  Nov 2006, p. 21.

–7  Moure-Eraso. “Nine years after…still no dust regulations.” Lexington Herald Leader, KY.

–7  Times Tribune (Eric Steinkopff), Corbin KY. “Jury: Borden liable for CTA fire.” 5-23-2007.

 

Narrative Information

 

CSB: “On February 20, 2003, a series of dust explosions at the CTA Acoustics (CTA) facility in Corbin, Kentucky, claimed the lives of seven workers, injured 37, and destroyed the manufacturing facility…This facility primarily made acoustic insulation for automobiles. The manufacturing process began by impregnating a fiberglass mat with phenolic resin, and then used air to draw the resin into the fiberglass webs. On the day of the explosion, a curing oven that had been left open because of a temperature control problem likely ignited the combustible resin dust stirred up by workers cleaning the area near the oven.

 

“The CSB also found that plant design, work practices, and housekeeping problems contributed to causing the explosions. The CTA building was not designed to prevent or minimize secondary dust explosions (minimizing flat surfaces where dust can accumulate and using fire walls to separate production lines). Although management was aware of dust explosion hazards associated with the materials being used, dust had accumulated in dangerous amounts throughout the production areas, in vent ducting, and in dust collector housings, due to inadequate housekeeping and maintenance. In addition, employees routinely used compressed air and brooms to clean production lines, creating clouds of resin dust.

 

“The MSDS[1] for the resin used at CTA did not adequately communicate that the material posed a dust explosion hazard. In addition, the resin supplier, Borden Chemical (Borden), had not communicated to CTA the safety lessons from the 1999 Jahn Foundry resin dust explosion,[2] even though documents obtained by the CSB indicated that Borden was aware of the explosion, which involved a resin similar to the one used at CTA.

 

“The Kentucky Office of Occupational Safety and Health (KYOSHA had inspected the facility, but had not issue citations regarding combustible dust hazards.

 

“In addition, the CTA facility had never been inspected by the Kentucky State Fire Marshal’s Office, and frequent inspections by CTA’s insurer had failed to identify phenolic resin as an explosion hazard. The CSB determined that if CTA had adhered to NFPA standards for housekeeping and fire/explosion barriers,[3] the explosions could have been prevented or minimized.” (CSB. Investigation Report: Combustible Dust Hazard Study. Nov 2006, p. 21-22.)

 

Moure-Eraso: “….Investigators found that CTA had been aware that combustible dust in the plant could explode, but did not modify the design of the plant to prevent the release and accumulation of the dust, communicate the hazard to workers or modify operating procedures….

 

“But dust explosions continued to occur elsewhere, leading the CSB in 2006 to recommend that the Occupational Safety and Health Administration should issue a federal regulatory combustible dust standard for general industry, to end these preventable tragedies.

 

“Yet, nine years after the CTA catastrophe, and more than five years after our recommendation to OSHA, there is still no comprehensive OSHA standard to prevent these accidents….

 

“Although OSHA agreed to develop a dust standard in April 2009, the agency’s most recent 2012 regulatory agenda does not include any specific milestones or targets for the standard’s development. Without a standard that comprehensively addresses the hazards of combustible dust, American workers will continue to be put at risk for future catastrophic explosions and fires….” (Moure-Eraso, Rafael (Chairman U.S. Chemical Safety Board). “Nine years after Corbin explosion, still no dust regulations.” Lexington Herald Leader, KY, 2-19-2012.)

 

Times Tribune/Steinkopff: “Borden Chemicals was ordered to pay CTA Acoustics more than $122 million after being found liable Monday by a jury for the 2003 plant explosion in Corbin, according to lawyers from both sides. A Laurel County circuit court jury in London found Borden Chemicals liable for the explosion and fire that killed seven employees at the CTA Acoustics plant in Corbin Feb. 20, 2003, according to a CTA press release.

 

“The trial, which began April 9 and lasted six weeks, ended Monday evening with the jury ordering Borden to pay CTA roughly $122 million for property damage and loss of profits, but it did not consider Borden liable for the deaths or serious bodily injury.

 

“ ‘The jury clearly understood that the phenolic resin sold by Borden was similarly involved in a deadly explosion at the Jahn Foundry in Springfield, Mass. on Feb. 25, 1999 in which three people were killed and nine people were injured,’ said CTA Chairman and CEO James J. Pike in a prepared press release. ‘Following that tragedy, Borden failed to notify any of its customers or to change the classification of their phenolic resin on their Materials Safety Data Sheet or to change their labeling to indicate the explosive characteristics of their phenolic resin powder.’

 

“But lead counsel for Borden Chemicals Hank Marshall painted a different picture and vowed not to give up their fight. ‘There were some very serious errors in the trial and as a result the jury did not hear the full extent of CTA’s knowledge of the risks of working with our product,’ Marshall said. ‘We were not allowed to introduce the findings of the Kentucky (Occupational Safety and Health Administration) that very clearly puts the blame for the accident on CTA. We intend to appeal and we’re confident that had the jury heard all the evidence of CTA’s knowledge, which the trial judge did not allow us to present, the outcome would have been different.’….

 

“The largest CTA customer, Ford Motor Company, temporarily closed four automobile assembly plants due to lack of parts that had been supplied by CTA….

 

“In 2006, Borden, CertainTeed and CTA agreed to an undisclosed settlement with 16 of the most critically injured workers or their families….” (Times Tribune (Eric Steinkopff), Corbin, KY. “Jury: Borden liable for CTA fire.” 5-23-2007.)

 

Newspaper at the Time

 

Feb 20: “Dozens of people are injured and a mile and a half wide cloud of cyanide[4] has been released into the air over North Corbin following an explosion this morning at CTA Acoustics….Every Laurel, Knox and Whitley County emergency and rescue service was called to the southern Laurel County plant after an explosion ripped through the rear of the building sending hundreds of employees scrambling for aid….

 

“One 28-year CTA employee said she spoke for 10 minutes to a man whose clothes were completely burned off. The woman stayed with him until help arrived, but his face was so severely burned, she said she didn’t know who she was talking to. ‘I saw a wall collapse, and I hid under my desk,’ she said. ‘When I came out, I saw five bodies lying around me.’….” (Times-Tribune, Corbin, KY. “Blast rips CTA.” 2-20-2003, p. 1.)

 

Feb 21: “Several CTA Acoustics workers remain in critical condition today following the explosion which sent 44 of its victims to hospitals Thursday morning prompting medical personnel to call the disaster one of the worst this area has ever experienced. Dr. George Liu, chief of general surgery at Baptist Regional Medical Center, called the number and severity of the injuries the most tragic of his career. ‘I’ve never seen anything like this,’ he said. ‘Some of the victims had 80 and 90 percent of their bodies burned.’….none of the injured had suffered broken bones or other additional injuries….” (Times-Tribune, Corbin, KY. “CTA explosion sends 44 to hospitals; at least 11 critical.” 2-21-2003, p. 1.)

 

Sources

 

Moure-Eraso, Rafael (Chairman U.S. Chemical Safety Board). “Nine years after Corbin explosion, still no dust regulations.” Lexington Herald Leader, KY, 2-19-2012. Accessed 8-6-2017 at: http://www.kentucky.com/opinion/op-ed/article44155764.html

 

Times-Tribune (Janie Taylor), Corbin, KY. “Air quality at expected levels after explosion…false cyanide report came from one emergency agency.” 2-22-2003, p. 1. Accessed 8-6-2017 at: https://newspaperarchive.com/corbin-times-tribune-feb-22-2003-p-1/?tag

 

Times-Tribune (Erin Moses, et al.), Corbin, KY. “Blast rips CTA.” 2-20-2003, p. 1. Accessed 8-6-2017 at: https://newspaperarchive.com/corbin-times-tribune-feb-20-2003-p-1/?tag

 

Times-Tribune (Janie Taylor), Corbin, KY. “CTA explosion sends 44 to hospitals; at least 11 critical.” 2-21-2003, p. 1. Accessed 8-6-2017 at: https://newspaperarchive.com/corbin-times-tribune-feb-21-2003-p-1/?tag

 

Times Tribune (Eric Steinkopff), Corbin, KY. “Jury: Borden liable for CTA fire.” 5-23-2007. Accessed 8-6-2017 at: http://www.thetimestribune.com/news/local_news/jury-borden-liable-for-cta-fire/article_0865b9e7-b815-5221-a54a-f9e0e6d27a57.html

 

U.S. Chemical Safety and Hazard Investigation Board (CSB). CTA Acoustics Dust Explosion and Fire (webpage). Washington, DC, CSB, 2-15-2005. Accessed 8-6-2017 at: http://www.csb.gov/cta-acoustics-dust-explosion-and-fire/

 

U.S. Chemical Safety and Hazard Investigation Board (CSB). Investigation Report: Combustible Dust Hazard Study (Report No. 2006-H-1). Washington, DC: CSB, November 2006, 108 pages.

 

 

 

 

 

 

 

[1] Material Safety Data Sheet.

[2] Feb 25, 1999, Springfield Mass.; 3 workers died and nine others seriously injured. (EHS Today, 10-14-1999.)

[3] Specifically cites NFPA (National Fire Protection Association) 654 (2000).

[4] False report by at least one emergency response agency. KY State Police spokesperson said the KSP was at least partially at fault for the report. (Times Tribune, Corbin, KY. “Air quality at expected levels after explosion…false cyanide report came from one emergency agency.” 2-22-2003, p. 1.)

— 21  AP. “`Mass Chaos’…nightclub in Chicago claims…21 lives.” Bryan Times, OH, 2-17-2003.

— 21  Durso, Fred Jr. “Managing the Masses. NFPA Journal, July/August 2010, pp. 71-73.

— 21  Emergency & Disaster Management, Inc. Chicago Disasters.

— 21  Palmer, J. Coyden. “10 years later E2 families seek answers.” Chicago Crusader, 2-23-2013.

— 21  Wilgoren, New York Times, February 18, 2003.

­­­­

Narrative Information

 

AP/Loomis: “CHICAGO — Hundreds of screaming guests rushed the exits of a crowded nightclub Monday after security guards used a chemical spray to quell a fight, and at least 21 people were crushed to death or smothered in the panic, officials and witnesses said.  “Firefighters responding to the scene found a number of locked or blocked doors and used sledgehammers and pry bars to open some of them so that people could be rescued, Fire Commissioner James Joyce said at a late morning briefing. “There were people trying to get out that could not get out,” Joyce said. “Locked and blocked doors are a contributing factor. We can’t explain how management or ownership would allow that.” The locked doors are a fire code violation, Joyce said.

 

“Twenty-one people were confirmed dead in the tragedy at the Epitome Night Club… Hospitals reported treating at least 50 for everything from critical injuries to asthma-like symptoms.  “Everybody smashed; people crying, couldn’t breathe,” said clubgoer Reggie Clark. “Two ladies next to me died. A guy under me passed out.”  Witnesses reported that panic broke out after the guards used pepper spray or Mace to break up a fight, but authorities did not immediately confirm that.

 

“There were more than 1,500 people in the two-story nightclub when someone released a chemical spray into the air sometime after 2 a.m., officials initially estimated. They could not immediately say what the legal capacity of the building was.  “It appears a disturbance from within led to a mass chaos where people headed for the door. Most of the fatalities appear to have been crushed or had injuries due to suffocation,” said police Officer Ozzie Rodriguez….

 

“Cory Thomas, 33, went to the club to pick up two friends. As he waited outside, he saw people inside the club start to back up against the glass front door.  “You could see a mound of people. People were stacking on top of each other, screaming and gagging.  The door got blocked because there were too many stacked up against it.”  “I saw them taking out a pregnant woman,” Thomas said. “She was in bad shape. I saw at least 10 lifeless bodies.”  “Kristy Mitchell, 22, was one of the people trampled on the stairway.  “People were stomping my legs,” she said. “When they pulled me up, I was dizzy and I couldn’t breathe.” Amishoov Blackwell, 30, was checking his coat on the second floor when people started rushing past him. The flow of the crowd pushed him back down the stairs and he fell on top of several people, he said. He was trapped on top of the others until firefighters rescued him about 30 minutes later. “It wasn’t nothing but two girls fighting,” Blackwell said. “Why’d they have to spray Mace?”

 

“The Rev. Jesse Jackson arrived at the scene early Monday and urged community members to help each other.  “We are asking area ministers to go to hospitals,” Jackson said. “My people are overwhelmed with the suddenness of this….”  (AP/Loomis 2003)

 

Wilgoren: “The Rev. Jesse Jackson, who spent much of today with relatives of victims and survivors, said those inside told him someone had yelled ”poison gas” and that fears of a terrorist attack fueled the chaos.” (Wilgoren, NYT, Feb 18, 2003)

 

AP/Loomis: “The president of a Chicago entertainment agency that has booked acts at the club said access to the building was unsafe for large crowds.  “The doorway was obviously inadequate for an emergency,” said Ron Onesti of Onesti Entertainment Co. “When the place is filled to capacity, the doorway is very thin.”

 

AP/Loomis: “The melee marks one of the nation’s deadliest stampedes.”  (AP/Loomis 2003)

 

Wilgoren: “A city lawyer said the second-story club was open in violation of a court order, a contention the club’s lawyer disputed.  The authorities said they would seek criminal contempt charges as early as Tuesday against the owners of the South Side establishment for allowing people into the nightclub, E2, which sits above the upscale steak and seafood restaurant Epitome. The club, known for raucous dance parties, had been ordered shut in July because of 11 violations of fire and building codes…. Dorothy Capers, the city’s deputy corporation counsel, said officials had been in court three times since July, most recently last month, trying to enforce the order barring use of the second story, which officials said was shuttered because of shoddy rehabilitation work and stairwells and exit lights that were not up to code…. In addition to the issue of the court order, Commissioner Joyce said, the required occupancy placard was missing from the second floor, and bags of laundry were blocking several doors.”  (Wilgoren, NYT, Feb 18, 2003)

 

Wilgoren: “A spokeswoman for the Cook County Medical Examiner’s office said the dead, 9 men and 12 women, ages 21 to 43.” (Wilgoren, NYT, Feb 18, 2003)

 

Durso: “….Crowd managers weren’t present at The Station. Nor had they been present at the E2 Nightclub in Chicago just days earlier, when a crowd crush killed 21 people. In the wake of those incidents, NFPA issued interim amendments to NFPA 101®, Life Safety Code®, and NFPA 5000®, Building Construction and Safety Code®, that took effect in 2003. The amendments addressed assembly occupancy main entrance egress width, sprinklers in certain assembly occupancies, and limitations on festival seating. The amendments also required the presence of a trained crowd manager for every 250 people in all assembly occupancies; previous editions of the codes required crowd managers only where the occupant load exceeded 1,000 persons….” (Durso, Fred Jr. “Managing the Masses. National Fire Protection Association, NFPA Journal, July/August 2010, p. 71 of 71-73.)

 

Sources

 

Associated Press (Brandon Loomis). “`Mass Chaos’ at a nightclub in Chicago claims at least 21 lives.” Bryan Times, OH, 2-17-2003. Accessed 10-27-2015 at: https://news.google.com/newspapers?nid=799&dat=20030217&id=CP0vAAAAIBAJ&sjid=sEkDAAAAIBAJ&pg=6410,4567611&hl=en

 

Durso, Fred Jr. “Managing the Masses. National Fire Protection Association, NFPA Journal, July/August 2010, pp. 71-73.

 

Emergency & Disaster Management Inc. “Chicago Disasters.” Accessed 1-22-2008 at:  http://www.emergency-management.net/chicago_di.htm

 

Palmer, J. Coyden. “10 years later E2 families seek answers.” The Chicago Crusader, Vol. LXXII, No. 44, 2-23-2013, p. 1. Accessed 10-27-2015 at: http://www.chicagocrusader.com/Editions/CHICAGO%20CRUSADER%2002-23-2013sm.pdf

 

Wikipedia. “2003 E2 Nightclub Stampede.” http://en.wikipedia.org/wiki/2003_E2_nightclub_stampede

 

Wilgoren, Jodi.  “21 Die in Stampede of 1,500 at Chicago Nightclub.”  New York Times, 20-18- 2003. Accessed 5-25-2016 at:  http://query.nytimes.com/gst/fullpage.html?res=9A04E7D81F3AF93BA25751C0A9659C8B63&sec=&spon=&pagewanted=2

 

 

–7  Cox, Mike. Texas Disasters: True Stories of Tragedy and Survival. 2006, p. 229.

–7  Dowling, Stephen. “What Caused the Space Shuttle Columbia disaster?” BBC, 1-30-2015.

–7  History.com.  This Day in History… Feb 1, 2003.  “Columbia Mission Ends in Disaster.”

–7  NASA. Space Shuttle Columbia and Her Crew (website). 8-23-2006 update.

–7  Sturkey. Mayday. Accident Reports and Voice Transcripts from Airline Crash… 2005, p.437.

 

Narrative Information

 

History.com: “On this day in 2003, the space shuttle Columbia breaks up while entering the atmosphere over Texas, killing all seven crew members on board.

 

“The Columbia’s 28th space mission, designated STS-107, was originally scheduled to launch on January 11, 2001, but was delayed numerous times for a variety of reasons over nearly two years. Columbia finally launched on January 16, 2003, with a crew of seven. Eighty seconds into the launch, a piece of foam insulation broke off from the shuttle’s propellant tank and hit the edge of the shuttle’s left wing.

 

“Cameras focused on the launch sequence revealed the foam collision but engineers could not pinpoint the location and extent of the damage. Although similar incidents had occurred on three prior shuttle launches without causing critical damage, some engineers at the space agency believed that the damage to the wing could cause a catastrophic failure. Their concerns were not addressed in the two weeks that Columbia spent in orbit because NASA management believed that even if major damage had been caused, there was little that could be done to remedy the situation.

 

“Columbia reentered the earth’s atmosphere on the morning of February 1. It wasn’t until 10 minutes later, at 8:53 a.m.–as the shuttle was 231,000 feet above the California coastline traveling at 23 times the speed of sound–that the first indications of trouble began. Because the heat-resistant tiles covering the left wing’s leading edge had been damaged or were missing, wind and heat entered the wing and blew it apart.

 

“The first debris began falling to the ground in west Texas near Lubbock at 8:58 a.m. One minute later, the last communication from the crew was heard, and at 9 a.m. the shuttle disintegrated over southeast Texas, near Dallas. Residents in the area heard a loud boom and saw streaks of smoke in the sky. Debris and the remains of the crew were found in more than 2,000 locations across East Texas, Arkansas and Louisiana. Making the tragedy even worse, two pilots aboard a search helicopter were killed in a crash while looking for debris. Strangely, worms that the crew had used in a study that were stored in a canister aboard the Columbia did survive.

In August 2003, an investigation board issued a report that revealed that it in fact would have been possible either for the Columbia crew to repair the damage to the wing or for the crew to be rescued from the shuttle. The Columbia could have stayed in orbit until February 15 and the already planned launch of the shuttle Atlantis could have been moved up as early as February 10, leaving a short window for repairing the wing or getting the crew off of the Columbia.

 

“In the aftermath of the Columbia disaster, the space shuttle program was grounded until July 16, 2005, when the space shuttle Discovery was put into orbit.”  (History.com.  This Day in History, Disaster, February 1, 2003.  “Columbia Mission Ends in Disaster.”)

 

Sources

 

Cox, Mike. Texas Disasters: True Stories of Tragedy and Survival. Guilford, CT: Globe Pequot Press, 2006.

 

Dowling, Stephen. “What Caused the Space Shuttle Columbia disaster?” BBC, 1-30-2015. Accessed 10-27-2015 at: http://www.bbc.com/future/story/20150130-what-caused-the-columbia-disaster

 

History.com. This Day in History, Disaster, February 1, 2003.  “Columbia Mission Ends in Disaster.” Accessed 12-6-2008 at:  http://www.history.com/this-day-in-history.do?action=tdihArticleCategory&displayDate=02/01&categoryId=disaster

 

NASA (National Aeronautics and Space Administration). Space Shuttle Columbia and Her Crew (website). 8-23-2006 update. Accessed 10-27-2015 at: http://www.nasa.gov/columbia/home/index.html

 

Sturkey, Marion F. Mayday. Accident Reports and Voice Transcripts from Airline Crash Investigations. Plum Branch, SC: Heritage Press International, 2005.

 

 

–6  CSB. “Dust Explosion at West Pharmaceutical Services, Kinston, North Carolina…”

–6  CSB. Investigation Report: Combustible Dust Hazard Study (Report 2006-H-1). 2006, p.19.

–6  Philadelphia Inquirer. “Plant explosion teaches a West CEO a lesson in leadership.” 3-2-2015.

 

Narrative Information

 

CSB: “On January 29, 2003, a powerful explosion and fire ripped through the West Pharmaceutical Services rubber-manufacturing plant in Kinston, North Carolina, taking the lives of six employees, and injuring 38 others including two firefighters who responded to the accident. The blast occurred without warning at 1:28 p.m. during a routine workday and could be heard 25 miles from the plant. A student at a school more than half a mile away was injured by shattered glass. Flaming debris set woods on fire as far as two miles away.

 

“With a sound described by some employees as ‘rolling thunder,’ the explosion blew off exterior siding from the building and sent a fireball and a cloud of smoke rising high into the air. The explosion ignited fires throughout the facility and disabled the building’s sprinkler system. Two 7,500-gallon plastic tanks of mineral oil collapsed from the heat, further fueling the blazes. The largest fire occurred in a rubber storage warehouse, which burned for more than two days. The rubber-manufacturing area of the plant was destroyed, the warehouse collapsed, and most of the building was rendered unusable. The company relocated the plant several miles away but did not resume rubber compounding, resulting in the loss of jobs in Kinston.

 

“All the fatalities occurred on the ground level of the plant, mostly in the vicinity of the rubber-production line. In the aftermath of the explosion, many workers were dazed or buried under debris. Responders and other employees equipped with flashlights assisted them out of the plant to triage areas. The most severely injured were airlifted to burn trauma centers.

 

“The CSB investigated the accident to determine its root causes. The investigation traced the explosion to a hazard that developed in the plant over the years: combustible dust from a plastic raw material had accumulated on hidden surfaces above the production area, creating the fuel for a massive explosion and fire.

 

Rubber Process Created Hidden Dangers

 

“West Pharmaceutical is one of the world’s largest manufacturers of rubber components for drug vials and syringes, and the Kinston facility was a major employer in North Carolina’s Lenoir County. At the plant, batches of rubber were compounded in mixers, rolled into strips, and then either molded or shipped off site. To reduce the stickiness of the rubber, the strips were conveyed through a tank containing very fine talc-like polyethylene powder mixed with water. The coated rubber strips were then blown dry with fans. Polyethylene dust became airborne in the process.

 

The polyethylene dust settled on surfaces around the production area. Because the facility produced supplies for medical use, cleanliness was a high priority, and crews continuously cleaned dust from visible areas. However, dust was also drawn upward through several ventilation air intakes that were located over an acoustic tile ceiling installed above the rubber-production area. Above that ceiling — visible only to maintenance workers — the dust gradually built up to a thickness of one-quarter to one-half inch on ceiling tiles, beams, conduits, and light fixtures. As much as a ton of combustible powder could have accumulated in the area above the ceiling, just a few feet over the heads of unsuspecting production workers, investigators said.

 

“Extensive damage to the plant made it impossible to determine what event initiated the first dust explosion, but the CSB report described several possible ignition sources, including an overheated batch of rubber, an electrical fault, a hot lighting ballast, or a spark from an electric motor. The first explosion dispersed other dust accumulations into the air around the production area and ignited them, causing a devastating cascade of fires and explosions.

 

Combustible Dust Hazard Overlooked

 

“West installed the rubber-making process in Kinston in 1987, originally using a coating of zinc stearate to prevent rubber strips from sticking. In 1990 the company began exploring the possible use of polyethylene as an alternative to zinc stearate. Corporate staff conducted a ‘new material review’ — including an examination of the material safety data sheet (MSDS) provided by the polyethylene powder manufacturer. The MSDS warned of the polyethylene powder’s potential to

cause a dust explosion. In 1992, West received an updated MSDS from the polyethylene manufacturer that specifically referred users to National Fire Protection Association (NFPA) Standard 654. This standard is a detailed guidance document for preventing dust explosions. A copy of this MSDS was transmitted to the Kinston facility.

 

“However, West did not reexamine the safety of the powder or consult the NFPA standard when it began using polyethylene in the manufacturing process at the Kinston facility in 1996. The company had contracted with a small Pennsylvania company, Crystal Inc., to provide a thick paste of water and polyethylene. Crystal obtained the polyethylene powder from the same manufacturer that earlier supplied West. Crystal generated an MSDS for the paste and provided the MSDS to West. But this document did not warn of the potential hazard of a dust explosion from dried paste — even though Crystal understood the intended end-use of the product in Kinston.

 

“The U.S. Occupational Safety and Health Administration (OSHA) requires employers to inform workers about chemical hazards by providing training and access to MSDSs. Although the Kinston plant had the MSDSs warning of the explosive properties of polyethylene powder, employees had not received any significant training about combustible dust hazards. Had maintenance workers been aware of the catastrophic nature of this hazard, they could have alerted management to the presence of dangerously large dust accumulations above the acoustic ceiling.

 

“Several years after the Kinston plant began using polyethylene in 1996, accumulated powder ignited during a welding operation near the rubber-making equipment, causing a fire but not an explosion. West Pharmaceutical did not conduct a documented investigation of this incident, thereby missing an opportunity to reevaluate the safety of the dried polyethylene powder.

 

Fire Safety Standards Not Followed

 

“Good engineering practice calls for consultation with available codes and standards during project design. West was well-positioned to understand its own rubber process and the materials in use. However, the company hired outside engineering contractors to design and install the process in Kinston. That process was not suitable for handling combustible powders, such as polyethylene or zinc stearate, the CSB determined. For example, the use of fans to dry the coated rubber dispersed dust throughout the work area. The unsealed acoustic tile ceiling allowed large amounts of dust to accumulate in concealed areas that were difficult to clean. The electrical fixtures and wiring in the production area were general-purpose and not rated for use around combustible dust.

 

“NFPA Standard 654 includes a variety of good practices to prevent dust explosions. The standard states that dust accumulations of just 1/32 of an inch thick — an amount less than the thickness of a dime and far less than what had built up above the ceiling in Kinston — create the conditions for a dangerous explosion and must be removed. Specific NFPA provisions that would likely have prevented the tragedy include segregating dust-producing operations; sealing off walls, ceilings, and partitions to prevent intrusion and accumulation of dust; installing electrical equipment suitable for explosive atmospheres; and regularly training employees on combustible dust hazards.

 

“However, the Kinston facility was not required to comply with NFPA 654 under either North Carolina state law or federal workplace safety regulations. In addition, North Carolina workplace and fire safety inspectors had only limited knowledge of combustible dust hazards, the CSB determined.

 

Recommendations

 

“As a result of this accident and a number of other fatal dust explosions, the Board launched a national safety study to examine the adequacy of current regulations, standards, and practices to prevent industrial dust explosions. On September 23, 2004, the Board approved the final investigation report on the West Pharmaceutical accident and issued a series of safety recommendations to avoid similar tragedies in the future.

 

“To West Pharmaceutical Services Inc.:

 

“The CSB recommended that all West Pharmaceutical facilities handling combustible powders follow NFPA 654. The company should revise its procedures for reviewing new materials to ensure that hazards are identified, controlled, and communicated to workers.

 

“To the North Carolina Department of Labor:

 

“The Board urged the department, which oversees workplace safety in the state, to identify manufacturing industries at risk for dust explosions and develop an educational outreach program on dust hazards.

 

“To the North Carolina Building Code Council:

 

“The Board recommended that North Carolina require mandatory compliance with NFPA 654, the national fire code for combustible powders, and institute an appropriate training program for state and local code officials.” (CSB. “Dust Explosion at West Pharmaceutical Services, Kinston, North Carolina, January 29, 2003.” Investigation Digest. April 2005.)

 

Sources

 

U.S. Chemical Safety and Hazard Investigation Board (CSB). “Dust Explosion at West Pharmaceutical Services, Kinston, North Carolina, January 29, 2003.” Investigation Digest. April 2005, Washington, DC: Accessed 10-27-2015: http://www.csb.gov/assets/1/19/West_Digest.pdf

 

U.S. Chemical Safety and Hazard Investigation Board. Investigation Report: Combustible Dust Hazard Study (Report No. 2006-H-1). Washington, DC: CSB, November 2006, 108 pages.

 

Philadelphia Inquirer (Jane M. Von Bergen). “Plant explosion teaches a West CEO a lesson in leadership.” 3-2-2015. Accessed 10-27-2015 at: http://www.philly.com/philly/blogs/jobs/INQ_JOBBING_West-Pharmaceutical-Morel-explosion-CEO-Kinston-Philadelphia-Exton.html