Cook Country Administration Building Fire in Chicago - October 17, 2003

Sunday, November 12 2006 @ 07:08 pm EST

Contributed by: Don Winner

By: Adam Groves - On October 17, 2003, a fire started in a supply room on the 12th floor of the 35-story Cook County Administration Building in Chicago’s Downtown Loop. The fire was relatively small, but the supply room was adjacent to one of the two stairwells in the building that employees could use to evacuate during emergencies. Responding to the fire with 135 firefighters and paramedics and 45 pieces of equipment, the Chicago Fire Department successfully contained and extinguished the fire, but six civilians died from smoke inhalation. To attack the fire, firefighters opened a door that connected the supply room to the building’s southwest stairwell, giving them access to the flames, but also letting smoke escape into the enclosed stairway. Simultaneously, workers were attempting to evacuate the building down the same stairwell, where smoke was now rising as if in a chimney. When the evacuees turned back to exit the smoke-filled stairwell, they found that the doors back into their offices were locked. Luckily an employee on the 27th floor had placed a doorstop in the stairwell door, allowing many of the trapped people to escape the smoke. After the fire was contained, however, firefighters found the bodies of thirteen workers who did not make it up to the 27th floor. Fire department personnel revived seven of the victims, but the remaining six suffocated in the stairwell. (more)
Not A Very Big Fire

Editor's Comment: In Panama High Rise buildings that were built after 1995 must have three things - a pressurized stand-pipe, a fire alarm, and elevators that can be controlled by fire fighters. That's it. All of the buildings in Panama are built basically to the same specifications as this building in Chicago. This should not have been a fatal fire. Notice in the photo below that there are three buckets being used to fight the fire from the street which runs right next to the building. In Panama City there is only one similar piece of equipment and it has a maximum reach of 85 feet. The effective reach is further reduced if the bucket has to extend to a building that is set-back from the street.

Maximum Reach of Fire Equipment 85 Feet

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What Happened? Initial investigations revealed a number of factors that led to the loss of life. Most notably, the building did not have sprinklers above the lobby as it was built before codes required sprinklers on every floor in skyscrapers. The building also lacked pressurized stairwells, which block smoke from flowing in, and stairwell “smart-locks” that can be unlocked remotely during emergencies. The evacuation of the upper floors, as ordered by building security without notifying the firefighters, also contributed to the tragedy. Fire experts maintain that emptying an entire building is unnecessary during some small high-rise fires. The workers on the upper floors would have been safe had they remained in their offices.

The Cook County Administration Building in Chicago

Cook County appointed an independent commission for an in-depth inquiry into the fire and, in July 2004, recommendations were issued to the city. The report incorporated and expanded upon plans and procedures the Chicago Fire Department had adopted since the fire, such as a new High-Rise Incident Command Order, which, among other policy changes, required mandatory searches of all stairwells from top to bottom during high-rise fires, and facilitated improved communications between 911 dispatch, the incident commander, and the firefighters in the building. In addition, the city also partnered with the Illinois Fire Service Institute for training in high-rise firefighting and rescue techniques to better prepare for such emergencies. These efforts were tested in December 2004, when Chicago firefighters responded to a major fire on the 29th floor of the Loop’s LaSalle Bank building. The new policies and training proved effective, as there were no fatalities.


CONSTRUCTION INNOVATION Volume 10, Number 2, June 2005

Fire research

IRC investigates fire that killed six office workers in Chicago

A fire in the 36-story unsprinklered Chicago Cook County Administration Building on October 17, 2003, resulted in six people killed and a dozen injured. Although such a catastrophic fire is rare in a high-rise office building, it was essential to investigate this event in great detail to learn from this tragedy and make recommendations to prevent further such tragedies.

James Lee Witt Associates (JLWA) was asked by the State of Illinois to gather experts from several organizations to conduct an exhaustive review of the fire. As part of the review, the National Institute of Standards and Technology recreated the fire using computer modelling, while a group of fire investigators reviewed the fire department operations and conducted an examination of whether the building complied with the applicable code (see sidebar). In addition, IRC's Fire Research program was retained to conduct a human behaviour study.

The IRC study aimed at learning what had helped and what had hindered the safe evacuation of occupants during the fire. A survey was used to interview all building occupants. In total 1,862 surveys were distributed, 551 of which were returned. Of these, 89 were from occupants who were in the building at the time of the fire.

The fire began on a Friday at around 5 p.m., when most employees had already left for the day. Security camera recordings indicate that only 250 occupants were still in the building at that time.

The occupants' responses to the fire were strongly influenced by their activities at the time they were alerted. Voice communication messages were issued instructing the occupants to evacuate using the stairwells. Despite these messages, many occupants, who were preparing to leave for the weekend, and were on their way out, left the 'normal' way — that is, by the elevators. Although the voice communication system was used every 15 seconds during the fire, the live messages issued were essentially limited to instructing occupants to evacuate, or to evacuate using the stairwells.

Two interacting factors contributed to the loss of life during this fire: the locked stairwell doors and the fact that firefighters attacked the fire from the stairwell. Although stairwell-based firefighting is common in high-rise buildings, it requires the door from the stairwell to the floor where the fire is located to be left open. Under these conditions, a considerable quantity of smoke gathers in the stairwell shaft, which then acts as a chimney.

If occupants are also using the stairwell to evacuate, those occupants are at risk of injury or death as a result of smoke inhalation. And if this situation is combined with locked stairwell doors, occupants have no chance to escape from this smoke.

The survey results show that although 85% of the overall respondents had received fire-safety training, they were ill prepared to deal with an actual fire. The official evacuation plan, which called for a phased evacuation, was understood by only 20% of the respondents. Furthermore, 48% were not aware that the stairwell doors would lock behind them upon entering the stairwell.

The IRC human behaviour study makes several recommendations:

1) Stairwell doors should be permanently unlocked at least at every fifth floor.

2) Voice communication messages should be provided in real time and should include the following information: what is happening, where it is happening, and what the best course of action is.

3) There needs to be a procedure for clearing the stairwells of occupants prior to and during stairwell-based firefighting activities.

4) Every building should develop a Building Emergency Action Plan (BEAP), which outlines various possible emergencies and provides alternative procedures for occupant safety.

5) Building occupants should be trained according to this BEAP, and there should be full evacuation drills.

The complete report on the review of this fire and its list of recommendations can be found at The Chicago Fire Department and the City of Chicago have reviewed and implemented several of the recommendations, and in some cases, have gone even further; for instance, the stairwell doors are now either unlocked or will unlock upon alarm activation in all high-rise buildings.

This fire took place in Chicago where the building code requirements and fire department operating procedures may be somewhat different from those found in Canada. However, some of the research findings are relevant for fire-safety planning in any jurisdiction.

Despite the annual training that took place with 85% of the occupants, the vast majority did not understand the phased-evacuation process planned for that building. It seems that the complexity of such a procedure, although workable during drills, fell apart during an actual emergency, for both the trained staff and the building occupants. Furthermore, signs posted in the building led to some misunderstandings. For example, signs were posted to warn occupants that for security reasons stairwell doors were locked at all times (see photo); however, some occupants assumed that these doors would unlock automatically during an emergency.

Specific questions about this project can be directed to Dr. Guylène Proulx at (613) 993-9634, fax (613) 954-0483, or e-mail


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