WE, the Coroner's Jury, have completed an investigation of the circumstances surrounding the December 1, 1958 fire in Our Lady of the Angels school at 909 N. Avers Avenue, Chicago, Cook County, Illinois. The investigation included an inspection of the fire scene, questioning of witnesses and a study of the fire-safety problems pertaining thereto.
We consider the purpose of the investigation by the jury to not only find the cause of death but also to determine the possible culpability of persons and agencies involved and, of greatest importance, to recommend measures for the prevention of similar catastrophes.
Judging from the evidence presented, the fire originated in the stairwell area at the northeast corner of the school building and had been burning for sometime before it was discovered. However, the exact point of origin cannot be established and we therefore have reached the conclusion that the origin of the fire is undetermined.
We have also carefully considered the evidence and information presented that pertained to the cause of the fire. We have reached the conclusion that the cause is undetermined.
We have prepared the attached recommendations with respect to fire-safety in schools for consideration by responsible officials.
Proper fire protection is NOT a luxury - IT IS A NECESSITY. It is just as important to a school as having a heating plant or proper desks. School officials have a moral responsibility to return the pupil safely to his home — education is not their sole function. To get proper fire protection, all that is needed is (a) the desire to have it, (b) money and (c) time. These recommendations are based primarily on safety to life, with property preservation of only secondary significance.
To have a fire, one needs only air, fuel and a source of ignition. The former is a result of housekeeping and construction, the latter is a matter of control over persons and heat producing devices. To successfully combat fire, it is mandatory that it be confined to the room or area of origin — that alarms of fire be sounded immediately -- that realistic building evacuation procedures start at once.
Many portions of the existing Chicago Fire Prevention Code are satisfactory — they have been studied but no further recommendation is needed. Consequently, certain basic fire prevention recommendations do not appear below.
Failure to comply with the first two recommendations below would result in a complete reappraisal of adequate school protection from a fire safety standpoint -- these two are basic and must be adopted to secure adequate fire protection,
(*) "Approved" (in the following recommendations) means manufactured in conformity with the Standards of the National Fire Protection Association, together with testing and listing or certification by a nationally recognized fire prevention equipment laboratory (such as Underwriters' or Factory Mutual Laboratories).
COMMENT: School fire hazards may be classed as light, ordinary or extra hazard. Light hazard areas include classrooms, hallways, stairwells, gymnasiums and auditoriums. Ordinary hazard areas include stages, boiler rooms, storage areas, shops, domestic science, manual training, etc. Extra hazard areas occur where hazardous materials or activities (such as spray painting) are conducted. Criteria for fire protection will vary according to this area classification.
RECOMMENDATION: Provide an approved (*) automatic sprinkler system in all school buildings (regardless of height) of the types below; said systems to have water flow detection and alarm devices.
(a) Fire-resistive schools are those built of non-burnable materials whose supporting members are well fireproofed. (Type I construction). Sprinkler systems here should protect stairwells and all areas of "ordinary" or "extra" hazard.
(b) Incombustible schools are those built of non-burnable materials and whose supporting members are lightly fireproofed or are unprotected. (Type II construction). Sprinkler systems here should protect stairwells, hallways, attics and all areas of "ordinary" or "extra" hazard.
(c) Schools of ordinary construction are those having masonry walls but with wooden floors and roofs. (Type III construction). Sprinkler systems here must cover all areas, including attics and concealed spaces over false ceilings.
(d) Schools of wooden construction have wood walls, floors and roofs. (Type IV construction). Sprinkler systems here should be the same as Type III schools, i. e., total sprinkler coverage.
It is further recommended that all new construction of schools be limited to the fire-resistive and incombustible types, and where a school property consists of several buildings that the buildings be well separated.
NOTE: Sprinkler systems need maintenance and periodic testing. Maintenance is best accomplished by qualified personnel cognizant of and operating according to the provisions of Pamphlet No. 13-A of the National Fire Protection Association, or by means of a maintenance contract with the company installing the sprinkler system. Testing is best accomplished by the fire insurance inspection bureau having jurisdiction in the state in which the school is located.
COMMENT: Heat, flame and toxic fire gases will rise to the uppermost portions of a building through vertical passageways (such as stairwells, elevators, dumbwaiters, service shafts and the like) unless these passageways are enclosed.
RECOMMENDATION: Totally enclose all vertical passageways with incombustible construction and protect all openings into them with approved (*) fire doors (Class B type) as presently required by the Chicago Fire Prevention Code. All view panels in doors should be only of wired glass. Door closers or retards must not permit doors to be left in an open position since open doors permit toxic gases to permeate hallways before heat or flame can operate fusible-link hold-open devices on door closers.
NOTE: Some older schools have masonry ventilation shafts that end in open attics. These shafts should be torn out or blocked off at each floor with incombustible construction; They now merely act as flues to permit the very rapid spread of fire and invariably allow the entire roof structure to be completely enveloped by fire very quickly. They are a distinct hazard.
COMMENT: As a further safeguard supplementing Recommendation Nos. 1 and 2, it is vital that heat, flame and toxic fire gases in hallways be kept out of classrooms or other pupil areas.
RECOMMENDATION: (new construction) Provide approved (*) fire barrier doors (Class C type) on all corridor and room partition openings, (old construction). If corridor and room doors are of the heavy, no-panel, wood type, they will offer sufficient fire retardance for evacuation purposes. If these doors are of the light, thin panel wood type, the corridor side of such doors should be protected with sheet metal of 18-gauge thickness minimum, bolted to door at corners and midpoints, with screws between bolts.
COMMENT: The door opening protection covered in Recommendation No. 3 will be of no value if ordinary glass transoms or ordinary glass corridor windows are allowed to exist.
RECOMMENDATION: Ordinary glass transoms over doors into hallways and ordinary glass windows in corridor walls should either be removed and the void space filled with equivalent wall construction existing in the corridor walls, OR transoms should be nailed shut, their operating hardware removed and the ordinary glass replaced with wired glass or protected with sheet metal (as outlined in Recommendation No. 3). Ordinary glass in corridor windows should be replaced with wired glass.
COMMENT: It is of prime importance that immediate notification of the start of a fire be given to the occupants of a school and also to the local fire department. It is preferable that this be done automatically -- manual operation should also be provided.
RECOMMENDATION: Provide a building fire alarm system that can be operated both automatically and manually to alert school occupants and the Fire Department that an emergency fire condition has begun.
If alarm system is electrically operated, connect it to the building electric supply in such a manner that fire or faults in building wiring will not remove current from the alarm circuit. If alarm system is manually operated (solid-rod mechanical type), attach an electric switch to the pull-rod so that it will initiate an alarm to the Fire Department.
Alarm signals must be of a distinctive nature, different from all other bell or siren signals in daily use. Fire alarms must not be used for any other school signal purpose. Alarms must be heard in every room or building area over the usual noise level of that area (gymnasiums and music rooms may need oversize or individual alarms). Public address systems may be modified to transmit sound of fire alarms throughout building.
Manual operation of alarm system is accomplished by having conspicuously marked alarm switches at both ends of corridors (if this places them over 100 ft. apart, install a control midway between them). Controls should not be over 4 ft. above floor level.
Sprinkler system water flow devices should automatically operate building alarm system and also initiate an alarm to the local fire department.
COMMENT: It is vitally necessary that an alarm go to the nearest Fire Department as soon as fire starts. Only they can provide the needed manpower, ladders and extinguishing equipment to save lives and preserve property. If this alarm is delayed for any reason,lives may be lost. Outside public fire alarms are very important since National Fire Protection Association statistics show that 65%,of school fires are discovered by passersby.
RECOMMENDATION: Extend city fire alarm circuits so every school property has a fire alarm pull-box at or within 100 ft. of the entrance to the school building. Location of this city alarm box should be marked conspicuously. If a city box exists within 500 ft. of a school entrance now, extend its circuit to an auxiliary pull-box at the school entrance. If school property consists of several buildings on a common site, connect all building alarm systems to the city box so that building fire alarms are also sent to the Fire Department, same to apply to single building properties.
In locales where there is no city fire alarm system, an alarm control or fire phone suitably housed and conspicuously marked should be placed at the school's entrance and connected to the Fire Department over leased telephone wires so as to operate an alarm in the nearest fire station.
COMMENT: Rescue is the first duty of a Fire Department at a school fire. It is imperative that sufficient manpower and ladder equipment respond to the first alarm of fire at a school. An alarm from a city box in Chicago will bring an adequate Fire Department response. A "still" telephone alarm from a school does not bring sufficient manpower and ladders.
RECOMMENDATION: Fire Department operating procedures should be immediately set up to furnish a "box" alarm response to all schools even though alarm comes to the department via telephone. School locations should be posted so alarm operators can handle this action when "still" alarms are received.
COMMENT: After an alarm of fire has alerted building occupants and the Fire Department, and while pupils are exiting from the building,adult school personnel and custodians can handle incipient fires or prevent their spread provided proper hand fire extinguishing equipment is available.
RECOMMENDATION: Enforce Paragraph 90-21 of the Chicago Fire Prevention Code that requires each school building to have a proper number of the correct type of approved (*) hand fire extinguishers properly distributed throughout the entire school premises. Remove Paragraph #64-4.1 from the Code since it is in conflict with Paragraph 90-21.
NOTE: Schools usually represent fires in combustible material,therefore Class A fire extinguishers are the only proper type. Boiler rooms, shops, manual training, electric motors require Class B and types of extinguishers. Only fire extinguishers bearing the label of a nationally recognized fire equipment testing laboratory should be permitted on school property. The provisions of Standard No. 10 of the National Fire Protection Association should be implicitly followed.
Carbon tetrachloride fire extinguishers should never be used in school pupil areas they are only of Class B type and the fumes they generate are toxic.
Fire extinguishers should always be hung on walls at waist height and so located that they cannot be bumped by pupils. Unlocked enclosures for them are desirable. Their location should be conspicuously marked.
COMMENT: The principle of horizontal separation of school building hallways to minimize fire spread and provide smoke-free areas should be accomplished. Thus pupils in an endangered area may find a safer ..... area momentarily until they can be safetly(sic) moved out through unendangered exits. This is best done by the use of smoke barrier doors.
RECOMMENDATION: In hallways over 300 ft. long, swinging smoke barrier doors should be installed to subdivide hallway areas. These doors may have wired glass panels in them for student supervision.
COMMENT: It is useless to spend large sums for enclosures and fire doors if school personnel wedge or block such doors in an open position. This is a most serious practice and it can nullify the best of protection. It is so important that it needs classifying as a legal misdemeanor.
RECOMMENDATION: By ordinance, make it illegal to block or wedge open any fire safety door in an open position. Require fire inspectors to report every violation and hold person in charge of each school building responsible.
Require, by ordinance, that every fire safety door in a fire wall (Class A) or a vertical passageway enclosure (Class B) bear a signor stencil, reading similar to the one below, or equivalent:
FIRE SAFETY DOOR
Keep Closed at All Times
Illegal to Block Door Open
COMMENT: Gas lights for exit indication have no place in modern schools - they are a hazard and should be removed.
RECOMMENDATION: Require that only electrically lighted exit signs be permitted in school property. In new construction, electric circuits supplying exit signs should be separate circuits used for no other purpose and so connected that they will remain lighted even though all other electric circuits fail through involvement by the fire.
COMMENT: Flame, smoke and toxic fire gases can be transmitted throughout a school by means of heat ducts, return air ducts and ventilation systems in daily usage. (Recommendation No. 2mentions old unused ventilation ducts.)
RECOMMENDATION: It is recommended that in all schools having central air supply fans and/or central air exhaust fans, there be installed automatic heat or smoke detection units in the intake of each of the exhaust fans and in the discharge side of the air supply fans of the electrical type. Detection units should be interconnected to all of the exhaust and supply fans in such manner that actuation of any one of these heat or smoke detection devices will automatically stop all supply and all exhaust fans in the building.
COMMENT: While windows are not recognized as legitimate normal exits from a school building, they must be used as exits sometimes under emergency conditions. Screening over windows can prevent their use as emergency exits.
RECOMMENDATION: Prohibit the nailing of screening over school room windows through which persons might have to clamber under emergency conditions. Permit screening on gymnasium windows or others that are too high above floor levels to permit their use as an exit. If screening is needed over grade or first floor windows to prevent glass breakage from play or vandalism, have screens attached to window by hinged screen frames, easily operable and unlocked. Prohibit use of non-movable glass block in windows of classrooms.
COMMENT: Overcrowding of school room areas hampers proper exit of pupils, contributes to exit congestion and possible panic. The present Chicago Fire Prevention Code is unrealistic in that it restricts pupil density to 20 sq. ft. per person in rooms having movable furniture but permits unlimited pupil density when room furniture is permanently attached to floor.
RECOMMENDATION: Revise Code to limit all school room occupancy to a 20 sq. ft. per pupil basis. (Area used to be net room area, excluding hallways, service areas, lobbies, etc.)
COMMENT: Fire is no respecter of persons or legalities. If a fire hazard exists and is a true fire hazard, it should be corrected even though it is not specifically covered by ordinances.
RECOMMENDATION: Fire Prevention Bureau inspectors should be required to report to the Bureau all fire or life safety hazards that exist. Should such inspections reveal any new or previously unrecognized hazards not covered by the Code, the Bureau should call these hazards to the attention of the proper fire prevention Code revision authority.
COMMENT: School personnel are primarily interested in educational matters, they need assistance in being informed regarding fire hazards - many do not know that certain conditions are fire hazardous.
RECOMMENDATION: The Fire Prevention Bureau should prepare a complete and detailed manual for school personnel or conduct training of school personnel on fire safety.
COMMENT: Fire drills are a vital part of school life safety. They are a responsibility of the school system governing body, who should set up the proper administrative procedures for conducting fire drills. Fire prevention bureau inspectors should witness occasional drills and report to school officials any deviations from proper procedures.
RECOMMENDATION: Require at least monthly fire drills with no advance notice given to anyone that a drill will be held. Require total evacuation of the building (visitors, nurses, kitchen help, etc.)
Every fire drill must simulate a fire condition somewhere in the school, such as a blocked off exit. Pre-planning of different drill routes with all teachers is vital at beginning of school year.
COMMENT: Schools depend on paper usage for pupil education,therefore, waste paper is a common hazard and proper waste paper. disposal is very important.
RECOMMENDATION: Provide proper approved incineration equipment, safely arranged, in cutoff basement boiler room or other segregated service area. Waive incineration if waste paper is baled daily, kept in a sprinklered segregated storage room, and removed entirely weekly. Temporary daily storage accumulations should be permitted only in covered metal drums, kept in a fire-resistive area under custodial control. The use of outside open burning pits for paper disposal should be prohibited.
COMMENT: All doors along normal exit paths through and from a school building must open in the direction of exit travel. They must be easily opened.
RECOMMENDATION: Require all doors that pupils will use in exiting from a building in time of emergency to open in the direction of exit travel, doorstop be equipped with panic-bar type hardware. The only exception to this would be doors to classrooms, which doors should be of the schoolroom type having a key lock but always operable by knob from inside the classroom.
COMMENT: Combustible trim and combustible acoustical ceiling tile in schools add to the flame spread potential, especially in corridors.
RECOMMENDATION: Combustible trim and combustible acoustical treatments should have their surfaces covered with an approved flame-retardant paint.
Recent advancements in flame-retardant paints permit these paints to be made up in any color, to be washable, and to reduce the formation of smoke as the combustible bums by as much as 90%,thus greatly enhancing pupil evacuation from burning buildings.
COMMENT: It is not enough to specify fire-safe construction for new schools. If existing schools are not brought up to fire-safety standards, very little will be gained by even the best of ordinances.
RECOMMENDATION: Provide that all legislation affecting life and fire safety in school buildings be made retroactive to existing buildings, with provisions for deliberate speed or a reasonable time period of compliance.
22) A D D E N D A
In the discussion of these recommendations, the jury considered many worthwhile fire safety measures that are essentially administrative by school system governing bodies rather than legislative in nature. They are appended below in the form of "Recommended Good Practices."
23) Excellent housekeeping is the best fire prevention measure that any school can practice. A well protected and maintained combustible school can be safer than a congested poorly maintained incombustible building where no attention is paid to combustible storages, fire safety doors or enclosures. The use of hallways, corridors and stairwells for the storage of combustibles of any nature whatsoever must be prohibited. Pupil's clothing should not be hung in the open in hallways; cloakrooms should be constructed or metal corridor lockers provided. Building service areas should eliminate old furniture, trash, old lumber and other combustibles — periodic clean out of these materials is vital --they should be allowed only temporarily in sprinklered segregated custodial areas. Pupils should not be permitted in custodial areas.
24) Old boiler rooms in combustible buildings should have masonry walls and partitions, metal lath and plaster ceilings, have old unused openings bricked up, and have approved (*) Class A. fire doors on all usable openings (i.e., the heating device room must be cut off 100% from the rest of the building). This cutoff should include fuel rooms and combustible storage and paper incineration rooms.
25) Electrical defects or misuse of electricity is responsible for 35% of the fires originating in schools, according to the National Fire Protection Association. Only responsible electricians should be allowed to work on school wiring — custodians or older students should not be permitted to do this work. The city Electrical Department or a reputable electrical firm should check each school at least annually for needed permanent circuit extensions, overloading of circuits, overfusing,and other electrical defects.
26) All doors, windows and locks on same should be constantly kept in easily operable condition. The custodian or a responsible designated adult should check every morning before school opens to make sure that all doors are unlocked, that all panic-bar hardware on them is operative,and that all exit lights are lit.
27) The present Fire Prevention Code appears to be adequate in its requirements for standpipe and small hose in schools. The Code should also require that school stages with scenery conform to all provisions required of theaters. The matter of scenery storage and housekeeping in "prop"rooms is especially important. While the present Code asks that all classrooms over a certain size have two means of exit travel, it is not valid to consider that two doors in a room opening into the same corridor meets this important requirement. The Fire and Building Departments of the city should take special cognizance of this feature in future inspections. The present Code is satisfactory in its requirements for fire escapes and smokeproof towers -- however, existing schools should be locked at more critically to see if additional realistic paths of exit are needed.
28) The Chicago school system, both public and parochial, has almost a thousand buildings and hundreds of thousands of pupils. These fire safety recommendations will add many new maintenance problems (especially with sprinkler systems) not heretofore encountered. Major school systems should emulate major industry and employ a qualified fire protection engineer to plan for, supervise and maintain all fire safety requirements in the school system. He should also conduct a continuing educational program for school personnel and conduct training of custodial forces of schools in the care of and use of fire protection and fire extinguishing equipment. Fire safety devices are only effective when they are in the hands of and are used by informed adult personnel.
29) The Chicago Fire Prevention Code is a formidable document. It largely repeats almost all of the provisions of certain Standards developed by technical Committees of the National Fire Protection Association. These Standards are under constant review annually by these Committees and are thus brought up to date annually in line with new developments,new techniques, and continuing fire safety research. It is legally permissible to incorporate these Standards into city Codes. It can be done by a so-called "enabling Act", wherein the dated Standard is mentioned by title and is adopted "as amended from time to time". This will keep city Codes up to date. It is recommended that those applicable Standards of the National Fire Protection Association affecting construction of and fire protection equipment in schools be incorporated into the Chicago Code, as outlined above. An example of this principle is in Par. 90-21 of the present Chicago Code.
30) A portion of the cost of major fire protection can be eliminated if the protection is planned for while the new school is still on the drawing board. It is a wise practice to have all school plans for new construction checked by the local fire insurance rating authority or other equivalent authority having jurisdiction in the city, county or state check these plans to insure that no important fire protection feature has been omitted. This is particularly apropos of sprinkler equipment, fire walls and door cutoffs.
31) These recommendations are specifically aimed at schools — many of them are equally apropos to other institutions such as hospitals, nursing homes, orphanages and the like. The jury recommends equal attention be given to these occupancies by Code revision authorities.
The coroner's "blue ribbon" jury that investigated the fire in Our Lady of the Angels parochial school, 909 North Avers Ave., Chicago,Illinois, on December 1, 1958 was composed of the following individuals.