FIRE AT THE DETENTION CENTRE SCHIPHOL OOST 26th October 2005 This fire was thouroughly investigated by the Dutch Safety Board and the final report and the appendices can be found on the website of The Dutch Safety Board on the PUBLICATIONS page The information in this article about the building and the fire was found in their report. It describes their findings, but gives also conclusions about the responsability of the various authorities and administrations involved in this tragic event.The report is detailed enough to be used for some FRAME calculations to find out if the use of FRAME would helped the authorities to do a better job and eventually to prevent this disaster.   Description of the disaster. In the night of 26 to 27 October 2005, the detention centre at Schiphol-Oost was struck by a large fire shortly before midnight. Eleven cell occupants died in their cells during the fire, as a result of carbon monoxide poisoning. Due to the fact that a cell door was left open after the rescue of one of the cell occupants, and a large quantity of flammable material was present in the cell, a large amount of smoke developed in the corridor and the fire was able to develop further. The fire occurred on 26 October 2005 shortly before midnight on the bed in Cell 11 of K Wing. A technical cause of the fire has virtually been eliminated. It is possible that a discarded cigarette caused the fire. Fire tests have shown that the initial development of the fire may have proceeded along a chain of fuels (bedding, mattresses, wall covering), with each link providing sufficient energy for the ignition of the next. The two mattresses played an essential role in the entire cell catching fire. The opening and leaving open of the door of Cell 11 accelerated the development of the fire. Smoke and fire was able to spread outside the cell. If the door had been closed again after it was opened, the fire development would have been interrupted. The size into which the fire developed in a short period of time can be partly explained by the large quantity of flammable material in the cell, including in particular the wall covering. The accelerated fire development which occurred after the second mattress of the bunk bed caught fire was coupled with a sudden increase in smoke production. This increased smoke development, which is characteristic of a fire in the flashover phase, is primarily caused by an increasing shortage of oxygen in the room on fire; the nature of the burning materials is of less importance in this respect. Due to the accelerated spreading of smoke in the corridor, it was physically impossible for the rescuing guards to release all the cell occupants from their cells. The Smoke and Heat Exhaust Ventilation System, which should ensure exhaust ventilation of smoke and heat, was not working during the fire. The fire was able to spread spatially from the corridor primarily because of the shell construction. In the corridor itself, the fire remained stationary due to the limited supply of fresh air, with the exception of the far wall of K Wing, where open air was able to enter through the open emergency door. The organization of the Detention Centre Schiphol-Oost was insufficiently prepared and set up for an outbreak of fire, as a result of which the staff members on duty were faced with a virtually impossible task. The Site Manager did not draw up any risk inventory in advance, and did not sufficiently think through how the staff should act in the event of fire. The main directorate of the Custodial Institutions Service (DJI) did not provide any framework and/or create any conditions for this. In addition, supervision was limited.   The fire brigade arrived relatively late at the fire. The reasons for this lie both with the fire brigade and with the management of the detention centre. The automatic fire alarm system did not notify the fire brigade immediately of the fire, the detention centre was not prepared for the arrival of the fire brigade and the fire brigade was insufficiently prepared for the situation at the detention centre. Insufficient harmonization had taken place between the fire brigade and the detention centre, as a result of which it was not ascertained that, based on the Fire Safety Concept for Cells and Cell Buildings, the fire brigade would only be on site and ready to deploy after 15 minutes, and that until that time, the in-house emergency and first-aid team would have to cope on its own. In view of the late hour and the actual deployment of the fire brigade and the stage at which the fire was at that moment, the chances that the eleven victims could still be saved were small. Responsabilities. The three main parties responsible for the fire safety of K Wing of the Detention Centre Schiphol-Oost were: 1) the Custodial Institutions Service, 2) The Government Buildings Agency and 3) the Haarlemmermeer Municipal Council. The Board considers the DJI to be the party primarily responsible for fire safety. The Custodial Institutions Service bears statutory responsibility for the safety of the cell occupants and the staff, as user of the detention centre. The DJI bears responsibility to the Government Buildings Agency for drawing up the Schedule of Requirements for the building. The DJI is ultimately the party under whose responsibility persons are incarcerated, and can exercise a direct influence on safety (including fire safety), and therefore bears primary responsibility.   As commissioner for the construction and later as owner of the detention centre, the Government Buildings Agency bears responsibility for the realization of a detention centre which can be used in a fire-safe manner.   The Municipal Council of Haarlemmermeer issues the building and Occupancy Permits, and bears responsibility for supervision and compliance during the construction and use of the detention centre. On the basis of its responsibility for a fire safe building, the RGD has insufficiently discharged its role, in view of the fact that K Wing did not comply with the Buildings Decree. Prior to the construction, insufficient account was demonstrably taken of the risks regarding fire safety, and these were not made known to the DJI on completion of the building. The Municipal Council of Haarlemmermeer discharged its role insufficiently, in terms of its responsibility for granting permits, supervision and compliance. It should not have issued the permits (the permits were granted on the basis of limited information and a building plan which was in breach of construction legislation) and its supervision was too superficial. FRAME - calculations. The report states that the building did not comply with the Dutch Buildings decree and that inadequate proof was given that the proposed design alternatives guaranteed an equivalent level of fire safety.   One of the possible uses of FRAME is precisely the proof of an overall equivalent fire safety. This can be done by making a calculation for a similar code compliant building to define the level of safety which is built in the code requirements and a second calculation for the proposed alternative. When the R-values of the second calculation are equal or lower than those of the first, it can be assumed that the alternative is equivalent. The level of fire safety of the code requirements. It is important to appreciate the law maker uses the average existing situation as implicit basis for code writing, but that this foreknowledge is not mentioned in the codes. For a detention building, the most common construction type is a non-combustible masonry and concrete building with almost no immobile fire load, and a mobile fire load of 70 to 280 MJ/m². Based on these assumptions, the conditions for compartment size, walking distances, etc. are then defined to assure a certain level of safety.   The Dutch building decree has lower requirements for temporary constructions than for permanent buildings. This can be justified by the fact that the required level of safety is based on the low probability of a serious fire during the life cycle of the building. assuming for a temporary construction a life cycle of 10 years and 50 years for a permanent one, the probability of occurrence of fire is already 5 times less during that life cycle, which justifies the use of building elements with a higher failure rate with still the same level of safety.   The Dutch buildings decree stipulates a 20 min fire resistance for internal walls in a temporary construction instead of 60 min for permanent buildings.   The first FRAME calculation was made to define the R- values that can be expected in a detention centre in compliance with the Buildings decree, of conventional non combustible construction with the average mobile fire load. An automatic fire detection system is provided, which is not mandatory in the decree, but is is assumed that this is standard practice of the DJI and RGD. The report of the first FRAME calculation can be found here . The mobility factor p was defined for "immobilised persons" as the cell doors must be opened by the staff to enable evacuation of the detinees. The calculated risks are R=0.36, R1=1.06 and R2=0.36, indicating a building with a low risk for property and an acceptable level for the occupants. Remark that without the automatic fire detection, the level of safety for the occupants would be insufficient according to FRAME. The different construction. The cell building did not comply with the Dutch Buildings decree and some measures were taken to compensate in the belief that an equivalent level of safetywas obtained: a SHES-installation with limited capcity, a dry sprinkler network in the void above the cells (to be fed by the fire brigade); immediate action by the staff and a 24 hrs manned security post.   The report of the safety board a general remark is made about this, considering that buidling deficiencies cannot be compensated by an emergency organisation, because human action always remains vulnerable element. In FRAME such organisational measures have a limited weight in the assessment but cannot compensate building deficiencies, which is in line with the criticism of the safety board.   The SHES installation can be evaluated in FRAME with factor v. The dry sprinkler network fed by a fire brigade inlet cannot be entered in the calculation. It is a non compliant system, which has no value, which was proven by the reality. It is a mystery why such thing was proposed and accepted: as prinkler system without a fixed water supply does not work, it is like a car with an empty fuel tank.   The safety board report staes on p.111 :   "Additionally, it appears from the response to the Board’s draft report that there was a lack of clarity about the number of available emergency exits, in part because of the presence of the door in the end wall of the wing. The question is whether the fencing surrounding the entire detention centre can be regarded as an equivalent solution in response to the requirement in the legislation that the exit route must lead to a different fire compartment. If the fencing around the penal site had indeed been consciously selected as an equivalent solution in response to the failure to comply with the performance requirement329, then this ought to have been included in the Building Permit. All penal institutions must have an enclosed external space in place (see Article 3 of the Police Detention centres Regulations). The Buildings Decree did not deem the exit to the external space to be an exit leading to a smoke-free exit route. The appeal to equivalence is therefore not well-founded."   I feel free to disagree with this statement. A general rule in fire safety is that a person is considered to be safe, once he has left the building. This is not eveident for a detention centre, which means that a person is also considered to be safe once he is in an other compartment. This is complementary to the general rule, but it does not mean that the general rule ( outside = safe) should be void. In the American standard NFPA 101, exits to a courtyard are accepted as valid.  A more serious objection is the fact that the door in facade had to be opened by the guards. Doors can only be accepted as emergency exits, when they are unlocked in case of a fire. This would be possible if the doors were unlocked by the action of the fire detection system, but such provision was not foreseeen.   The report indicates that the high fire load due to the wooden paneling of the containers used as cells, wasd a dominant factor in the size of this drama. The fire load density in the cells was estimted to be about 1960 MJ/m² . For the whole cell block this would result in an averag fire load density of 1300 MJ/m².   As the Dutch building decree says nothing about changing fire load densities, it is possible that a less expert designer overlooks the impact of this design change. This cannot happen with FRAME. The introduction of the higher fire load in the second FRAME- calculation shows clearly that there is no equivalent level of safety, and that the fire load is so high that it can be expected that a fire would make victims. FRAME makes a distinction between the mobile and immobile fire load. Some doubt can exist whether the lining of the cells is a mobile or an immobile fire load . When the containers are considered as part of the construction , than Qi will be about 1000 MJ/m² , which results in a high value for the environment factor r. When the cell containers are seen as content inside the building, than the lining is added to the mobile fire load, which gives a high value for the venting factor v. This fits better to the real fire as it developed, and the value of v indicates than that the design of the SHES installation was too small to cope with this type of fire development.  Remark that in both cases , the result of the persons risk calculation is equally bad.  Because of the higher fire load, FRAME questions also the available water supplies. This evaluation reflects the problems met with the water transport during the fire brigade operations, but has only an impact on the property risk, not on the risk for the occupants. The designer reckoned with a first intervention team as this was mandatory according to the work protection legislation. It was also assumed that two escape directions were available, although this implies unlocking the doors by the fire detection system. The second calculation (see attached report) gives the following results : R= 0.75, R1= 2.03 and R2= 0.44. This means that there is no equivalency with a code complying building, and that the risk for the occupants is too high, certainly considering that a logarithmic scale is used . The increase of R1 from 1 to 2 means a 10x higher probability of victims. The proposed design does not pass the FRAME-test for a fire safe building. The real situation. During the fatal night a number of features did not work as designed : the SHES failed to open, there was no correct transmission of the alrm to the fire brigade, the doors could not be opened on time, and that was a lack of staff. Entering these shortcomings in a FRAME calculation immediately gives alarming low values for the acceptable risk A1, which is an indication of a dangerous situation.   The largest impact comes from deleting the second escape route, which gives a risk value of R1= 15,5when the lining is included in the mobile fire load. The report mentions the fact that the fire brigade was unable to organise rescue operations, because they could not enter the K-wing . Other alternatives. It is somehow surprising that no consideration was givent to protect the cells with sprinklers: they are only 13 m² large, two fast- response sprinklers per cell could do the job and a small water supply,as for the hose reels would be adequate. This alternative can be entered in FRAME as "sprinklers in high risk zones" in factor U. Changing the data in the FRAME calculation indicates this this gives a better but still inadequate level of safety. An other possibility was to equip the cell doors with a remote unlocking system, activated after the fire alarm. This can be entered in FRAME by changing the mobility factor p from 8 "immobilised persons" tor 2 (mobile but dependent), which would lower the persons' risk to R1=1.05; By playing in this way with variants in the FRAME calculation, it becomes possible to find the most elegant solution that gives the building an accepatble level of fire safety. Erik De Smet, 22 februari 2008 PRINT  THIS PAGE  (pdf)