At approximately 5:00 p.m. on October 17, 2003, a fire began in a storage closet on the 12th floor of a Cook County Administration Building in Chicago. Since there were no Fire Safety Director personnel at the building, the building engineer decided to evacuate. The Emergency Voice/Alarm Communications (EVAC) system was activated, informing personnel that they should evacuate the building using any set of stairs. The Chicago Fire Department (CFD) was called and began fighting the fire from the southeast stairway on the 12th floor.
Personnel evacuating from above the 12th floor in the southeast stairway were stopped at the 12th floor by firefighters and told to go back. When they did, they found all the doors locked up to the 27th floor. However, before all the evacuees on the stairway could make it up to the 27th floor, the firefighters opened the stairway door to fight the fire. This, combined with a smoke tower system that may not have been functioning correctly, led to the stairway filling with smoke and toxic gases, which overcame several people on the stairs. Six of these people died. The last body was found in the stairway approximately 90 minutes after the fire began.
A report commissioned by the Governor of Illinois found multiple issues that led to the deaths. There was no s sprinkler system, which allowed the fire to spread. The stairway doors were locked, and the evacuees and CFD personnel were generally unaware that they’d be locked, since there was no evacuation procedure or mandatory fire drills in the building. The building had a Fire Safety Director, who was not certified and was 40 minutes away from the building when the fire occurred, and no deputies. The firefighters appeared to place a priority on fighting the fire over searching for trapped people, even after several 9-1-1 calls indicated there were personnel trapped on the stairs. Miscommunication and a lack of leadership within the CFD meant that 90 minutes elapsed before victims were found in the stairway. Had they been found sooner, more would have survived. Additionally, the fire department did not follow certain procedures, such as breaking windows above and below the firefighting site to allow smoke to escape and searching the area before opening a door that was trapping smoke.
A thorough root cause analysis built as a Cause Map can capture all of these causes in a simple, intuitive format that fits on one page. To view the complete investigation in visual form, click on “Download PDF” above.
A Cause Map also captures proposed solutions. A solution is tied to a particular cause on the map. Solutions are placed directly above the causes they control. Some of these solutions have already been implemented, and many are valid for any high rise building to consider implementing.
Learn more about the Cook County Administration Building fire.