On April 11, 2010, a fire broke out in a store on the first level of an apartment building on the 200 block of Grand Street in Chinatown, New York City. The fire would eventually reach 7 alarms, requiring 250 firefighters to fight. Once firefighters were able to enter the building the next day, they found one body. 33 people, including 29 firefighters, were injured and approximately 200 were left homeless, as the blaze left three buildings needing to be demolished and at least two more severely damaged.
For years the buildings affected (which were more than a century old) had been neglected, including violations for missing smoke detectors and a boiler which released smoke into the buildings. At this point it’s unclear how these violations may have contributed to the fire and its aftermath. At the time of the fire, the buildings were for sale for over $9 million, although no offers had been made. There were many goals impacted by the fire, but the loss of human life and number of injuries are the focus for our investigation.
The injuries (many of which were smoke inhalation) were caused by a seven-alarm fire. The fire was able to reach seven alarms because the fire was able to quickly spread through the six-story building. In order for a fire to start heat, fuel and oxygen are required. There’s no shortage of fuel and oxygen in an apartment building, due to necessities for people to live there. The heat (or ignition source) may have been provided by exposed wiring that many residents have complained of, or the boiler previously cited for neglect. Or, it may have been something else altogether. (However, arson is not suspected at this point.)
The fire was able to spread so quickly due to a large number of voids and shafts in the building – a function of its age. Another cause that may have contributed to the death was a potential lack of warning of the fire due to the missing smoke detectors for which the building had also been previously cited.
Throughout an investigation there may be additional tools that help to clarify the incident. Here we use a timeline to show the sequence of events. A timeline is especially useful for complex events such as this.
A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page. In fact, the outline, Cause Map and timeline for this event easily fit on one page. (View them by clicking “Download PDF” above.) Even more detail can be added to this Cause Map as more information is released about the incident. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.