Questions are being raised as to how many people were in the nightclub at the time of the incident.  This will become an important issue as the inquiry into the disaster progresses as the level of club occupancy could be used as a factor in contributing to the severity of the disaster and hence in apportioning responsibility.  Another issue that has been raised is whether or not more exits would have made a material difference to the outcome. To examine these issues we can do some simple analysis based on a number of assumptions and what the media are currently reporting.

So what do we (think we) know about the Kiss fire incident according to accounts in the media:

1) The club has a floor area of 615 m².  However, it is not known how this breaks down to dance floor, bar, toilets, circulation space etc.

2) The maximum travel distance to the front door is reported as being 32m.

http://world.time.com/2013/01/29/focus-turns-to-brazilian-club-safety-after-fire/

3) The maximum legal occupancy of the club is reported as being 691 people.

4) The only available exit has a width of 3m.

http://g1.globo.com/rs/rio-grande-do-sul/tragedia-incendio-boate-santa-maria-entenda/platb

5) The club owner insists that there were only 600 to 700 people in the club at the time of the incident.  However, the band’s guitarist told media that there were between 1200 and 1300 people in the club at the time and the police have given the same estimate.  The owner suggests that the higher estimates are due to clubers cycling into and out of the club.

http://www.foxnews.com/world/2013/01/31/nightclub-fire-that-killed-235-prompts-inspections-closures-night-spots-across/

6) It has now been reported that the band did in fact use flares during their show.  The flares were outdoor flares which are cheaper ($1.25 a piece) then indoor flares ($35 each).

http://world.time.com/2013/01/29/focus-turns-to-brazilian-club-safety-after-fire/

7) According to what I understand to be the fire certificate, the club is credited with having 2 emergency exits — hence 3 exits in total, one main and 2 emergency.  However, this is not clear from the article which later refers to these ‘emergency exits’ simply as ‘exits’, in which case the club may have been certified as having 2 exits, 1 main and 1 emergency exit. So it appears from the media accounts that the club was certified as having 3 or 2 exits — depending on the interpretation of the article.

http://g1.globo.com/rs/rio-grande-do-sul/noticia/2013/01/boate-informou-em-laudo-ter-duas-saidas-diz-brigada-militar.html

QUESTIONS:

In discussion with a Brazilian fire safety consultant based inSao Paulo, Dr Rodrigo Machado Tavares, Dr Tavares suggests that the local fire codes would require the Kiss nightclub to have:

– three exits,

– emergency lighting,

– emergency exit signage,

– an alarm system.

This answers many of the questions posed in my last blog (Yet Another Nightclub Tragedy — Grief tainted with anger, 29/01/13) however, it poses many serious questions concerning the licensing, inspection and enforcement process in Brazil.

Furthermore, it appears that the expired license has been reported as suggesting that the club had three (or at least two) exits.  Unless the missing exit or exits have been bricked up since the license was issued, or that the exit(s) were there but were locked or blocked during the incident and so could not be used, how could a license be issued stating that the club had three (or two) exits?  One has to ask if inspections of the club were ever performed.  If they were performed, how could an inspector fail to notice that two (or one) exits were missing?

Given that the nightclub had only a third of the legally required number of exits, one has to wonder whether this would have made a material difference to the outcome.

Concerning the number of people in the club, this is important as it is the manager’s responsibility to control the number of people in the club.  The manager suggests that the there were 700 people in the club, as allowed by the questionable ‘license’.  If there were 700 people in the club, this would be of benefit to the manager as it suggests overcrowding — his responsibility — would not have been a major factor and refocuses attention on the questionable fire license.  If there were 1200 people in the club, this deflects some degree of blame from the band — for allegedly starting the fire using flares — and for the code enforcement agency for permitting the license in the first place.

Is it likely that there were 1200 people in the Kiss Nightclub at the time of the incident?

SIMPLIFIED ANALYSIS:

Let’s do a simplified analysis on numbers of exits and number of people.  Note that this analysis is crude and a more thorough analysis would be required to establish the relevance of these key parameters.  The simplified analysis is dependent on a number of simplifying assumptions detailed below.

1) Assuming the 3m available exit width and a population of 1200 and 700, approximately how long would it have taken for the population to get out?

Let’s simplify the calculation and assume the population reacts immediately (zero response time) and let’s also assume that all the people are queued up at the exit ready to go.  Assuming a unit flow of 1.33 p/m/s (UK ADB) then the exit could sustain a flow of 3.99 p/s and it would require:

– at least 300 s for 1200 people to exit and

– at least 175 s for 700 people to exit.

2) How much time would be available for people to get out?  This is extremely difficult to estimate without doing a detailed analysis.  But let’s use the Rhode Island Nightclub fire as a rough guide.  After about 100 s conditions in the Station Nightclub were non-survivable. The floor area of the Station Nightclub was about 412 m² and so the Kiss nightclub is some 50% larger.  Based on this let’s assume that people had 50% longer to get out, making it 150 s for non-survivable conditions to develop.  This is admittedly a very crude estimation and may over estimate the amount of time available.

In 150 s, using the single available exit we could expect about 600 people to get out:

– generating a death toll of 100 people assuming there were 700 people in the club, as claimed by the manager,

– generating a death toll of 600 people assuming the band/authorities are correct and there were 1200 in the club.

Given the current death toll of 235, it is possible that there were 835 people in the club.  If correct, this would suggest that while the club was overcrowded, it is unlikely that there were as many people as suggested by the band/authorities.

A note of caution, remember, the assumptions that have been made are rather crude. The population is unlikely to have had zero response times, but evidence from the Rhode Island fire would suggest that in these types of situations, occupant response times are quite small of the order of a few seconds.  We can slightly improve these approximations by relaxing the zero response time assumption and assuming that the first people start to move in 10 s and that the closest people to the exit are located a third of the maximum distance (11m) and that the people located here move at 1.1 m/s.  This would add about 20 s to the estimated exit times OR reduce the available safe egress time by 20 s.  So let’s assume that we have 130 s to get out.

In 130 s, using the single available exit we could expect about 519 people to get out:

– generating a death toll of 181 people assuming there were 700 people in the club, as claimed by the manager,

– generating a death toll of 681 to be killed if the band/authorities are correct and there were 1200 in the club.

Given the current death toll of 235, it is possible that there were 754 people in the club.  This would shift the club occupancy even closer to that suggested by the nightclub owner.

We may also assume that the unit flow achieved by the exit was better than that prescribed in the UK regulations, which by their nature are conservative.  This would get more people out of the nightclub within the 130 s available time, increasing the size of the estimated population within the club.  However, in such situations, especially after the first few people have exited, the exit flow will become competitive rather than ordered, which will tend to reduce the exiting efficiency and hence the achieved unit flow rate.  In reality, the unit flow rate achieved by the exit will vary throughout the evacuation, being somewhat greater than that specified by the regulation at the start of the evacuation and being somewhat less towards the end of the evacuation.  Without undertaking a detailed analysis it is difficult to suggest a reasonable value for the unit flow rate, so for the purposes of this blog we will keep it as it is.

It is worth noting the following:

– if the average unit flow rate of the exit is greater than that used in these calculations, more people would have been able to exit in the available time and hence the estimate of the club occupancy would go up,

– if the average unit flow rate of the exit is less than that used in these calculations, fewer people would have been able to exit in the available time and hence the estimate of the club occupancy would go down.

Given the uncertainties I will stick to the initial estimates.

3) What would have happened if there were the legally required 3 exits in the club?  To answer this requires us to know the total available exit width.  Let’s assume that the club would have followed UK requirements.  An assembly space of more than 600 people would require 3 exits (as apparently does the local requirements).  Using BS 9999, the minimum total exit width for the 3 exits would be 4.3m.  Here we assume that all three exits have the same width.

If we make similar assumptions to that in (1) and in addition that all three exits were available and the population is equally divided between the three exits, then the combined flow would be 5.7 p/s and :

– 700 people would be able to exit in 123 s

– 835 people would be able to exit in 147 s

– 1200 people would be able to exit in 211 s

Assuming the same amount of time is available for safe egress i.e. 150 s, then:

– all 700 people would be able to safely evacuate, i.e. the legal occupancy would have been able to safely evacuate.

– all 835 people who are estimated to have been in the club would have managed to safely evacuate

– of the 1200 people, 855 would manage to get out, and the death toll would have been 345.

So these simplistic calculations suggest that if the club and the legally required minimum number of exits (3) with an exit width as specified by the BS 9999 and:

– the legal maximum population (700), then it is possible that everyone would have managed to evacuate before conditions in the club became non-survivable.

– if the population of the club was 835, then it is possible that everyone would have managed to evacuate before conditions in the club became non-survivable.  So even though the club was overcrowded on the night, it is possible that everyone would have managed to evacuate.

– if the population of the club was 1200, the population suggested by the band/authorities, then it is possible that 855 people would have managed to evacuate before conditions in the club became non-survivable and 345 people would have died.  So if the population was as high as 1200, even if the legally required exit capacity was provided it is unlikely that everyone would have managed to evacuate.

It has to be emphasised that these calculations are extremely crude, but they serve to demonstrate how important it is establish the correct number of people that were in the club at the time of the incident.  They also demonstrate that had the club had the required number of exits, it is possible that the death toll in this incident could have been significantly reduced.

To do a more thorough analysis on this incident would require fundamental data describing the club and the materials within the club, the number of people in the club and their distribution.  With this information it would be possible to undertake sophisticated fire and evacuation analysis of the type undertaken for the Rhode Island Nightclub fire.

Rhode Island Fire Simulation:

https://www.youtube.com/watch?v=o197yeup1BQ&list=PLC82636C7790DE890&index=1

Rhode Island Coupled Fire and Evacuation Simulation:

https://www.youtube.com/watch?v=gmPOIriMiyU&list=PL482FD999D5793B82&index=1

Paper describing simulations: http://fseg.gre.ac.uk/fire/pub.asp

Paper 223. “Coupled Fire/Evacuation Analysis of the Station Nightclub Fire”. Galea E.R., Wang, Z., Veeraswamy, A., Jia, F.,Lawrence, P., and Ewer, J. Proceedings of 9th IAFSS Symposium Karlsruhe,Germany, 2008, ISNN 1817-4299, pp 465-476. DOI:10.3801/IAFSS.FSS.9-465

http://g1.globo.com/rs/rio-grande-do-sul/noticia/2013/01/conheca-vitimas-do-incendio-em-casa-noturna-em-santa-maria-rs.html

It is even more heartbreaking to learn that this tragic loss of life may have been needless and preventable.  As more details of this tragedy begin to emerge, heartbreak turns to anger.  While the details are still not known for certain, the more that comes out in the media the more this carnage appears to have been a preventable tragedy and a failure of regulation, enforcement and management.

What do we know from the reports in the media:

1) From CNN we are told that the club’s license had expired in August 2012 and had not been renewed.  We are also told that the owners had said that the club was properly permitted and had been inspected by the fire marshal.

http://edition.cnn.com/2013/01/28/world/americas/brazil-nightclub-fire-main/index.html

According to reports on CNN, a state fire official suggested that the maximum capacity of the club was 1000 people.

http://edition.cnn.com/2013/01/28/world/americas/brazil-nightclub-fire/index.html

This suggests that at least up to August 2012 the club had been considered appropriate and compliant with the local codes.

2) It has been reported in most media accounts that the club had only one exit.  In some media accounts the word emergency exit has been used, which suggests that there may be at least two exits, while in other accounts it has been categorically stated that the club had just one exit.

http://www.guardian.co.uk/world/2013/jan/28/brazil-nightclub-fire-police-question

A schematic of the club on a Brazilian web site shows only a single exit (also see below).

http://g1.globo.com/rs/rio-grande-do-sul/tragedia-incendio-boate-santa-maria-entenda/platb

3) Most recent reports suggest that fire and rescue officials estimate that there were 1500 people in the club at the time of the incident.

http://g1.globo.com/rs/rio-grande-do-sul/tragedia-incendio-boate-santa-maria-entenda/platb

4) While it is still not confirmed, it now appears likely that the band did make use of pyrotechnics during their show, and this was a well known feature of the band.  Reports have even suggested that they made use of three flares.

http://www.guardian.co.uk/world/2013/jan/28/brazil-nightclub-fire-police-question

http://www.bbc.co.uk/news/business-21196209

http://www.nytimes.com/2013/01/29/world/americas/brazil-fire-nightclub.html?_r=0

It is not clear what is meant by a flare, but it is likely to be more than a sparkler!

5) All accounts so far suggest that the fire started in foam sound proofing and spread rapidly.

http://edition.cnn.com/2013/01/28/world/americas/brazil-nightclub-fire/index.html

However, the fire cause is not known at this stage.  It may, as media accounts suggest, have been caused by the pyrotechnics, or it may have been caused by an electrical fault.  We simply do not know at this stage.

6) The exit route was dark.

http://edition.cnn.com/2013/01/28/world/americas/brazil-nightclub-fire/index.html

7) In none of the accounts that I have read is mention of a fire alarm sounding.

8) At first security guards thought that there was a fight or that people were trying to leave without paying so they initially blocked the exit.

http://edition.cnn.com/2013/01/28/world/americas/brazil-nightclub-fire/index.html

9) Reports have highlighted that many bodies were found in the toilets.

10) Reports have suggested that at least one fire extinguisher failed to operate.

http://news.sky.com/story/1043674/brazil-nightclub-fire-security-blocked-exit

Taking these points one can begin to ask some questions concerning the Brazilian fire safety regulations, the enforcement of those regulations and the quality of the management at the club.

REGULATIONS and ENFORCEMENT:

a) How could Brazilian building regulations (or the local code) permit a place of public assembly, with a reported capacity of 1000 people, to have only a single exit?  Even though the license had expired and was under review, the club was considered compliant up to when the license expired in August 2012, so the exit capacity was deemed to be acceptable. Furthermore, what total exit width is required by regulation?   With a capacity of 1000 people I would have expected at least three exits with a total exit width of at least 6m.

b) It appears that no fire alarm sounded.  Was this because the alarm failed or did the club not have an alarm?  If the club did not have an alarm, how could the building regulations possibly permit this?  Had an alarm sounded, perhaps the security guards would not have initially prevented people from escaping, possibly reducing the death toll.  If the club had an alarm was it operational prior to the fire?  If not, could this have been overlooked during a fire inspection?

c) It is reported that the exit route was dark.  Was there no emergency lighting in the club or did it fail?  If there was no emergency lighting how could this be permitted by the regulations?  Had emergency lighting been available, perhaps people would not have tripped in the exit path and perhaps people would not have mistaken the toilets for an exit route. If the club had emergency lighting was it operational prior to the fire?  If not, could this have been overlooked during a fire inspection?

Schematic of the Kiss Nightclub

d) What does the Brazilian code require in terms of emergency exit signage?  Is this required?  Had it been in place, perhaps so many people would not have mistaken the toilets as a means of escape. If emergency exit signage was required by law and it was in place, was it operational prior to the fire?  If not, could this have been overlooked during a fire inspection?

e) The fire appears to have started in the sound proofing foam that lined the ceiling and spread rapidly producing large amounts of toxic fumes.  What type of foam was this?  Was it protected in some way e.g. coated or covered with a fire resistive material?  What do the Brazilian fire regulations say about the type of foams that can be used in places of assembly?  If the use of foam is permitted, was the foam in place compliant with standards prior to the fire?  If not, could this have been overlooked during a fire inspection?

f) What do Brazilian regulations say about the use of indoor pyrotechnics?  If like most countries they permit the use of such devices, what provisions are made to limit their use and ensure that they are used in a responsible manner?   Concerning the use of flares, surely this cannot be permitted?

g) Is it required by Brazilian fire regulations to regularly inspect mandatory fire fighting equipment? If so, what is the frequency?  If regulations stipulate they are to be inspected, were the fire extinguishers in the club inspected prior to the fire?

MANAGEMENT:

a) It is reported that the maximum occupancy for the club was 1000, yet fire authorities suggest that there could have been as many 1500 people in the club.  What means did management have to ensure that the number of people in the club did not exceed their license limit?

b) If the use of pyrotechnics are permitted under Brazilian code, what measures did the management have in place to ensure their safe use?

c) It is reported that fire extinguishers failed to operate.  Did the club management have the fire extinguishers serviced on a regular basis?

d) What training did the club staff have in terms of fire fighting and crowd management?

These are just some of the questions that need to be answered if the root causes of this tragedy are to be addressed.  It is possible that this tragedy was no accident i.e. an unforeseeable event, but the result of a predictable and preventable failing of Regulation, Enforcement and Management.  If so, then immediate measures must be taken to correct the failings in order to ensure a safer Brazil – let this be the legacy of the Kiss Nightclub victims.

Finally, this tragedy provides a couple of hard learnt lessons for the rest of the world:

1) Stop the use of pyrotechnics indoors, they are just too dangerous.

2) Inspection and enforcement must be taken as seriously as legislation.

In the Rhode Island case, fire works started by the band set alight PU foam which was used as sound proofing cladding on the walls.  The PU rapidly burnt producing thick choking smoke, laden with deadly Carbon Monoxide gas and Hydrogen Cyanide gas.  People were rapidly overcome by the toxic gases and the rapid resulting flashover.  Coupled fire and evacuation computer simulations of the Rhode Island nightclub fire produced by FSEG suggest that after approximately 100 seconds from ignition, around 100 people would be dead due to the inhalation of toxic fire gases and the effects of flashover.  In the Rhode Island case, while the club was full, it was within legal limits and the nightclub had four exits (including the main exit), but the majority of the patrons tried to use the main entrance, the exit that they used to come into the club.

Media accounts are suggesting that between 300 and 2000 people were in the Kiss Nightclub at the time of the fire.  It is also not clear how many exits the nightclub had, media reports suggest that the nightclub had only one emergency exit and that fire fighters had to make a hole in the wall to assist people to escape.  As the Rhode Island Nightclub fire demonstrated, fires in such environments, fuelled by PU foam will spread extremely rapidly producing large amounts of highly toxic gases, providing people in the crowed venue little time to get out.

If the reports in the media are correct, then it is surprising that only 180 people have lost their lives.  I would not be surprised if the death toll rises, especially if the occupancy is more than 300.  Large crowds, within a confined space, whose walls are clad with combustible PU foam, with limited means of egress, probably in the dark, a number of who are probably intoxicated and then allowing the use of pyrotechnics is a recipe for disaster.   Indeed, building regulations and planning permission should not permit such death traps to exist in the first place and enforcement authorities should ensure that they do not occur.

Once the blame game starts, I hope that the bereaved families do not simply point their finger at the nightclub owner but look beyond this, to their local government authorities that have responsibility for planning permission and building control and to enforcement authorities that have responsibility for inspecting premises.  It is too easy to simply blame the owner.  More importantly, to do so will simply allow this type of tragedy to happen again and again.

Furthermore, while this type of disaster can happen anywhere in the world, and it has — USA, Russia, China and Argentina to name just four recent disasters – it is to be hoped that a country with the responsibility of hosting the next Football World Cup and the Olympics, will ensure that their building regulations and the enforcement of those regulations are fit for purpose.   Not simply for the new build stadia, but for all the existing hotels, transportation hubs and entertainment venues that will be enjoyed by millions of tourists from around the world.

Finally, I wonder how long it is going to take before the media, and local government officials begin to attribute “panic” as a contributory factor in this tragedy, conveniently diverting attention from other potential systemic failures.

BACKGROUND INFORMATION: 

Rhode Island Fire Simulation: https://www.youtube.com/watch?v=o197yeup1BQ&list=PLC82636C7790DE890&index=1

Rhode Island Coupled Fire and Evacuation simulation:

https://www.youtube.com/watch?v=gmPOIriMiyU&list=PL482FD999D5793B82&index=1

Paper describing simulations: http://fseg.gre.ac.uk/fire/pub.asp

Paper 223. “Coupled Fire/Evacuation Analysis of the Station Nightclub Fire”. Galea E.R., Wang, Z., Veeraswamy, A., Jia, F.,Lawrence, P., and Ewer, J. Proceedings of 9th IAFSS SymposiumKarlsruhe,Germany, 2008, ISNN 1817-4299, pp 465-476. DOI:10.3801/IAFSS.FSS.9-465

LINKS TO NEWS ABOUT THIS INCIDENT:

SKY NEWS: Brazil Nightclub Fire Tragedy: 180 Killed.

http://news.sky.com/story/1043501/brazil-nightclub-fire-tragedy-180-killed

The Independent: ‘At least 180 killed’ inBrazilnightclub fire after pyrotechnics set sound-proofing alight

http://www.independent.co.uk/news/world/americas/at-least-180-killed-in-brazil-nightclub-fire-after-pyrotechnics-set-soundproofing-alight-8468600.html

http://www.youtube.com/FSEGresearch/

The point is that in the 21^st century factory workers should not be dying from these types of disasters.  The Triangle Shirtwaist fire was a milestone in the development of fire safety which lead to changes such as the requirement for improved access and egress within work places and the installation of fire extinguishers, fire alarms and sprinklers.   From fires such as the Triangle Shirtwaist fire and the countless lives lost in the battle with fire over the past 100 years, our understanding of fire and the means to combat fire has improved to the point where fires with multiple fatalities such as the Karachi factory fire should be a thing of the past.  Modern building design, fire fighting technology, regulation and enforcement should have prevented a fire in a Karachi clothing factory from becoming a disaster.

Once the blame game starts, I hope that the bereaved families do not simply point their finger at the factory owner but look beyond this, to their local government authorities that have responsibility for planning permission and building control and to enforcement authorities that have responsibility for inspecting premises.  It is too easy to simply blame the owner.  More importantly, to do so will simply allow this type of tragedy to happen again and again.

http://www.bbc.co.uk/news/world-asia-19577450

http://www.bbc.co.uk/news/world-asia-19566851

http://www.youtube.com/FSEGresearch/

The storage of petrol or diesel at home is potentially a very dangerous practice.  If you do feel the need to store fuel at home it should be kept in a detached garage or shed.  The reason is obvious, if you have a fire in your house the fire can be accelerated by stored fuels.   Leaking fuels can also cause a fire so its best if it is not kept in living spaces. 

The law allows you to store a maximum of 15 litres of petrol in no more than two approved metal containers, or ten litres in two plastic containers. Neither plastic container should be of more than five litres’ capacity.  Approved containers are marked and approved for petrol storage and fitted with a secure cap to prevent leakage of liquid and fuel vapours.

Fuel can only be stored in a secured, locked shed or a garage. Garages should be detached from the house or separated by a fire door if it is adjoining. Fuel MUST not be stored within any living areas of your house.

Be smart and keep safe.

• Don’t start your own bonfire, safest way to enjoy the festivities is to go to an organised display.
• If you are going to set off your own fireworks remember:
  • Only buy fireworks marked BS 7114.
  • Don’t drink alcohol if setting off fireworks.
  • Store fireworks in a closed box; make sure the lid is firmly closed.
  • Have a bucket of water handy.
  • Make sure you have a torch with you.
  • Light fireworks at arm’s length with a taper.
  • Never go near a firework that has been lit.  Even if it hasn’t gone off, it could still explode.
  • Never put fireworks in your pocket.
  • Never throw fireworks — this is illegal and you could get a fine of up to UK£5000!
  • Always supervise children around fireworks.
  • Light sparklers one at a time and wear gloves.
  • Never give sparklers to a child under five.
  • Keep pets indoors.

Have fun!

Ed Galea
12 Sept 2001

http://fseg2.gre.ac.uk/HEED/sept_11_short.html