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ESG 201- Learning from Engineering Disasters
Group Members: Emma Tobias, Gabriel Aponte, Juliana Rogin, Margo Ganon, Richard Schmoll
Brazilian Nightclub Fire
The Kiss nightclub fire was a disaster that occurred during the early morning hours of January 27th, 2013. The nightclub resided in the Sede District, Santa Maria, in Rio Grande do Sul, Brazil. The fire started around 2:30 AM and spread across the entire nightclub, killing over two hundred people and injuring over six hundred more [1]. It was the third deadliest nightclub fire in recorded history, only surpassed by the 1942 Cocoanut Grove fire in Boston, which killed almost five hundred people, and the 2000 Luoyang Christmas fire in China, which killed three hundred people [2]. It was also the second deadliest fire in Brazil since 1961, behind the Niterόi Circus fire that killed five hundred and three people [3].
The nightclub was a major feature of college life, and the event, known as a “freshers’ ball”, had been organized by students from the Federal University of Santa Maria for the night the fire occurred [4]. Santa Maria is a university city with a population of 260,000 people. Because the event was planned towards the end of the summer, many of the students participating were scheduled to resume class that upcoming Monday. The band Gurizada Fandangueira, who is famous for their pyrotechnic displays, was scheduled to play that night for the event.
The fire began after the use of a pyrotechnic machine that produced colored sparks, according to Rodrigo Martins, the guitarist for the band. “I looked up and I saw the fire was spreading… the drummer tried to throw water on it, and it looked like the fire spread more then.” A fire extinguisher was used to try to put the flames, but “it didn’t work”, Martins said [5]. People were initially blocked from escape from the security guards, according to survivors and police inspector Marcelo Arigony, who added “several security guards also died.”[3]
Guido Pedroso Melo, the city’s fire department commander, stated that the first firefighters who responded to the scene were having trouble entering the nightclub because “there was a barrier of bodies blocking the entrance”. “It was like one of those films of the Holocaust”, police inspector Sandro Meinerz said. “We had to use trucks to remove (the bodies). It took about six hours to take the bodies away.” Once the fire began, some people ran away from the nightclub, while others tried to help their friends by carrying them to safety. Within minutes, however, most of the victims suffocated under the heavy smoke, officials reported [3].
Of the 241 victims, 90% died due to asphyxiation caused by smoke inhalation [4], and the vast majority of the victims were found in the bathrooms. Many others were trampled during a stampede to the front doors of the nightclub [5]. Eighty of the victims were students of the Federal University of Santa Maria. Of the five band members who performed that night, only one did not make it out safely, the accordion player Danilo Jaques [4]. It was thought that while Danilo made it out originally, he went back in for his accordion. One hundred seventeen people were sent to the hospital for treatment, with most suffering from gas poisoning. Fourteen patients were treated for severe burns [6]. Of the two hundred forty one deaths, two hundred thirty two of them perished at the nightclub [7], while nine more succumbed to their injuries at hospitals in the following days.
The compounding human factors that attributed to the fire all could have been avoided. Series of mistakes by the parties involved contributed to the death toll. If one of these factors could have been avoided then the likelihood of the severity of the fire would have been reduced.
Before the fire engulfed the night club, the Brazilian country-pop band Gurizada went on the stage around 2:30 am. While preforming, the band planned on using pyrotechnics in order to draw the attention of the crowd. Instead of using pyrotechnics rated for indoor use, the band decided to use road flares and a flag. This decision by the band was perhaps the most egregious error that occurred that night. If the club had not allowed the use of the pyrotechnics, or required the use of proper indoor equipment, the incident would have never happened. After the pyrotechnics were lit, they quickly went out of control. The fire on the flag then rapidly spread to the ceiling of the night club.
During the early stage of fire, both a club security guard and the bands vocalist attempted to fight the fire. They grabbed the nearest fire extinguisher, but it was unable to extinguish the rapidly growing blaze. It was later found out that the extinguisher had not been properly inspected, had a properly working extinguisher been in its place the fire may have been contained to small scale. Patrons soon saw the smoke bellowing out from the stage area. The people who were closest to the stage started to run, looking for the exit to the street. The security guards prevented people from exiting because they did not realize the club was on fire. People who were in the central part of the club and the VIP area faced, according to witnesses, the resistance of security guards who initially barred people who had not followed their orders. In addition to the security guards blocking the way, there was a small space that separated the door from the entrance / exit that further prevented evacuation.
With the exits to the club restricting the flow of the evacuation, the smoke and the club’s dark environment made it difficult for people to locate the correct exit. A group of club attendees ran into the restrooms thinking they could exit the club in that manner. Sadly that decision proved fatal as those who ran to the restrooms were not able to escape. While this was going on, survivors tried help the evacuation by breaking the front of the building. Unable to break the cement construction, the hundreds that were trapped in the bathroom suffocated.
In addition to the many human errors, there were many structural and legal errors involved. These factors ranged from the layout of the club to the amount of people allowed in the club on the fatal night. These too could have been easily avoided, reducing the death toll or possibly avoiding the tragedy all together
The acoustic insulation used in the club was not the most fire retardant available. The material itself may have aided the spread of the fire throughout the club. Once the foam insulation caught fire, the fire preceded to spread to areas that were not affected. In addition after the fire had been overhauled, and the cause of death of the two hundred and forty one victims determined, it was found that this coating material aided in the asphyxiation and suffocation of the victims’. Doctor Paulo Beltrame, one of the many doctors who were outside the club treating victims said, “Large amounts of toxic smoke quickly filled the room, and I would say that at least 90 percent of the victims died of asphyxiation, the toxic smoke made people lose their sense of direction so they were unable to find their way to the exit.”[5]
When the material caught fire it began to give off both carbon monoxide and cyanide. The Acoustic insulation was believed to have been ignited by one of the human errors associated with the incident. The source of the insulations foams ignition was the use of the flare by Marcelo de Jesus dos Santos, who was the lead singer of the band. Unfortunately the effects of the smoke and harmful gasses left many of the survivor’s with lingering injuries. Six hundred and twenty three people were left injured after the blaze.
The layout of the building was also a contributing factor to the blazes destruction. The fire took place in the back of the club on the stage. The exit was hard to distinguish due to the smoke. In addition to determining a point of exit, the club only had the one exit. It was also down a hallway sectioning of the VIP area of the club. The patrons who were in the VIP area were the ones believed to have sought escape within the bathroom. The bathroom had a window in it, but the victims were unable to escape due to bars on the window preventing unauthorized entrance and exit.
The Brazilian Pyrotechnics Authority (BPA) also identified the type of flare used as unsafe for indoor use. Unfortunately this flare was used by the band in their show. The flare that caused the blaze had a minimum high of 4 feet, with the maximum capability reaching higher than the clubs ceiling. In addition to the height specifications the flare was designed to be set off and placed on the floor with a safe radius of at least 10 meters being maintained. The use of the flare is strictly forbidden indoors and near any flammable materials. The cost of the flare ranges between four to five dollars and is commonly used in outdoor events. The cost of the proper indoor flare was slightly more expensive at a cost of 35 dollars. The use of the approved indoor flare would have more than likely prevented the blaze and the limitations and proper usage of the flare should have been addressed prior to the performance.
The investigation done by the police also pointed out the number of club patrons was at least 1,300 people in the nightclub Kiss at the time. This shows the overwhelming amount of overcrowding in the club at that time. Under legal circumstances the club was not to exceed the capacity of six hundred ninety one persons as authorized by firefighters.
The testimony of one hundred people also showed that one of the band members tried to put out the initial flames with a fire extinguisher. Another eighty four reported that security guards at the nightclub Kiss prevented the exit of the victims for a few seconds after starting the fire. Kiss had the capacity for six hundred ninety one people, but police estimated total attendance of about 1,300. The club had only one access door, which was small in width making it impossible for more than one to exit at a time. These are all major factors in the tragic outcome of the night club fire. If the owners, band, or security guards were able to control events they may have avoided the fire.
After the fire, twenty eight people were named in a legal state document for being responsible for the tragedy. Some of the people listed faced charges for the fire, while others did not. The mayor of Santa Maria, and the commander of the Fire Department in the region, were also listed in the investigation. Police are looking at evidence that the crime of manslaughter had occurred as well. Many firefighters are blamed for letting ordinary people entered the nightclub while it was burning in order to help in the rescue. In this process, five people died from suffocation. Nine responsible, including the mayor, servers and the municipal defendants may account for administrative misconduct.
There are many safety features that should have been in place in the night club which would have drastically reduced the severity of the failure. There should be at least two exits, preferably in different areas of the establishment in the event that one becomes unusable. These doors should be properly labeled and recognizable by large exit signs. A working sprinkler system should have been installed within the club in case of fire. The working sprinkler system would have ensured that the fire could not have spread. Fire extinguishers and fire alarms should be placed that they are accessible everywhere in the club, meaning about every 20 meters. The fire extinguishers should be checked regularly so as to guarantee that they remain full and operational.
Acoustic insulation, as well as any other materials within the building structure, should be flame-retardant. This will help to stop the spread of flames in the event of a fire. There should always be at least one member on staff who is trained in emergency management, especially given the large capacity of the venue. Having at least one person who knows how to direct customers out of the building, and who knows the proper protocols in the event of an emergency, could make a tremendous impact in the future. Mapping routes out of the building in the event of an emergency would also be beneficial. These routes should be displayed within the establishment where anyone entering the building will be able to see it and therefore know where the exits are located. In addition, these routes should be marked with arrows capable of being illuminated even with a loss of power.
Buildings being constructed should be made to follow the most recent fire and electric codes at the minimum, but should exceed current policies in the event the regulations become stricter. Following with this, buildings should never exceed maximum capacity at any time. Overcrowding leads to more complications in the event of an emergency and make exiting the establishment much more difficult.
Since the 1950’s, cities in Brazil have upgraded their fire codes, but they still do not compare to those as set in countries such as the US. After major fire incidents in the 50’s, architects were required to provide plans for buildings to the local fire stations which would serve the area where the building was constructed. Still more laws were passed into the 60’s, but they were not seen by the public to have accomplished much after the occurrence of the fires in 1972 and 74 raised more concerns. In 1976, still more regulations were passed which dealt with the installation of fire doors, fire extinguishers, sprinkler systems, having clearly labeled emergency stairways.
While the government continued to focus on updating regulations, major fires still occurred, including one in 2001. During the fire, no alarm sounded, the sprinkler system was not activated, and the emergency exits remained locked. Even though regulations may be in place, the systems must be tested to be functioning. As in the nightclub fire, there were no working emergency systems in place. Investigators at similar large-scale fires in Brazil have suggested that if occupants of the building were aware of emergency procedures the number of deaths would have been decreased significantly. Besides procedures being in place and functioning properly, occupants must be aware of procedures, rather than have them neglected by management.
As with any regulation in place, loopholes will always be found in the system. One example is that of sprinkler systems. Fire code requires a sprinkler system to be installed, but states nowhere that they are required to be in use. These loopholes in regulations, and the unwillingness of property owners to protect the well-being of their occupants, continue to attribute to the number of unsafe buildings, resulting in constant increase of fires within the country of Brazil.
The Kiss nightclub fire had multiple impacts, both on the society and legally. The effects that the fire had on the society began immediately and continue to this day. The immediate effects on the society include the effects the disaster had on the people of the community. Families and friends were left devastated as news of the tragedy reached them. Jim Crabtree, one of the nurses who was involved with the victims, states that there were “incessantly ringing phones, and the realization[s] that someone is desperately trying to reach someone else who is now dead”[9] Families were left frantic as they tried to get in touch with their loved ones. After the fire, many of the families and friends moved out of the area, and an estimated loss of 20% in the property value in the region has been made. Nightclubs and parties shut down throughout the country in respect of the tragedy, as well as carnivals and festivals. Vigils were held outside the location of the club, hospitals, and the gym where the victims were originally taken. Colleges suspended classes to give students time, and even three months later there was a tribute to the victims’ families in which they prayed for each other and their lost loved ones. Brazilian president Dilma Rousseff stated, "I want to tell the Brazilians and the population of Santa Maria, that we stand together in this sad moment" He was at a summit of the EU and the countries of Latin America in Chile, and left the summit early to come back to Brazil and visit grieving families of the victims. The President also declared three days of official mourning for the country. Santa Maria's city government established a thirty day official mourning period in which all parties and celebrations were canceled. [9] Marches took place all over the city demanding justice for those responsible and to honor the dead. Across the continent, other countries responded to Brazil’s tragedy. Countries such as Argentina and Peru sent over skin grafts to aid the hospitals. The Health Minister of Argentina, Juan Luis Manzur, made arrangements for the delivery of skin bound for those injured by the fire, stating: "We will make available to our Brazilian counterparts the amount of skin we can provide"[9]
A long term impact of the fire on those injured is an increase in the risk of cancer due to the inhalation of fumes. Another health risk is Post Traumatic Stress Disorder (PTSD). A case of this has already been seen, as one of the victims in the hospital attempted to hang himself after a few weeks. [9] This event has achieved worldwide, international media such as CNN, BBC, RTP, Washington Post, and the New York Times.
With two hundred forty one young college students killed, and hundreds of others injured, the Kiss nightclub fire was devastating. A lot of blame was tossed around in various areas. Club owners, band members, fire marshals and various members of government have been indicted and various charges. The Brazilian police did a thorough investigation making sure no stone was left unturned.
A fire of this magnitude needed extraordinary circumstances in order to be as distressing as it was. As noted, the reasons behind this fire were a cascade of failures, one on top of the other. The fire was first started by the lead singer of the band Gurizada Fandangueira, Marcelo de Jesus dos Santos. He has been indicted on murder charges. He was responsible for lighting the pyrotechnic device in the first place, which lit the sound proofing that was in the ceiling. The other person arrested that was affiliated with the band was their producer, Luciano Augusto Bonilha Lion. The two men decided to buy the cheaper outdoor fireworks for the indoor event. The outdoor fire work is about $4-$5 while the indoor one was more along the lines of $35. [10] They were not the only ones at fault though. The band is famous for their pyrotechnic displays; they haven’t had any problems in the past, why now? How did a cheap $5 firework cause one of the most catastrophic fire in Brazil’s history? You have to look at the management of the building.
Two hundred forty one people died, a lot of things have to go wrong for that. According to eye witnesses and some members of the band, they noticed the sound proofing catching fire and spreading. The first thing the band member did was go for a fire extinguisher, but it didn’t work [11] From there the fire quickly spread, causing a thick, black smoke, making it impossible for patrons to see where they were going. Hundreds of people (well over one thousand) start pushing and shoving trying to find the exit. Some people saw a green light and mistook it for an exit, it was actually the bathroom. People were being trampled and crushed trying to get out of the front, but they were initially prevented from leaving. Brazil has a law where people order drinks and pay as they are leaving instead of right away like in the United States. Security and management thought people were skipping out on their tabs, so they prevented them from leaving the single front exit. Only once the fire picked up did they allow people to leave, but by then it did not matter. Based off the description there are some noticeable problems right away.
Many people involved with the club’s ownership have been indicted and charged with murder. These people include the two main owners of the club, Elissandro Callegaro Spohr and Mauro Londero Hoffman. They ran everything and owned the majority of the club [12]. The other owners, who have also been charged with murder include Angela Aurelia Callegaro (sister of Elissandro), and Marlene Therese Callegaro (mother of Elisandro). Ricardo Castro Pasche, the club manager, has also been brought up on murder charges. The two people charged with most of the crimes were Spohr and Hoffman. They were the ones that allowed at least one thousand people (counting the injured and those that gave eye witness reports) into a club that had a maximum capacity of 691, according to a fire permit that was actually expired at the time of the incident. Furthermore, this was not the first time the club was overcrowded. Kiss nightclub was well known for having nights were the club was packed with between 1000 and 1500 people [13]. From a management stand point it makes sense, more people means more money. From a safety stand point however, it is an extremely risky move. The overcrowding was the main reason behind the trampling. In addition to that, the two owners have also had charges brought up on them in 2012 for falsely imprisoning customers that had not paid their tabs [14]. They have a history a blocking exits and it was another reason of why innocent lives were lost.
The Regional Council of Engineering and Agronomy created a list of the factors that contributed to the disaster. The ones that were specific to the clubs management include; faulty fire extinguishers, overcrowding, the flammable acoustic insulation, the insignificant amount of exits (minimum of two and they only had one), no proper air exhaust system, no lighting system to illuminate the exit, and no proper Fire Prevention Plan [15]. Club management wanted to cut as many corners as they could. The flammable sound proofing is cheap, having broken fire extinguishers are cheaper than having to pay for the inspection or new ones, and training employees in proper fire prevention means paying them for training. But how could a club with so many apparent flaws get away with so much? The Kiss nightclub opened in July of 2009, they needed permits from the city and from the fire department to prove it was safe. The club was actually up and running for about six months without a legal permit from the city, and a year without a permit from the fire department [16]. But still, how did they get a fire permit in the first place? The quick answer is corruption.
In the list of people indicted on murder charges include two fire inspectors; Gilson Martins Dias and Vagner Guimarães Coelho. They were both responsible for the initial fire inspection of the nightclub back in 2009. According to a nightclub owner who did not want to be identified "The rule is pick up the phone and call a friend in the city" [17]. It is tough to start up a small business in Brazil, with the cost of permits and inspections; it leaves a lot of club owners in debt before the grand opening. Therefore it is cheaper to pay off a public official then to have the inspection done. The following were indicted for manslaughter because of allowing the initial permits for Kiss to get processed and approved, while also not properly placing fines and following protocol; Miguel Caetano Passini (Secretary of Urban Mobility), Luiz Alberto Carvalho Junior (Environment Secretary); Beloyannes Orengo Pietro Junior (Department of Urban Mobility), Marcus Vinicius Bittencourt Biermann (Department of Finance). To give an idea of how corrupt the situation was, an engineer by the name of James Mutti actually revoked the clubs permit due to the fact that there was no fire prevention plan, a single exit and flammable sound proofing; but other retired fire fighters, Clandio Silva Ribeiro being one of them, re-established the permit [18]. Most of the time the owner of a building would write up a document saying that everything was being implemented and what fire prevention measures were being taken. The fire fighters would then take the owners word for it without going to inspect the establishments.[19] The fire prevention sector of fire fighters have always had a monetary relationship with private companies. This leads to pay offs, which creates buildings and establishments that are by no means up to regulations.
Architects provided testimony stating that they made twenty nine amendments to the nightclubs floor plan in order to make it safer, and made efforts to have it renovated. These amendments never came to light; the city had the paper work but never acted on it. Rafael de Oliveira, the architect of the city, stated that the changes were withdrawn and that it was the responsibility of the owners to have to renovations done, not the city. Higher government officials disagreed claiming that the mayor knew of the amendments but did not act. The mayor, Cezar Schirmer has also been indicted because of it [20].
The Kiss tragedy brought the problems that the city had with ensuring safety in establishments to light. Since the event, the city’s politicians have been attempting to pass legislation for fire safety and new regulations for stricter inspections. This includes fines for buildings found that do not follow safety protocols. The fact the club had only one exit was because of a loophole in Brazilian building codes. Codes don’t specify the amount of exits needed but states instead the amount of doors needed [21]. Previous legislation was too vague at establishing what sectors (state, municipal, or fire prevention) were in charge of inspecting certain things. For example, the foam in the ceiling was responsible for the quick spread of the fire and the toxic fumes, but neither fire fighters nor the city are responsible for inspecting it, so it was a safety hazard that was not looked at [21]. Currently, legislation is being written up creating a clear divide as to what sectors are responsible for inspecting.
Soon after the fire, the governor of São Paulo, Geraldo Alckmin, ordered immediate inspection of clubs in the state. Over three hundred clubs were visited and over one hundred of them failed to have fire permits. Sixty six of those that did have permits had irregularities as to what was in the permit and what was in the club. Those clubs without permits have been closed until they have passed inspection, and those with faulty permits had ten days to make the proper changes or they risked losing their licenses [22]. There were also inspections done in the state of Minas Gerais, with joint operations by the fire department, municipal, and military police. Four clubs were closed in the city of Pouso Alegre, four in Cambui and two in Alfenas, all for lack of fire permits. Rio de Janeiro has also been inspecting clubs and out of the two hundred that were inspected only 5% were thought to be above safety standards [22]. Due to this, the business sector is taking a huge hit because of all the clubs closing, but fire safety is more important than losing more innocent lives.
The disaster that occurred can be analyzed through an ethical point of view. The NSPE Code of Ethics for Engineers states “Engineers shall hold paramount the safety, health, and welfare of the public.”[23] This statement relates to the nightclub fire because those who designed the club’s systems should have realized that the club posed a threat due to the lack of safety. Further the code of ethics for engineers’ states that “Engineers shall approve only those engineering documents that are in conformity with applicable standards.”[24] Ethical issues surround the Brazilian nightclub fire; these issues include the use of outdoor flares, the use of pyrotechnics inside the club, the failure to check the fire extinguishers, the lack of exit signs, the bouncers blocking the doors, and the fact that in the club there were a thousand more people than legally allowed. The use of the outdoor flares raises an ethical issue because of the threat it posed to the safety of the patrons. The band, who are responsible this issue, knowingly bought flares that were cheaper instead of the more expensive ones that would have eliminated the chance of a fire occurring. The act goes against moral values due to the endangerment that they caused. The failure to check the extinguishers, lack of exit signs, and the bad design of the club comes down to being the responsibility of the owners. The owners allowed shows that caused customers to be at risk, which goes against the code of ethics for businesses. The security guards blocking the doors raise a question of human ethics, one of individuals putting others at risk. And the overcrowding of the club is again the fault of the owners and those in charge. Another ethical issue that has been raised is the fact that the Kiss Nightclub was allowed to still be operating even though it failed to comply with existing safety regulations. The club’s license had actually expired in August of the year before, and had never been renewed. [9] Therefore operation of the club itself was illegal. City officials, such as fire marshals, should have shut down the establishment long before this disaster occurred.
Another way to analyze the event that occurred would be the use the equation for risk. It stands as:
Vulnerability*Probability of Occurance*Cost
RISK= Mitigation
The vulnerability in this event was how susceptible the club was to damage. This includes fire damage, water damage, damage caused by humans and so on. For this event it was fire damage. The vulnerability of the club was raised due to the fact that there were no working fire extinguishers, sprinkler systems, working fire alarms, and there was only one exit. The probability of occurrence went up due to the lack of safety features and the severe overcrowding of the club. If there had been working safety features the probability of this happening would have been lower. The cost of this disaster was the lives of over two hundred people, and the injuries to over six hundred, as well as the cost of the damage done to the club. The club was almost burned to the ground, and fixing it would cost hundreds of thousands of dollars. Another factor in the magnitude of the fire is the repercussions on other businesses. Due to the new regulations implemented, other business owners had to pay to make sure their establishments were up to code. Other costs include the lawsuits filed against the nightclub owners, and the expenses that the government covered. The Brazilian government paid for the costs of the funerals and various other expenses. In terms of mitigation, the club owners had one exit, and a fire extinguisher, which did not work, and security guards, which actually made the problem worse instead of better as they should have. However, if one were to calculate the risk, they would see that the chances of the event happening and the magnitude of the risk is larger than it should be. Due to the lack of preparedness, the vulnerability, the probability of occurrence, and the cost all increase drastically.
The irresponsibility of the Kiss club owners, fire fighters, and Gurizada Fandangueira’s band members is the reason for so many young people’s lives being lost. Poor fire safety regulations were practiced all in the name of profit. However, the people of Brazil are not letting this incident cripple them, but instead are fighting hard to make sure justice is served, and legislation is passed to ensure that such a tragedy does not happen again.
References
[2] http://www.reuters.com/article/2013/01/27/us-brazil-nightclub-fire-idUSBRE90Q07B20130127
[3] http://bigstory.ap.org/article/more-90-dead-nightclub-fire-brazil
[4] http://www.bbc.co.uk/news/world-21220308#TWEET559281
[5] http://news.yahoo.com/neglect-errors-blame-brazil-nightclub-fire-200250681.html
[6] http://edition.cnn.com/2013/01/27/world/americas/brazil-nightclub-fire
[8]http://www.cnn.com/2013/01/28/health/cell-phones-death
[9]http://pt.m.wikipedia.org/wiki/Inc%C3%AAndio_na_boate_Kiss
[10] http://exame.abril.com.br/jornalistas/marco-prates&usg=ALkJrhiGqJC6TVL_GcCovuBfq1ekBBDqiQ
[12] http://www.bbc.co.uk/news/world-latin-america-22010406
[23] http://www.nspe.org/Ethics/CodeofEthics/index.html
[24] http://www.cnn.com/2013/01/27/world/americas/brazil-nightclub-fire
http://g1.globo.com/rs/rio-grande-do-sul/tragedia-incendio-boate-santa-maria-entenda/platb/