Case Study 7

One Meridian Plaza Highrise Fire of 1991

Although this fire took place 21 years ago, it remains one of the most significant non-terrorist associated highrise fires in the last century of U.S. fire history. On that fateful evening of February 23, 1991, an alarm of fire was received by the Philadelphia Fire Department reporting a fire on the “upper floors” at One Meridian Plaza. Fire-due fire companies made their best guess assessment of the situation and began fire suppression operations.

For this Case Study and analysis you will be using the PDF document titled, “Highrise Office Building Fire One Meridian Plaza, USFA-TR-049” located in the required reading section of your Unit VII Study Guide.

You must read the document in order to analyze and write your Case Study analysis summation of the incident. Your Case Study and analysis paper will consist of the following minimum number of pages from beginning to end (for a total of 11 pages): BFS 3251, Introduction to Fire Protection 5

 A cover page (5 points)

 Nine pages of summary text addressing the following topics (10 points per page):

o Building construction, occupancy, and fire protection systems

o Response, fire attack, fire spread, loss of lives, and extinguishment

o Strengths and weaknesses of incident command

o Lessons gained or lost with passage of time

 A reference page (5 points)

S. Fire Administration/Technical Report Series

Highrise Office

Building Fire
One Meridian Plaza

Philadelphia, Pennsylvania

USFA-TR-049/February 1991

U.S. Fire Administration Fire Investigations Program

T he U.S. Fire Administration develops reports on selected major fires throughout the country. The fires usually involve multiple deaths or a large loss of property. But the primary criterion for deciding to do a report is whether it will result in significant “lessons learned.” In some
cases these lessons bring to light new knowledge about fire–the effect of building construction or
contents, human behavior in fire, etc. In other cases, the lessons are not new but are serious enough
to highlight once again, with yet another fire tragedy report. In some cases, special reports are devel-
oped to discuss events, drills, or new technologies which are of interest to the fire service

The reports are sent to fire magazines and are distributed at National and Regional fire meeting

The
International Association of Fire Chiefs assists the USFA in disseminating the findings throughout the
fire servic

On a continuing basis the reports are available on request from the USFA; announce-
ments of their availability are published widely in fire journals and newsletters.

This body of work provides detailed information on the nature of the fire problem for policymakers
who must decide on allocations of resources between fire and other pressing problems, and within
the fire service to improve codes and code enforcement, training, public fire education, building
technology, and other related areas.

The Fire Administration, which has no regulatory authority, sends an experienced fire investigator
into a community after a major incident only after having conferred with the local fire authorities
to insure that the assistance and presence of the USFA would be supportive and would in no way
interfere with any review of the incident they are themselves conductin

The intent is not to arrive
during the event or even immediately after, but rather after the dust settles, so that a complete and
objective review of all the important aspects of the incident can be made. Local authorities review
the USFA’s report while it is in draft. The USFA investigator or team is available to local authorities
should they wish to request technical assistance for their own investigation.

This report and its recommendations were developed by USFA staff and by TriData Corporation,
Arlington, Virginia, its staff and consultants, who are under contract to assist the USFA in carrying
out the Fire Reports Program.

The USFA greatly appreciates the cooperation received from the Philadelphia Fire Department.
In particular, the assistance and information provided by Fire Commissioner Roger Ulshafer
(ret.), Commissioner Harold Hairston, Deputy Commissioner Christian Scheizer (ret.), Deputy
Commissioner Phil McLaughlin, Deputy Commissioner Matthew J. McCrory J

, Battalion Chief
Theodore Bateman, Battalion Chief Richard Bailey, and Lieutenant Matthew Medley were invaluable.

For additional copies of this report write to the U.S. Fire Administration, 16825 South Seton Avenue,
Emmitsburg, Maryland 21727. The report is available on the USFA Web site at http://www.usfa.dhs.gov/

Highrise Office Building Fire
One Meridian Plaza

Philadelphia, Pennsylvania

Report by: J. Gordon Routley
Charles Jennings
Mark Chubb

This is Report 049 of the Major Fires Investigation Project conducted
by TriData Corporation under contract EMW-90-C-3338 to the United
States Fire Administration, Federal Emergency Management Agency.

Department of Homeland Security
United States Fire Administration

National Fire Data Center

U.S. Fire Administration

Mission Statement

As an entity of the Federal Emergency

Management Agency (FEMA), the mission

of the U.S. Fire Administration (USFA) is to

reduce life and economic losses due to fire

and related emergencies, through leader-

ship, advocacy, coordination, and support. We

serve the Nation independently, in coordina-

tion with other Federal agencies, and in part-

nership with fire protection and emergency

service communities. With a commitment to

excellence, we provide public education, train-

ing, technology, and data initiatives.

Foreword

This report on the Philadelphia, Pennsylvania,

One Meridian Plaza

fire documents one of the most
significant highrise fires in United States’ history. The fire claimed the lives of three Philadelphia
firefighters and gutted eight floors of a 38-story fire-resistive building causing an estimated $100
million in direct property loss and an equal or greater loss through business interruption. Litigation
resulting from the fire amounts to an estimated $4 billion in civil damage claims. Twenty months
after the fire this building, one of Philadelphia’s tallest, situated on Penn Square directly across from
City Hall, still stood unoccupied and fire-scarred, its structural integrity in question.

This fire is a large scale realization of fire risks that have been identified on many previous occasions.
The most significant new information from this fire relates to the vulnerability of the systems that
were installed to provide electrical power and to support fire suppression efforts. In this incident
there was an early loss of normal electrical power, a failure of the emergency generator and a major
problem with the standpipe system, each of which contributed to the final outcome. These experi-
ences should cause responsible individuals and agencies to critically re-examine the adequacy of all
emergency systems in major buildings.

When the initial news reports of this fire emerged, attention focused on how a modem, fire-resistive
highrise in a major metropolitan city with a well-staffed, well-equipped fire department could be
so heavily damaged by fire. The answer is rather simple — fire departments alone cannot expect or
be expected to provide the level of fire protection that modern highrises demand. The protection
must be built-in. This fire was finally stopped when it reached a floor where automatic sprinklers
had been installed.

This report will demonstrate that the magnitude of this loss is greater than the sum of the individual
problems and failures which produced it. Although problems with emergency power systems, stand-
pipe pressure reducing valves, fire alarm systems, exterior fire spread, and building staff response can
be identified, the magnitude of this fire was a result of the manner in which these factors interacted
with each other. It was the combination of all of these factors that produced the outcome.

At the time of the One Meridian Plaza fire, the three model fire prevention codes had already adopted
recommendations or requirements for abating hazards in existing highrise buildings. Each of the
model building codes contains explicit requirements for fire protection and means of egress in
highrise buildings. Actions were and are underway in many cities and several States to require ret-
rofitting of existing highrise buildings with automatic sprinkler systems, fire detection and alarm
systems, and other safety provisions. Since the Meridian Plaza fire, the National Fire Protection
Association’s Technical Committee on Standpipe Systems has proposed a complete revision of NFPA
14, Standard for Installation of Standpipe and Hose Systems. The new version of NFPA 14 was approved by the
NFPA membership at the 1992 fall meeting in Dallas, Texas. All of these efforts are necessary and
commendable. To prove successful, however, they must take a comprehensive, holistic approach to
the problem of highrise fire safety, if we are to keep One Meridian Plaza from being surpassed by yet
another devastating fire.

TaBle OF COnTenTs

OVERVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SUMMARY OF KEY ISSUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

THE BUILDING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Stairways. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Elevators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Heating, Ventilation, and Air Conditioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Plumbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Electrical and Communications Risers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Emergency Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

FIRE PROTECTION SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Fire Detection and Alarm Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Standpipes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Automatic Sprinklers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

THE FIRE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Delayed Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Initial Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Electrical Power Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Initial Attack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Fire Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Water Supply Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Three Firefighters Lost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Continuing Efforts to Improve Water Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Firefighting Operations Suspended . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Fire Stopped . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ANALYSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Smoke Movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Fuel Loading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Structural Conditions Observed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

INCIDENT COMMAND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Logistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

continued on next page

BUILDING AND FIRE REGULATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

FIRE CODE ENFORCEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

LESSONS LEARNED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

CONCLUSION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

SOURCES OF INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

APPENDIx A: Elevation Drawing of the Building and 22nd Floor Plan, Floor of Origin . . . .

APPENDIx B:

Building Emergency Instructions

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

APPENDIx C: Philadelphia Fire DepartmentHighrise Emergency Procedures . . . . . . . . . . . .

APPENDIx D: Factory Mutual Engineering CorporationPressure Reducing Valve Loss
Prevention Data Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

APPENDIx E: Philadelphia Fire DepartmentPressure Regulating Device Fact Sheet . . . . . . . .

APPENDIx F:

Philadelphia Fire Department Block Inspection Program

. . . . . . . . . . . . . . . .

APPENDIx G: Philadelphia Fire Code Amendments Adopted after the One Meridian
Plaza Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

APPENDIx H: Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Table of Contents (continued)

1
Highrise Office Building Fire
One Meridian Plaza

Philadelphia, Pennsylvania
February 23, 1991

Local Contacts: Commissioner (ret.) Roger Ulshaf

Commissioner Harold Hairston
Deputy Commissioner (ret.) Christian Schweizer
Deputy Commissioner Phil McLaughlin
Deputy Commissioner Matthew J. McCrory, Jr.
Theodore Bateman, Battalion Chief
Richard Bailey, Battalion Chief
Matthew Medley, Lieutenant
City of Philadelphia Fire Department
240 Spring Garden Street
Philadelphia, Pennsylvania 19123-2991
(215) 592-5962

oVerVIew
A fire on the 22nd floor of the 38-story Meridian Bank Building, also known as One Meridian Plaza,
was reported to the Philadelphia Fire Department on February 23, 1991 at approximately 2040
hours and burned for more than 19 hours. The fire caused three firefighter fatalities and injuries to
24 firefighters. The 12-alarms brought 51 engine companies, 15 ladder companies, 11 specialized
units, and over 300 firefighters to the scene. It was the largest highrise office building fire in modern
American history — completely consuming eight floors of the building — and was controlled only
when it reached a floor that was protected by automatic sprinklers. A table summarizing the key
aspects of the fire is presented on the following pages.

The fire department arrived to find a well-developed fire on the 22nd floor, with fire dropping down
to the 21st floor through a set of convenience stairs. (For an elevation drawing of the building and
the 22nd floor plan see Appendix A.) Heavy smoke had already entered the stairways and the floors
immediately above the 22nd. Fire attack was hampered by a complete failure of the building’s elec-
trical system and by inadequate water pressure, caused in part by improperly set pressure reducing
valves on standpipe hose outlets.

2 U.S. Fire Administration/Technical Report Series

SUMMArY oF KeY ISSUeS
Issues Comments

Origin and Cause The fire started in a vacant 22nd floor office in a pile of linseed oil-soaked rags left by a contractor.

Fire Alarm System The activation of a smoke detector on the 22nd floor was the first notice of a possible fire. Due
to incomplete detector coverage, the fire was already well advanced before the detector was
activated.

Building Staff Response Building employees did not call the fire department when the alarm was activated. An employee
investigating the alarm was trapped when the elevator opened on the fire floor and was rescued
when personnel on the ground level activated the manual recall. The fire department was not
called until the employee had been rescued.

Alarm Monitoring Service The private service which monitors the fire alarm system did not call the fire department when the
alarm was first activated. A call was made to the building to verify that they were aware of the
alarm. The building personnel were already checking the alarm at that time.

Electrical Systems Installation of the primary and secondary electrical power risers in a common unprotected enclo-
sure resulted in a complete power failure when the fire damaged conductors shorted to ground.
The natural gas powered emergency generator also failed.

Fire Barriers Unprotected penetrations in fire-resistance rated assemblies and the absence of fire dampers in
ventilation shafts permitted fire and smoke to spread vertically and horizontally.

Ventilation openings in the stairway enclosures permitted smoke to migrate into the stairways,
complicating firefighting.

Unprotected openings in the enclosure walls of 22nd floor electrical closet permitted the fire to
impinge on the primary and secondary electrical power risers.

Standpipe System and
Pressure Reducing Valves
(PRVs)

Improperly installed standpipe valves provided inadequate pressure for fire department hose
streams using 1-3/4-inch hose and automatic fog nozzles. Pressure reducing valves were
installed to limit standpipe outlet discharge pressures to safe levels. The PRVs were set too low
to produce effective hose streams; tools and expertise to adjust the valve settings did not become
available until too late.

Locked Stairway Doors For security reasons, stairway doors were locked to prevent reentry except on designated floors.
(A building code variance had been granted to approve this arrangement.) This compelled firefight-
ers to use forcible entry tactics to gain access from stairways to floor areas.

Fire Department Pre-Fire
Planning

Only limited pre-fire plan information was available to the Incident Commander. Building owners
provided detailed plans as the fire progressed.

Firefighter Fatalities Three firefighters from Engine Company 11 died on the 28th Floor when they became disoriented
and ran out of air in their SCBAs.

Exterior Fire Spread
“Autoexposure”

Exterior vertical fire spread resulted when exterior windows failed. This was a primary means of
fire spread.

Structural Failures Fire-resistance rated construction features, particularly floor-ceiling assemblies and shaft enclo-
sures (including stair shafts), failed when exposed to continuous fire of unusual intensity and
duration.

Interior Fire Suppression
Abandoned

After more than 11 hours of uncontrolled fire growth and spread, interior firefighting efforts were
abandoned due to the risk of structural collapse.

Automatic Sprinklers The fire was eventually stopped when it reached the fully sprinklered 30th floor. Ten sprinkler
heads activated at different points of fire penetration.

USFA-TR-049/February 1991 3

The three firefighters who died were attempting to ventilate the center stair tower. They radioed a
request for help stating that they were on the 30th floor. After extensive search and rescue efforts,
their bodies were later found on the 28th floor. They had exhausted all of their air supply and could
not escape to reach fresh air. At the time of their deaths, the 28th floor was not burning but had an
extremely heavy smoke condition.

After the loss of three personnel, hours of unsuccessful attack on the fire, with several floors simul-
taneously involved in fire, and a risk of structural collapse, the Incident Commander withdrew all
personnel from the building due to the uncontrollable risk factors. The fire ultimately spread up to
the 30th floor where it was stopped by ten automatic sprinklers.

THe BUIlDInG
One Meridian Plaza is a 38-story highrise office building, located at the corner of 15th Street and
South Penn Square in the heart of downtown Philadelphia, in an area of highrise and mid-rise
structures. On the east side, the building is attached to the 34-story Girard Trust Building and it is
surrounded by several other highrise buildings. The front of the building faces City Hall.

One Meridian Plaza has three underground levels, 36 above ground occupiable floors, two mechani-
cal floors (12 and 38), and two rooftop helipads. The building is rectangular in shape, approximately
243 feet in length by 92 feet in width (approximately 22,400 gross square feet), with roughly
17,000 net usable square feet per floor. (See Appendix A for floor plan.) Site work for construction
began in 1968, and the building was completed and approved for occupancy in 1973.

Construction was classified by the Philadelphia Department of Licenses and Inspections as equivalent
to BOCA Type 1B construction which requires 3-hour fire rated building columns, 2-hour fire rated
horizontal beams and floor/ceiling systems, and 1-hour fire rated corridors and tenant separations.
Shafts, including stairways, are required to be 2- hour fire rated construction, and roofs must have
1-hour fire rated assemblies.

The building frame is structural steel with concrete floors poured over metal decks. All structural
steel and floor assemblies were protected with spray-on fireproofing material. The exterior of the
building was covered by granite curtain wall panels with glass windows attached to the perimeter
floor girders and spandrels.

The building utilizes a central core design, although one side of the core is adjacent to the south
exterior wall. The core area is approximately 38 feet wide by 124 feet long and contains two stair-
ways, four banks of elevators, two HVAC supply duct shafts, bathroom utility chases, and telephone
and electrical risers.

Stairways

The building has three enclosed stairways of concrete masonry construction. Each stairway services
all 38 floors. The locations of the two stairways within the building core shift horizontally three
or four times between the ground and the 38th floor to accommodate elevator shafts and machine
rooms for the four elevator banks. Both of these stairways are equipped with standpipe risers.

Adjacent to the stairway enclosures are separate utility and HVAC shafts. There are pipe and duct pen-
etrations through the shaft and stairway enclosure walls. The penetrations are unprotected around
the sleeved pipes and fire dampers are not installed in HVAC ducts penetrating the fire-resistance

4 U.S. Fire Administration/Technical Report Series

rated wall assemblies. This effectively creates many openings between the utility shafts, and the
individual floors, primarily in the plenum area above the ceilings, as well as between the shafts and
the stairway enclosures.

The third enclosed stairway is located at the east end of the building. This stairway attaches the floors
of the Meridian Plaza to the corresponding floors of the Girard Trust Building. Adjacent to the east
stairway is an additional enclosed utility shaft which also has pipe and duct penetrations through
the shaft enclosure walls. There are no fire or smoke barriers around the sleeved pipes and no fire
dampers in the HVAC ducts that penetrate the shaft walls.

Elevators

Elevator service is provided by four zoned elevator banks identified as A through D. Elevator
Bank A serves floors 2-1

Elevator Bank B has two shafts which enclose seven elevators: six are
passenger elevators that serve floors 12-21, and one is a freight elevator that serves floors 22-38.
Elevator Bank C serves floors 21-29, and Elevator Bank D serves floors 29-37. The elevator shafts
are constructed of concrete and masonry and extend from the first floor or lower levels to the
highest floor served by the individual elevator banks. At the top of each elevator bank is the associ-
ated elevator equipment room.

The elevator shafts that serve the upper floors are express rise and do not have openings to the lower
floors. Only the Bank C passenger elevators and the freight elevator served the fire floors. The eleva-
tor shafts did not appear to play a significant role in the spread of combustion products.

Each elevator lobby is equipped with a smoke detector that, when activated, recalls the elevator cars
to the first floor lobby. Firefighter’s service (elevator recall) features were added in 1981 under
provisions of the State Elevator Code.1 Occupant use of elevators in emergencies is addressed in the
Building Emergency Instructions shown in Appendix B.

Heating, Ventilation, and Air Conditioning

The heating, ventilation, and air conditioning (HVAC) system is composed of four air handling
systems. Two systems are located in the 38th floor mechanical room and service the east and west
halves of the upper floors. The other two systems are located in the 12th floor mechanical room and
service the east and west halves of the lower floors. Each system supplies air to its respective floors
through one or two supply air shafts located within the building core and receives return air from its
associated return air shafts. Return air shafts are located at each of the four building corners. Upon
examination at selected locations, the HVAC supply and return air shafts did not appear to have fire
dampers at the duct penetrations on each floor.

Plumbing

The bathroom utility piping extends through the 38 floors through pipe chases that are formed
by the space between two walls. These pipe chases transfer location as the bathroom locations
change floor to floor. Upon a sample examination of the pipe chases, it was found that floor
penetrations were not closed or sealed to maintain the integrity of the fire- resistance rated floor/
ceiling assemblies.

1 In Pennsylvania, elevators are regulated through the State Department of Labor and Industry.

USFA-TR-049/February 1991 5

Electrical and Communications Risers

The electrical and telephone risers are enclosed in separate rooms on each floor. The rooms are
located directly above one another and are intended to function as vertical shafts, with rated separa-
tions required at horizontal penetrations from the shafts into floor and ceiling spaces at each level.
Within the telephone and electrical rooms, unprotected penetrations of the floor assemblies allow
conduits and exposed wires to travel from floor to floor. Several breaches of fire-resistance rated
construction were observed in the walls separating the electrical and telephone rooms from the ceil-
ing plenums and occupied spaces on each floor.

Emergency Power

The building electrical system receives power from two separate electrical substations and is backed-up
by an emergency generator. The two sources of power are arranged so that the load would automati-
cally transfer to the second source upon failure of the first. Electrical power for One Meridian Plaza
and four adjacent buildings is distributed from the basement of 1414 S. Penn Square.

The electric service enters the building via the basement from the adjoining building and is distrib-
uted to the 12th and 38th floor mechanical rooms via the electrical risers in the building core. From
the 12th and 38th floor mechanical rooms, electrical power is distributed to the major mechanical
systems and to a buss bar riser, which services distribution panels on the individual floors.

Emergency power was provided by a 340 kw natural gas-fired generator located in the 12th floor
mechanical room. The generator was sized to supply power for emergency lighting and the fire
alarm system, the fire pump located on the 12th floor and one car in each bank of elevators. The gen-
erator’s fuel was supplied by the building’s natural gas service. This generator was not required by
the building code, since the building’s electrical power was supplied by two separate substations.

The generator was reported to have been tested weekly. The last recorded test date was January
30, almost four weeks before the fire, and the maintenance records indicate that problems were
encountered during engine start-up under load conditions at that time. During a detailed inspection
following that test, a damaged part was discovered and replaced. After the repair, the generator was
started without a load and appeared to work properly, but no subsequent tests were performed to
determine if the problems persisted under load conditions.

Records of earlier maintenance and test activity suggest that load tests were performed only occa-
sionally. Test and maintenance records indicate a long history of maintenance problems with the
emergency generator system. Many of these problems became manifest during or immediately after
conducting tests under load.

FIRe PROTeCTIOn sYsTeMs
At the time of construction, the Philadelphia Building Code required only a local fire alarm system
with manual stations at each exit and smoke detectors in the supply and return air shafts. Hose
stations supplied from the domestic water service and portable fire extinguishers were required
for occupant use. Dry standpipes were installed for fire department use. Below ground levels were
required to be provided with automatic sprinklers.

As a result of local code changes, several improvements to the fire protection systems were made in
the years following the building’s construction.

6 U.S. Fire Administration/Technical Report Series

In 1981, the Philadelphia Department of Licenses and Inspections implemented amendments to
the fire code which were intended to address the life safety of highrise building occupants. These
requirements included installation of stair identification signs, provisions to permit stairway re-
entry, and installation of smoke detection in common areas in the path of access to exits. The
“common areas” provision of the code was intended to address corridors and exit passageways in
multi-tenant floors. The smoke detector requirements were interpreted in such a way that single
tenant “open plan” floors were only required to have detectors installed at the exits; the entire floor,
although open, was not considered a “common area.”. Smoke detectors were also installed in the
return air plenum adjacent to the return air shaft intakes in each corner of the building. These provi-
sions required that building owners file permits for this work within one year of the code change.
City records do not indicate when this work was performed in this particular building or if it was
inspected and approved.

Fire Detection and Alarm Systems

At the time of construction, One Meridian Plaza was equipped with a coded manual fire alarm
system with pull stations installed adjacent to each of the three exit stairwells on each floor. Smoke
detection was provided in the major supply and return air ducts at the mechanical floor levels.

After the 1981 fire code amendments were enacted, the hardware on stairway doors was required to
allow access from stairs back to floor areas or to be unlocked automatically in the event that the fire
alarm was activated. One Meridian Plaza was granted a variance from this provision and generally
had unlocked doors every three floors.

Approximately one and a half years before the fire, a public address system was installed throughout
the building. This system was operable from the lobby desk and had the capability of addressing
floors, stairways, elevator machine rooms, and elevators. Two-way communication was possible
with elevators and elevator machine rooms.

As additional devices and systems were installed, they were connected to the fire alarm system to
sound through the single-stroke bells originally installed with the manual fire alarm system. Smoke
detector and water flow signals were assigned their own codes to allow annunciation not only at the
lobby but throughout the building for those members of the building staff who knew the codes.

Standpipes

The occupant use standpipe system, which was connected to the domestic water supply, provided
two outlets per floor with 100 feet of 1-1/2-inch hose and a nozzle. The hose cabinets were located
in corridors on each floor.

A dry standpipe system was originally installed with 6 inch risers in the west and center stair towers
and outlets for 2-1/2 fire department hoselines at each floor level. This system was converted to a
wet riser system in 1988, to supply automatic sprinklers on some of the upper floors. An 8 inch
water supply was provided to deliver water to two 750 gpm electric fire pumps, one in the basement
and one on the 12th floor.

The basement pump supplied the lower standpipe zone (floors B-12) while the 12th floor pump
served the upper zone (floors 13-38).

There was no standpipe in the east stair tower.

USFA-TR-049/February 1991 7

A November 1988 Board of Building Standards decision permitted both zones to be served by a
common fire department connection, as part of a plan that would provide for the installation of
automatic sprinklers on all floors by November 1993.2

Due to the height of the zones and the installation of fire pumps, pressures exceeded the 100 psi
limit permitted by NFPA 14, Installation of Standpipe and Hose Systems at the standpipe hose outlets on
several lower floors in each zone. Pressure restricting devices, which limit the discharge through
standpipe outlets by restricting the orifice, were installed on the mezzanine and second floor levels
and on floors 26 through 30. Pressure reducing valves, which regulate both static pressure and dis-
charge pressure under variable flow conditions, were installed on floors 13 through 25.

Both types of devices prevent dangerous discharge pressures from hose outlets at the lower floors of
each standpipe zone. The Philadelphia Fire Department investigators report that the plans submitted
at the time the standpipes were converted did not indicate that PRVs were to be installed.

Automatic Sprinklers

Only the service floors located below grade were protected by automatic sprinklers at the time of
construction. Conversion of the dry standpipe to a wet system with fire pumps facilitated the instal-
lation of automatic sprinklers throughout the building. At the request of selected tenants, sprinklers
were installed on several floors during renovations, including all of the 30th, 31st, 34th, and 35th
floors, and parts of floors 11 and 15. Limited service sprinklers, connected to the domestic water
supply system, were installed in part of the 37th floor. The building owners had plans to install
sprinklers on additional floors as they were renovated.

THe FIre

Delayed Report

At approximately 2023 hours on February 23, 1991, a smoke detector was activated on the 22nd
floor of the One Meridian Plaza building. The activated detector is believed to have been located at
the entrance to the return air shaft in the northeast corner of the building. At that time there were
three people in the building, an engineer and two security guards.3 The alarm sounded throughout
the building and elevator cars automatically returned to the lobby. The building engineer investi-
gated the alarm using an elevator on manual control to go to the 22nd floor. The central station
monitoring company that served the building reportedly called the guard desk in the lobby to report
the alarm. The call came in before the engineer reached the fire floor, and the alarm company was
told that the source of the alarm was being investigated. The alarm company did not notify the fire
department at that time.

When the elevator doors opened at the 22nd floor, the engineer encountered heavy smoke and heat.
Unable to reach the buttons or to leave the elevator car to seek an exit, the building engineer became
trapped. He was able to use his portable radio to call the security guard at the lobby desk requesting

2 Philadelphia Fire Department, “Investigative Report,” Section M, p. 2.

3 The building staff regulated the after-hours population of the building through a lighting request system where tenants
lights would be turned on for the duration of their work. In addition, there was a security system in the building that
recorded any passage through stairwell doors.

8 U.S. Fire Administration/Technical Report Series

assistance. Following the trapped engineer’s instructions, the security guard in the lobby recalled the
elevator to the ground floor using the Phase II firefighter’s safety feature.

The second security guard monitored the radio transmissions while taking a break on the 30th floor.
This guard initially mistook the fire alarm for a security alarm believing that he had activated a ten-
ant’s security system while making his rounds. He evacuated the building via the stairs when he
heard the building engineer confirm there was a fire on the 22nd floor.

The roving guard reported that as he descended from the 30th floor the stairway was filling with
smoke. He reached the ground level and met the engineer and the other security guard on the street
in front of the building.

The Philadelphia Fire Department report on the incident states that the lobby guard called the alarm
monitoring service to confirm that there was an actual fire in the building when the engineer radi-
oed to her from the 22nd floor. After meeting outside and accounting for each other’s whereabouts
the three building personnel realized that they had not yet called the fire department.

The first call received by the Philadelphia Fire Department came from a passerby who used a pay
telephone near the building to call 9-1-1. The caller reported smoke coming from a large building
but was unable to provide the exact address. While this call was still in progress, at approximately
2027 hours, a call was received from the alarm monitoring service reporting a fire alarm at One
Meridian Plaza.

Initial Response

The Philadelphia Fire Department dispatched the first alarm at 2027 hours consisting of four engine
and two ladder companies with two battalion chiefs. The first arriving unit, Engine 43, reported
heavy smoke with fire showing from one window at approximately the mid-section of the building
at 2031 hours. A security guard told the first arriving battalion chief that the fire was on the 22nd
floor. Battalion Chief 5 ordered a second alarm at 2033 hours.

While one battalion chief assumed command of the incident at the lobby level, the other battal-
ion chief organized an attack team to go up to the fire floor. (The Philadelphia Fire Department’s
“Highrise Emergency Procedures” Operation Procedure 33 is presented in Appendix C.) The bat-
talion chief directed the attack team to take the low-rise elevators up the 11th floor and walk up
from there.

Electrical Power Failure

Shortly after the battalion chief and the attack team reached the 11th floor there was a total loss of
electrical power in the building. This resulted when intense heat from the fire floor penetrated the
electrical room enclosure. The heat caused the cable insulation to melt resulting in a dead short
between the conductor and the conduit in both the primary and secondary power feeds, and the loss
of both commercial power sources. The emergency generator should have activated automatically,
but it failed to produce electric power. These events left the entire building without electricity for the
duration of the incident in spite of several efforts to restore commercial power and to obtain power
from the generator.

This total power failure had a major impact on the firefighting operations. The lack of lighting
made it necessary for firefighters to carry out suppression operations in complete darkness using

USFA-TR-049/February 1991 9

only battery powered lights. Since there was no power to operate elevators, firefighters were
forced to hand carry all suppression equipment including SCBA replacement cylinders up the
stairs to the staging area that was established on the 20th floor. In addition, personnel had to
climb at least 20 floors to relieve fellow firefighters and attack crews increasing the time required
for relief forces to arrive. This was a problem for the duration of the incident as each relief crew
was already tired from the long climb before they could take over suppression duties from the
crews that were previously committed.

Initial Attack

As the initial attack crews made their way toward the 22nd floor they began to encounter smoke in
the stairway. At the 22nd floor they found the west stair tower door locked. The door was already
warped and blistering from the heat, and heavy fire could be seen through the door’s wire glass
window. A 1-3/4-inch handline was stretched up the stairway from a standpipe connection on
the floor below and operated through the window while a ladder company worked on forcing
open the door.

It took several minutes before the door could be forced open and an attempt could be made to
advance onto the fire floor with the 1-3/4-inch attack line. The crews were not able to penetrate
onto the 22nd floor due to the intense heat and low water pressure they were able to obtain from
their hoseline.

An entry was also made on the 21st floor where the firefighters were able to see fire on the floor
above through the open convenience stair. They attempted to use an occupant hoseline to attack the
fire but could not obtain water from that outlet. They then connected a 1-3/4 inch attack line to the
standpipe outlet in the stairway, but they could not obtain sufficient pressure to attack the flames. A
Tactical Command Post was established on the 21st floor and a staging area was set up on floor 20.

Fire Development

By this time fire was visible from several windows on the 22nd floor and crews outside were evacuat-
ing the area around the building and hooking up supply lines to the building’s standpipe connec-
tions. As flames broke through several more windows around a major portion of the fire floor, the
floor above was subject to autoexposure from flames lapping up the side of the building. Additional
alarms were called to bring personnel and equipment to the scene for a large scale fire suppression
operation.

As the fire developed on the 22nd floor, smoke, heat, and toxic gases began moving through the
building. Vertical fire extension resulted from unprotected openings in floor and shaft assemblies,
failure of fire-resistance rated floor assemblies, and the lapping of flames through windows on the
outside of the building.

Water Supply Problems

The normal attack hoselines used by the Philadelphia Fire Department incorporate 1-3/4-inch hose-
lines with automatic fog nozzles designed to provide variable gallonage at 100 psi nozzle pressure.
The pressure reducing valves in the standpipe outlets provided less than 60 psi discharge pressure,
which was insufficient to develop effective fire streams. The pressure reducing values (PRVs) were
field adjustable using a special tool. However, not until several hours into the fire did a technician

10 U.S. Fire Administration/Technical Report Series

knowledgeable in the adjustment technique arrive at the fire scene and adjust the pressure on several
of the PRVs in the stairways.

When the PRVs were originally installed, the pressure settings were improperly adjusted. Index val-
ues marked on the valves did not correspond directly to discharge pressures. To perform adjustments
the factory and field personnel had to refer to tables in printed installation instructions to determine
the proper setting for each floor level.4 For more detailed information about PRVs see Appendices D
and

Several fire department pumpers were connected to the fire department connections to the standpipe
system in an attempt to increase the water pressure. The improperly set PRVs effectively prevented
the increased pressure in the standpipes from being discharged through the valves. The limited
water supply prevented significant progress in fighting the fire and limited interior forces to operat-
ing from defensive positions in the stairwells. During the next hour the fire spread to the 23rd and
24th floors primarily through autoexposure, while firefighters were unable to make entry onto these
floors due to deteriorating heat and smoke conditions and the lack of water pressure in their hose-
lines. Windows on the 22nd floor broke out and the 23rd and 24th floor windows were subject to
autoexposure from flames lapping up the sides of the building.

On the street below pedestrians were cleared from the area because of falling glass and debris as
more and more windows were broken out by the fire. Additional hoselines were connected to the
standpipe connections, attempting to boost the water pressure in the system. However, the design
of the PRVs did not allow the higher pressures to reach the interior hose streams. Additional alarms
were requested to bring a five-alarm assignment to the scene.

Three Firefighters Lost

As firefighters attempted to make entry to the burning floors from the stairways, heavy smoke con-
tinued to build up within the stair shafts and banked down from the upper floors. An engine com-
pany was assigned to attempt to open a door or hatch to ventilate the stairways at the roof level to
allow the smoke and heat to escape. A captain and two firefighters from Engine 11 started up the
center stair from the 22nd floor with this assignment. Engine 11 subsequently radioed that they
had left the stairway and were disoriented in heavy smoke on the 30th floor. Attempts were made to
direct the crew by radio to one of the other stairways.

Shortly thereafter a radio message was received at the Command Post from Engine 11’s Captain
requesting permission to break a window for ventilation. This was followed moments later by a
message from a crew member of Engine 11 reporting that “the captain is down.” Approval was given
to break the window and rescue efforts were initiated to search for the crew. Search teams were sent
from below and a helicopter was requested to land a team on the roof. The search teams were able
to reach the 30th floor, which was enveloped in heavy smoke, but were unable to find the missing
firefighters. They then searched the floors above without success. An eight member search team
became disoriented and ran out of air in the mechanical area on the 38th floor, while trying to find
an exit to the roof. They were rescued by the team that had landed on the roof and were transported
back to ground level by the helicopter.

4 The pressure reducing valves in the vicinity of the fire floor (floors 18 through 20) were set at “80” on the valve index
which corresponded to a discharge pressure between 55 and 57 psi, depending on the elevation. This would provide a
nozzle pressure of 40 to 45 psi at the end of a 150- to 200-foot hoseline.

USFA-TR-049/February 1991 11

Several attempts were made to continue the search, until helicopter operations on the rooftop had
to be suspended due to the poor visibility and the thermal drafts caused by the heat of the fire. The
helicopter crew then attempted an exterior search, using the helicopter’s searchlight, and at 0117
located a broken window on the southeast corner of the 28th floor, in an area that could not be seen
from any of the surrounding streets. Another rescue team was assembled and finally located the
three missing members just inside the broken window on the 28th floor at approximately 0215. At
that time the fire was burning on the 24th and 25th floors and extending to the 26th.

The victims were removed to the Medical Triage Area on the 20th floor, but resuscitation efforts were
unsuccessful and they were pronounced dead at the scene. An estimated three to four hours had elapsed
since they had reported that they were in trouble and all had succumbed to smoke inhalation.5

The three deceased members of Engine Company 11 were Captain David P. Holcombe (age 52),
Firefighter Phyllis McAllister (43), and Firefighter James A. Chappell (29).

Prior to being assigned to this task, the crew had walked up to the fire area wearing their full pro-
tective clothing and SCBA and carrying extra equipment. It is believed that they started out with
full SCBA cylinders, but it is not known if they became disoriented from the heavy smoke in the
stairway, encountered trouble with heat build-up, or were exhausted by the effort of climbing 28
floors. Some combination of these factors could have caused their predicament. Unfortunately, even
after breaking the window they did not find relief from the smoke conditions which were extremely
heavy in that part of the building.

Continuing Efforts to Improve Water Supp

Because of the difficulty in obtaining an adequate water supply, a decision was made to stretch 5-inch
lines up the stairs to supply interior attack lines. The first line was stretched up the west (#1) stairwell
to the 24th floor level and was operational by 0215, approximately six hours into the fire. At 0221, a
12th alarm was sounded to stretch a second line, in the center (#2) stair. At 0455, a third 5-inch line
was ordered stretched, in the east (#3) stair. The operation in the east stair was discontinued at the
17th floor level at 0600. While the 5-inch lines were being stretched, a sprinkler contractor arrived
at the scene and began manually adjusting the pressure reducing valves on the standpipe connections.
This improved the discharge pressure in the hoses supplied by the standpipe system, finally provid-
ing normal handline streams for the interior fire suppression crews. At this point, however, the fire
involved several floors and could not be contained with manual hose streams.

Firefighting Operations Suspended

All interior firefighting efforts were halted after almost 11 hours of uninterrupted fire in the build-
ing. Consultation with a structural engineer and structural damage observed by units operating in
the building led to the belief that there was a possibility of a pancake structural collapse of the fire
damaged floors. Bearing this risk in mind along with the loss of three personnel and the lack of

5 The exact time that Engine 11 was assigned to attempt ventilation and the time the crew reported they were in trouble
are not known, since the tactical radio channel they were using is not recorded and detailed time records of this event
were not maintained during the incident. Estimates from individuals who were involved suggest that the assignment
was made between 2130 and 2200 hours and search efforts were initiated between 2200 and 2230 hours. The bodies
were located at approximately 0215 hours.

12 U.S. Fire Administration/Technical Report Series

progress against the fire despite having secured adequate water pressure and flow for interior fire
streams, an order was given to evacuate the building at 0700 on February 24. At the time of the
evacuation, the fire appeared to be under control on the 22nd though 24th floors. It continued to
burn on floors 25 and 26 and was spreading upward. There was a heavy smoke condition through-
out most of the upper floors. The evacuation was completed by 0730.

After evacuating the building, portable master streams directed at the fire building from several
exposures, including the Girard Building #1 and One Centre Plaza, across the street to the west were
the only firefighting efforts left in place.

Fire Stopped

The fire was stopped when it reached the 30th floor, which was protected by automatic sprinklers.
As the fire ignited in different points this floor level through the floor assembly and by autoexposure
through the windows, 10 sprinkler heads activated and the fires were extinguished at each point
of penetration. The vertical spread of the fire was stopped solely by the action of the automatic
sprinkler system, which was being supplied by fire department pumpers. The 30th floor was not
heavily damaged by fire, and most contents were salvageable. The fire was declared under control at
3:01 p.m., February 24, 1991.

analYsIs

Smoke Movement

The heated products of combustion from a fire have a natural buoyancy, which causes them to accu-
mulate in the upper levels of a structure. In a highrise building the stairways, elevator shafts, and
utility shafts are natural paths for the upward migration of heated products of combustion.

Stack effect is a natural phenomenon affecting air movement in tall buildings. It is characterized by
a draft from the lower levels to the upper levels, with the magnitude of the draft influenced by the
height of the building, the degree of air-tightness of exterior walls of the building, and temperature
differential between inside and outside air.6 This effect was particularly strong on the night of the
fire due to the cold outside temperature. Interior air leakage rates, through shaft walls and openings,
also modulate the rate of air flow due to stack effect. Smoke and toxic gases become entrained in this
normal air movement during a fire and are carried upward, entering shafts through loose building
construction or pipe and duct penetrations. The air flow carries smoke and gases to the upper por-
tions of the structure where the leakage is outward.

At the upper portions of the structure, smoke and toxic gases fill the floors from the top floor down
toward the fire, creating a dangerous environment for building occupants and firefighters. During
the investigation of this fire, this upward flow was evidenced by the presence of heavy soot in the
38th floor mechanical room and all the upper floors of the building. The path of smoke travel to the
upper floors was vividly evidenced by the soot remnants in HVAC shafts, utility chases, return air
shafts, and exhaust ducts.

6 Fitzgerald, R. (1981), “Smoke Movement in Buildings,” in Fire Protection Handbook, 15th ed., McKinnon, G. P., ed., Quincy,
MA: National Fire Protection Association, p. 3-32.

USFA-TR-049/February 1991 13

Fuel Loading

Fuel loading on the fire floors consisted mainly of files and papers associated with securities trading
and management consulting. At least one floor had a significant load of computer and electronic
equipment. In some cases, correlation could be found between heavy fuel load and damage to
structural members in the affected area. From the 22nd floor to the 29th floor, the fire consumed all
available combustible materials with the exception of a small area at the east end of the 24th floor.

Structural Conditions Observed

Prior to deciding to evacuate the building, firefighters noticed significant structural displacement
occurring in the stair enclosures. A command officer indicated that cracks large enough to place a
man’s fist through developed at one point. One of the granite exterior wall panels on the east stair
enclosure was dislodged by the thermal expansion of the steel framing behind it. After the fire, there
was evident significant structural damage to horizontal steel members and floor sections on most of
the fire damaged floors. Beams and girders sagged and twisted–some as much as three feet–under
severe fire exposures, and fissures developed in the reinforced concrete floor assemblies in many
places. Despite this extraordinary exposure, the columns continued to support their loads without
obvious damage.

InCIDenT COMManD
During nearly 19 hours of firefighting, the Philadelphia Fire Department committed approximately
316 personnel operating 51 engine companies, 15 ladder companies, and 11 specialized units,
including EMS units, to the 12-alarm incident. The incident was managed by 11 battalion chiefs
and 15 additional chief officers under the overall command of the Fire Commissioner. All apparatus
and personnel were supplied without requesting mutual aid. Off-duty personnel were recalled to
staff reserve companies to maintain protection for all areas of the city. Philadelphia uses an incident
management system known within the department as Philadelphia Incident Command (PlC). It is
based on the ICS system taught at the National Fire Academy.

Operations

The Department’s standard operating procedures for a highrise incident were implemented at the
time of arrival. Incident commanders were confronted with multiple simultaneous systems failures.
As a result, command and control decisions were based on the need to innovate and to find alternate
approaches to compensate for the normal systems that firefighters would have relied on to bring this
incident to a more successful conclusion.

Philadelphia Fire Department tactical priorities in a highrise fire focus on locating and evacuating
exposed occupants and making an aggressive interior attack to confine the fire to the area or at least
the floor of origin. Confronted with total darkness, impaired vertical mobility because the eleva-
tors were inoperable, water supply deficiencies which made initial attack efforts ineffective, vertical
fire spread via unprotected interior openings and external auto-exposure, and worsening heat and
smoke conditions in the stairways, the tactical focus shifted to finding something (perhaps anything)
which could be accomplished safely and effectively.

When Engine 11’s crew reported their predicament, the priority changed to attempting to locate
and rescue the trapped firefighters. Unfortunately, these efforts were in vain and nearly proved tragic

14 U.S. Fire Administration/Technical Report Series

when the eight firefighters conducting search and rescue operations became disoriented and ran out
of air in the 38th floor mechanical room and nearly perished while trying to locate a roof exit. The
rescue of these members was extremely fortunate in a situation that could have resulted in an even
greater tragedy.

Communications

As is often the case, communication at such a large incident presented a serious challenge to main-
taining effective command and control. The loss of electrical power plunged the entire building into
total darkness, forcing firefighters to rely on portable lights. This impacted even face-to-face com-
munications by making it difficult for people to identify with whom they were talking.

Radio communication was also affected by the significant duration of the incident. A field com-
munications van was brought to the scene early in the incident with a supply of spare radios and
batteries, but it was a major challenge to provide charged batteries for all of the radios that were in
use in the incident.

To ease congestion on fireground radio channels, cellular telephones were used to communicate
between the Command Post in the lobby and the staging area on the 20th floor. Several other com-
munications functions took advantage of the cellular telephone capability.

Logistics

The Logistics Section was responsible for several functions including refilling SCBA cylinders, sup-
plying charged radio batteries, and stretching the 5-inch supply line up the stairways. These were
monumental endeavors which required the labor of approximately 100 firefighters. Equipment
and supplies were in constant demand including handlights and portable lighting, deluge sets,
hose, nozzles and other equipment. The Staging Area on the 20th floor included the Medical and
Rehabilitation sectors.

The Philadelphia Fire Department used its highrise air supply system to refill air cylinders on the
20th floor. Falling glass and debris severed the airline, which is extended from the air compressor
vehicle outside the building to the staging area, and the system had to be repaired and reconnected
at the scene.

Safety

When things go wrong on a scale as large as One Meridian Plaza, safety becomes an overriding
concern. Firefighters were continually confronted with unusual danger caused by multiple system
failures during this incident. The deaths of the three firefighters and the critical situation faced by
the rescue team that was searching for them are clear evidence of the danger level and the difficulties
of managing operations in a dark, smoke-filled highrise building.

A perimeter was set up around the building to prevent injuries from falling glass and stone panels,
but it was necessary for personnel to cross this zone to enter and exit the building and to maintain
the hoselines connected to the standpipe system. One firefighter was seriously injured when struck
by falling debris while tending the hoselines. In addition, all supplies and equipment needed inside
the building had to cross the safety perimeter at some point.

USFA-TR-049/February 1991 15

Many firefighters working inside the building were treated for minor injuries and fatigue during the
fire. Rest and rehabilitation sectors contributed to firefighter safety by improving mental and physi-
cal stamina, and a medical triage treatment area was established on the 20th floor.

The physical and mental demands on personnel were extraordinary. In addition to managing the
physical safety of personnel, their emotional and psychological well-being were considered. The
department activated its critical incident stress debriefing program and relieved first and second
alarm companies soon after discovering that the crew of Engine 11 had died on the 28th floor.
More than 90 firefighters were debriefed on site after the dead firefighters were evacuated. The CISD
involvement continued after the fire, due to the tremendous impact of the loss and the risk to the
hundreds of firefighters who were involved in the incident.

The most courageous safety decision occurred when Fire Commissioner Roger Ulshafer ordered the
cessation of interior firefighting efforts and evacuated the building due to the danger of structural
collapse. Firefighters did not reenter the structure until the fire had been controlled by the automatic
sprinklers on the 30th floor and burned out all of the available fuels on the fire-involved lower levels.

BUIlDInG anD FIRe ReGUlaTIOns
When One Meridian Plaza construction began in 1968, the City of Philadelphia was enforcing the
1949 edition of the Philadelphia Building Code. This code was of local origin and contained minor
amendments that had been incorporated since its enactment. This building code made no distinc-
tion between highrise and other buildings; and therefore, no special highrise construction features
were required. The general focus of the code was to provide a high degree of fire-resistive construc-
tion rather than relying on automatic sprinkler protection or compartmentation.

In 1984, Philadelphia switched from a locally developed building code to one based on the BOCA
Basic Building Code/1981. That code has since been updated, and the BOCA National Building Code/1990
is currently in force in Philadelphia. Both of these codes contain provisions expressly addressing
highrise building fire protection, including a requirement for automatic sprinkler systems in all new
highrise buildings.

As a result of this fire, the City of Philadelphia has adopted an ordinance requiring all existing high-
rise buildings to be protected by automatic sprinklers by 1997. Also, officials of the Philadelphia
Fire Department have discussed proposing adoption of the BOCA National Fire Prevention Code with local
amendments, as opposed to continuing to develop their Philadelphia Fire Prevention Code locally.

In 1981, the City enacted amendments to its Fire Code requiring the installation of special fire pro-
tection features in existing highrise buildings. These modifications included:

• Fire alarm systems with smoke detection in elevator lobbies, entrances to exit stairways,
return air plenums, corridors, and other common or public areas.

• Stairway identification signs, (i.e., identification of the stairway, floor level, and the top and
bottom levels of the stairway).

• Stairway re-entry to permit occupants to retreat from stairways compromised by smoke or
fire and return to tenant spaces. (In the event doors were locked from the stairway side for
security reasons, provisions had to be made to unlock doors automatically upon activation of
the fire alarm system.)

16 U.S. Fire Administration/Technical Report Series

In November 1984, the Philadelphia Department of Licenses and Inspections issued a notice of
violation to the owners of One Meridian Plaza requiring compliance with these amendments. The
Board of Safety and Fire Prevention later granted the owners a variance to permit stairway doors to
be locked, provided that doors were unlocked to permit re-entry every third floor.7

FIRe CODe enFORCeMenT
The preparation and adoption of fire safety regulations is managed by the Philadelphia Fire Department
under the direction of the fire marshal. However, the department does not perform or direct com-
pliance inspections of individual properties. Fire code enforcement is delegated to the Department
of Licenses and Inspections (L&I) by city charter. This department performs the functions of the
building official in Philadelphia.

The fire department conducts inspections of properties applying for variances, follows-up citizen
complaints, and makes referrals to L&I. The block inspection program detailed in Fire Department
Operational Procedure 4 (see Appendix F) provides for the annual inspection of all buildings except
one and two family dwellings. However, fire department activities to detect and abate hazards are
primarily of an educational nature. Guidelines for referring serious or continuing hazards to L&I are
not detailed in the Block Inspection procedure; however, information regarding the maintenance of
referral and appeal records for individual properties is detailed.

It has been questioned whether the working relationship between line company personnel, the fire
marshal’s office, and the Department of Licenses and Inspections produces effective fire code compli-
ance. Senior fire department officials have expressed considerable dissatisfaction with the relation-
ship between the fire department and L&I, and continue to advocate a more active role for the fire
department in code enforcement matters.

Fire inspection records for One Meridian Plaza were examined after the fire to document code
enforcement actions requiring the installation or upgrade of fire protection features required by the
1981 fire code amendments. An August 17, 1990, L&I violation notice cited the owner for failing
to pay a non-residential inspection fee and noted that a reinspection would be conducted within 30
days. However, no record of a subsequent inspection was produced.

lessOns leaRneD
Perhaps the most striking lesson to be learned from the One Meridian Plaza highrise fire is what can
happen when everything goes wrong. Major failures occurred in nearly all fire protection systems.
Each of these failures helped produce a disaster. The responsibility for allowing these circumstances
to transpire can be widely shared, even by those not directly associated with the events on and before
February 23, 1991.

To prevent another disaster like One Meridian Plaza requires learning the lessons it can provide.
The consequences of this incident are already being felt throughout the fire protection community.
Major code changes have already been enacted in Philadelphia (see Appendix G) and new proposals

7 Records and reports provided by the Philadelphia Fire Department during this investigation do not indicate the dates
of either the appeal or this variance. Firefighters did report having to force entry on several floors during firefighting
because some stairway doors were locked.

USFA-TR-049/February 1991 17

are under consideration by the model code organizations. These changes may eventually reduce the
likelihood of such a disaster in many communities.

1. Automatic sprinklers should be the standard level of protection in highrise buildings.

The property conservation and life safety record of sprinklers is exemplary, particularly in high-
rise buildings. While other fire protection features have demonstrated their effectiveness over
time in limiting losses to life and property, automatic sprinklers have proven to provide superior
protection and the highest reliability. Buildings in some of the nation’s largest cities, designed
and built around effective compartmentation, have demonstrated varying success at containing
fires, but their effectiveness is often comprised by inadequate design or installation and may not
be effectively maintained for the life of the building. Even with effective compartmentation, a
significant fire may endanger occupants and require a major commitment of fire suppression
personnel and equipment. Retrofitting of automatic sprinklers in existing buildings has proven
effective in taking the place of other systems that have been found to be inadequate.

2. Requirements for the installation of automatic sprinklers are justified by concerns about
firefighter safety and public protection effectiveness, as well as traditional measures such as
life safety and property conservation.

The property protection value of sprinklers was recognized long before life safety became a
popular justification for installing fire protection. Life safety has become the primary concern in
recent times, justifying the installation of automatic sprinklers in highrise buildings. The value
of sprinklers as a means of protecting firefighters has rarely been discussed.

Members of the fire service should promote automatic fire sprinklers if for no other reason
than to protect themselves. Requiring the installation and maintenance of built-in fire protec-
tion should become a life safety issue for firefighters.8 The opposition to retrofit protection has
consistently cited cost concerns. Communities need to be made aware that the costs they defer
may be paid by firefighters in terms of their safety. This is above and beyond the potential loss
to citizens and businesses that is usually considered.

3. Code assumptions about fire department standpipe tactics proved invalid.

One of the principal code assumptions affecting fire department operations at One Meridian
Plaza concerned the installation of standpipe pressure reducing valves. The rationale for PRVs
is the concern that firefighters would be exposed to dangerous operating pressures and forces
if they connected hoselines to outlets near the base of standpipe risers of substantial height,
particularly those supplied by stationary fire pumps. For example, in a 275 foot high standpipe zone (the
highest permitted using standard pipe and fittings), a pressure of 184 psi is required at the base of the riser to overcome
elevation and produce the minimum required outlet pressure of 65 psi at the top of the riser. At this pressure, a standard
2-1/2-inch fire hose fitted with a 1-1/8-inch straight bore nozzle would produce a back pressure (reaction force) in
excess of 500 pounds. This is a well-founded concern; however, it is built upon the assumption
that fire departments use 2-1/2-inch attack lines and straight bore nozzles to attack fires from
standpipes. Most fire departments today use 1-3/4-inch and 2-inch hose with fog nozzles

8 A study by Charles Jennings reports that the firefighter injury rate in non-sprinklered highrise buildings is seven
times higher than in comparable buildings equipped with automatic sprinklers. “In Highrise Fires, Sprinklers Beat
Compartmentation —Hands Down.” U.S. Fire Sprinkler Reporter, April 1992, pp. 1,5-7.

18 U.S. Fire Administration/Technical Report Series

for interior attack. These appliances require substantially greater working pressures to achieve
effective hose streams.

In the aftermath of this incident, the NFPA Technical Committee on Standpipes has proposed a
complete revision of NFPA 149 to more closely reflect current fire department operating prac-
tices. Section 5-7 of the proposed standard requires a minimum residual pressure of 150 psi
at the required flow rate from the topmost 2-1/2-inch hose outlet and 65 psi at the topmost
1-1/2-inch outlet (presumably for occupant use). Minimum flow rates of 500 gpm for the
first standpipe and 250 gpm for each additional standpipe remain consistent with past editions
of the standard. The proposed new requirements limit the installation of pressure regulating
devices to situations where static pressures at hose outlets exceed 100 psi for occupant use hose
or 175 psi for fire department use hose. This will provide substantially greater flow and pres-
sure margins for fire department operations. These requirements are intended to apply to new
installations and are not retroactive.

Firefighters at One Meridian Plaza had great difficulty determining how to improve flow and
pressure from hose outlets during the fire. Even if firefighters could have closely examined
the valves, with good light and under less stressful conditions, it is unlikely that they would
have been able to readjust the valves. Numerical indicators on the valve stems represented
an index for adjustment not the actual discharge pressure. (This may have confused the
technicians responsible for installing and maintaining the valves. Investigators found valves
set at “20” and “80” on the index markings. To achieve 65 psi would have required a setting
from 88 to 91 on the index. A setting of 150 to 158 was necessary to produce the maximum
allowable 100 psi.)

Pressure regulating devices come in three different types:

• Pressure restricting devices which reduce pressure under flowing conditions by reducing
the cross- sectional area of the hose outlet.

• Pressure control valves are pilot-operated devices which use water pressure within the sys-
tem to modulate the position of a spring-loaded diaphragm within the valve to reduce
downstream pressure under flowing and non-flowing conditions.

• Pressure reducing valves use a spring-loaded valve assembly to modulate the position of
the valve disc in the waterway to reduce the downstream pressure under flowing and
non-flowing conditions.

Further differentiation within each of these types results from differences in manufacturer
specifications. (Details are provided in the Philadelphia Fire Department fact sheet on pressure
regulating devices in Appendix G.) Some devices are field adjustable, some are not. Some can
be removed to permit full, unrestricted flow, others cannot.

9 The report of the Technical Committee on Standpipes appears in the NFPA 1992 Fall Meeting Technical Committee Reports,
pp 331-367.

USFA-TR-049/February 1991 19

4. The requirements and procedures for design, installation, inspection, testing, and mainte-
nance of standpipes and pressure reducing valves must be examined carefully.

The proposed revision of NFPA 14 (1993) and a new NFPA document, NFPA 25, Standard for
the Installation, Testing, and Maintenance of Water-Based Fire Protection Systems (1992), address many of the
concerns arising from this fire regarding installation and adjustment of pressure reducing valves.
NFPA 14 requires acceptance tests to verify proper installation and adjustment of these devices.
NFPA 25 requires flow tests at five year intervals to verify proper installation and adjustment.

Neither of these standards proposes changes in the performance standards for the design of
pressure reducing valves.

Standard performance criteria for the design and operation of each type of valve should be
adopted to encourage user-friendly designs that will permit firefighters to achieve higher pres-
sure and flow rates without interrupting firefighting operations. The operation and adjustment
of valves should be easy to identify and clearly understandable by inspection and maintenance
personnel without reliance on detailed operating or maintenance instructions.

It is extremely important to have all systems and devices thoroughly inspected and tested at the
time of installation and retested on a regular basis. Fire suppression companies that respond to
a building should be familiar with equipment that is installed in its fire protection systems and
confident that it will perform properly when needed.

5. Inconsistencies between code assumptions and firefighting tactics must be addressed.

The inconsistency between fire department tactics and design criteria for standpipe hose outlet
pressures was widely recognized before this fire. However, little was done to change fire depart-
ment tactics or to amend the code requirements for standpipe installations.

Fire departments utilize lightweight hose and automatic nozzles for the same reasons the code
requires pressure reducing valves: firefighter safety. The inconsistency between these approaches
can cause serious problems. Where pressure reducing valves are not installed, fire departments
can usually augment water supplies by connecting to the fire department connections. However,
when contemporary firefighting tactics are employed and improperly adjusted PRVs are installed,
the combination is likely to produce hose streams with little reach or effectiveness.

The PRV equipped hose outlets on the 22nd floor of One Meridian Plaza, adjusted as reported
at the time of the fire, would have produced nozzle pressures of approximately 40 psi. This is
insufficient for a straight stream device and dangerously inadequate for a fog nozzle.

Standard operating procedures for highrise buildings, particularly those not protected by auto-
matic sprinklers, should reflect the potential need to employ heavy firefighting streams, which
may require higher flows and pressures.

Pre-fire planning is an essential fire department function.

The availability of information about the building was a problem in this incident.

The purpose of conducting pre-fire plans is to gather information about buildings and occupan-
cies from the perspective that a fire will eventually occur in the occupancy. This information
should be used to evaluate fire department readiness and resource capabilities. At a fire scene,
pre-fire plan information can be used to formulate strategies for dealing with the circumstances
which present themselves.

20 U.S. Fire Administration/Technical Report Series

Pre-fire planning activities should identify building and fire protection features which are likely
to help or hinder firefighting operations and record this information in a format usable to fire-
fighters at the scene of an emergency. Recognizing and recording information about restricting
devices and pressure reducing valves should be among the highest priorities. Information on
fire alarm systems and auxiliary features such as elevator recall, fan control or shutdown, and
door releases should also be noted.

The fire department was unable to obtain important details about the installed fire protection
at One Meridian Plaza during critical stages of the fire attack. Detailed information about the
design and installation of standpipes, pressure relief valves and the fire pump, could have aided
firefighters significantly if it had been available earlier in the fire.

Pre-fire plans and standard operating procedures should also consider evacuation procedures
and plans for the removal of occupants.

7. Standard Operating Procedures (SOPs) and training programs for fires in highrise build-
ings should reflect the installed protection and highrise fire behavior.

Training and SOPs should consider ways to achieve adequate fire flow with available pressures
and ways to improve flow and pressure when required. Tactics for placing multiple lines in
service simultaneously must also be developed and discussed.

Extensive pre-fire planning and training are required for fire department control of mechani-
cal smoke management systems to be effective. Training in the management of smoke should
consider stack effect and the ability to predict and/or direct ventilation in a real incident.

8. Safety-oriented strategies should dominate command decisions when multiple systems
failures become evident.

This incident presented command officers with an unprecedented sequence of system failures.
As more things went wrong, officers had to seek alternative approaches to manage the situation.
The time pressure and stress of fireground command can make it difficult to thoroughly evaluate
each alternative approach, particularly as new and unanticipated problems are presented in rapid
succession. Conservative tactics, oriented toward protecting the firefighters who must execute
them, should take precedence when confronted with an unknown and unanticipated situation,
since the potential consequences of fireground decisions can rarely be fully evaluated during
the incident. As much as possible, these alternatives should be considered beforehand in pre-
fire planning, standard operating procedures, and training materials, and by reviewing post-fire
critiques and reports of other incidents. This is an incident that will make a major contribution
to the knowledge of what can and will happen when major system failures occur in the worst
imaginable sequence.

9. Fire code enforcement programs require the active participation of the fire department.

In Philadelphia, responsibility for the fire code is fragmented. The fire department is respon-
sible for developing and maintaining fire code requirements, supervising the appeals process, and
investigating and referring fire code complaints. However, it does not conduct regular periodic
code enforcement inspections, issue permits, or develop target hazard protocols for ensuring that
inspections conducted by the responsible agency are addressing critical fire protection problems.

USFA-TR-049/February 1991 21

Many of the model code requirements that apply to highrise buildings are predicated upon
assumptions about firefighting strategies and tactics. Most model code organizations designate
the fire department, fire prevention bureau, or fire marshal’s office as the principal enforcement
authority for fire protection system requirements. Fire department personnel are in the best
position to validate code assumptions and see that the built-in fire protection and life safety
systems are functional and compatible. Moreover, the first-hand knowledge and experience of
firefighters with fire behavior is often an invaluable resource when interpreting fire and building
code requirements.

10. Code provisions should be adopted requiring highrise building owners to retain trained
personnel to manage fire protection and life safety code compliance and assist fire depart-
ment personnel during emergencies.

Model fire prevention codes require building owners to develop highrise fire safety and evacu-
ation plans to manage the life safety complexities of these buildings. The requirements are not
specific about what must be included in these plans, and they give no explicit consideration to
the problems of firefighting and property conservation.

Mandating the appointment and certification of individuals with specialized knowledge in code
requirements and building systems would go a long way toward ensuring that the unique
aspects of each highrise building are incorporated into detailed plans.

(New York City Local Law 5 requires that each owner designate a fire safety director. The respon-
sibilities of this individual for managing the life safety plan during an incident are clearly estab-
lished in this ordinance.)

11. Occupants and central station operators must always treat automatic fire alarms as though
they were actual fires, especially in highrise buildings.

Building personnel, alarm services, and fire departments must develop an expectation that an
automatic alarm may be an indication of an actual fire in progress. Automatic detection systems
have gained a reputation for unnecessary alarms in many installations. This has caused an atti-
tude of complacency that can be fatal in responding to such alarms. To change such attitudes and
expectations, it will be necessary to improve the reliability and performance of many systems.

By choosing to investigate and verify the alarm condition, the building engineer nearly lost his life. If not for the ability
to communicate with the lobby guard to relay instructions for manually recalling the elevator, this individual would likely
have shared the fate of his counterpart who died in a service elevator at the First Interstate Bank Building Fire in Los
Angeles (May 4, 1988).

Technological advances and improved maintenance procedures are the answers to solving the
nuisance alarm problem. In addition to requiring regular maintenance of systems by qualified
individuals, Philadelphia and other cities have stiffened the penalties on owners, occupants, and
central station operators who fail to report automatic fire alarm activations.

12. Incomplete fire detection can create a false sense of security.

Automatic fire detectors, like automatic sprinklers, are components of engineered fire protection
systems. A little protection is not always better than none. Over-reliance on incomplete protec-
tion may lead to a false sense of security on the part of building owners and firefighters alike.

22 U.S. Fire Administration/Technical Report Series

Automatic fire detectors can only notify building occupants or supervisory personnel at a cen-
tral, remote, or proprietary station that an event has occurred, and in some cases initiate action
by other systems to limit the spread of fire, smoke, or both. (In this case, automatic detectors
initiated an alarm, recalled elevators, and shutdown air handling equipment; however an eleva-
tor was subsequently used to go to the fire floor to investigate the alarm.)

Smoke detectors at One Meridian Plaza were installed in particular areas as required by the 1981
amendments to the fire code; that is at the point of access to exits, at the intakes to return air
shafts, and in elevator lobbies and corridors. The apparent underlying logic was to protect the
means of egress and to detect smoke in the areas where it was most likely to travel. It appears in
this case that the partitions and suspended ceiling contained the smoke and heat during the fire’s
incipient phase and prevented early detection. In all likelihood, the first detector may not have
activated until after the room of origin had flashed-over. Shortly after flashover, the suspended
ceiling in this area probably failed permitting the fire to spread throughout the return air ple-
num. Once the fire broke the exterior windows and established an exterior air supply there
was little that could be done to control the fire. Firefighters were disadvantaged by the delay in
reporting the fire.

13. Nationally recognized elevator code requirements for manual control of elevators during
fire emergencies work.

Elevator control modifications at One Meridian Plaza were accomplished in accordance with
Commonwealth of Pennsylvania requirements based on ANSI/ASME A17.l, Safety Code for Elevators
and Escalators. The elevators performed as expected by the standard. The only problem with the
elevator response was the decision of the building engineer to override the system to investigate
the alarm.

14. The ignition source provided by oil-soaked rags is a long recognized hazard that continues
to be a problem.

Had the contractor refinishing paneling on the 22nd floor not carelessly left oil soaked cleaning
rags unattended and unprotected in a vacant office, this fire would not have occurred. To pin-
point the particular source of ignition of this fire as the sole cause of the death and destruction
that followed is a gross oversimplification. Nevertheless, failure to control this known hazard
is the proximate cause of this disaster. The danger of spontaneous heating of linseed oil-soaked
rag waste is widely recognized. Each model fire prevention code requires precautions to pre-
vent ignition of such materials. At a minimum, waste awaiting removal from the building and
proper disposal must be stored in metal containers with tight-fitting, self-closing lids. Leaving
these materials unattended in a vacant office over a weekend was an invitation to disaster. This
is both an education and an enforcement problem for fire prevention officials.

15. Building security personnel should be vigilant for fire safety as well as security threats,
especially while construction demolition, alteration, or repair activities are underway.

Earlier in the day, the building engineer had become aware of an unusual odor on the 22nd
floor which he associated with the refinishing operations which were underway there. When
the alarm system activated later that evening he first believed the solvent vapors had activated a
smoke detector.

USFA-TR-049/February 1991 23

The roving security guard made no mention of anything unusual during his rounds of the fire
area earlier in the evening. It is conceivable that no detectable odor of smoke or audible or visible
signals of a fire were present when the guard last checked the floor. However, a cursory check
is not adequate when construction, demolition, renovations, or repair activities are underway
in a building area. Fire hazards are often associated with construction activities, and buildings
are especially vulnerable to fire during such operations. For these reasons, it should be standard
practice to check these areas even more carefully and thoroughly than usual. All building oper-
ating and security personnel should have basic training in fire prevention and procedures to be
followed when a fire occurs.

16. Emergency electrical systems must be truly independent or redundant.

Article 700 of the National Electrical Code recognizes separate feeders as a means of supplying
emergency power. However, Section 700-12(d) requires these services to be “widely separated
electrically and physically…to prevent the possibility of simultaneous interruption of supply.”
Installing the primary and secondary electrical risers in a common enclosure led to their almost
simultaneous failure when the fire penetrated voids in the walls above the ceiling of the 22nd
floor electrical closet. The intense heat melted conductor insulation resulting in dead shorts to
ground which opened the overcurrent protection on each service interrupting power through-
out the building.

Auxiliary emergency power capability was provided by a natural gas powered generator located
in the basement mechanical room. This generator was intended to supply one elevator car in
each bank, fire pumps, emergency lighting and signs, and the fire alarm system. However, this
generator set failed to produce power when needed. (Generator maintenance records indicated
a history of problems; however, the root cause or mechanism responsible for these problems
was not identified.)

Supplying the generator from the building natural gas service also left the emergency power sys-
tem vulnerable in the event of simultaneous failure of the electrical and gas public utilities. The
transformers that provided power for the adjacent building were installed in the basement of the
One Meridian Plaza Building. These transformers had to be shut down due to the accumulation
of water in the basement, resulting in the loss of power to this building as well. As a result the
elevators in the adjoining building could not be used.

17. The regulations governing fire-resistance ratings for highrise structural components should
be re-evaluated.

The degree of structural damage produced during the fire at One Meridian Plaza suggests that
the requirements for structural fire resistance should be reexamined. Floor assemblies deflected
as much as three feet in some places. The fire burning on multiple floors may have produced
simultaneous exposure of both sides of these assemblies, which consisted of concrete slabs on
corrugated decks, supported by structural steel beam and girder construction, sprayed with
cementitious fireproofing materials. The standard fire test for floor and ceiling assemblies
involves exposure from a single side only.

Columns and certain other structural elements are normally exposed to fire from all sides. In
this fire, the steel columns retained their structural integrity and held their loads. Experience in

24 U.S. Fire Administration/Technical Report Series

this and similar highrise fires suggest that columns are the least vulnerable structural members,
due to their mass and relatively short height between restraints (floor to floor). Major damage
has occurred to horizontal members, without compromising the vertical supports.

The development of uniform criteria for evaluating structural fire endurance accompanied the
development of skyscrapers in the early 20th century. Test methods developed at the beginning
of the century became the first fire-resistance standard in 1909,10 which endures today as ASTM
E119, Method of Fire Test of Building Construction and Materials. One of the principal criticisms of this
standard has been its lack of correlation with actual fire conditions.

Many fire protection professionals believe that the standard time- temperature curve used to
produce the standard fire exposure during testing is less severe than actual fires involving con-
temporary fuel loads. (The original test method was based on less volatile, primarily cellulosic,
fuels, while modern plastics and hydrocarbon-based furnishings and finishes produce much
more dangerous and severe fire exposures.) Others believe that the current test method works
well because it provides a good yardstick for comparing the performance of different systems and
has been in widespread use for many decades, generating volumes of data on many systems.11

18. Inspections must be conducted during and after construction to verify that penetrations in
fire-resistance rated assemblies are properly protected.

Voids and so-called poke-throughs in horizontal and vertical fire separation assemblies presented
ideal avenues of fire spread during the One Meridian Plaza fire. Openings in the partitions enclos-
ing electrical equipment on the floor of origin permitted the fire to reach and damage the electrical
risers, plunging firefighters into darkness early in the fire. Voids in stairwell enclosures permitted
smoke to spread in stairwells making firefighting operations difficult and exposing upper floors.
Smoke and fire also extended via pipe chases, and telephone and electrical closets.

Through-penetration protection has been a continuing concern and has received considerable
attention in building and fire codes in recent years. Each of the model building codes now contains
provisions requiring protection of poke-throughs in fire-resistance rated assemblies. Moreover, a
whole new industry has been developed to fill the technological void in through-penetration
protection which developed with the widespread acceptance of plastic pipe and cable.

The absence of fire dampers in mechanical system supply and return ducts at shaft penetrations
on each floor is of particular concern. There is evidence of smoke and fire spread through the
air handling system. Nationally recognized model building, fire, and mechanical codes have
contained requirements for fire dampers in these locations for many years. The installation of
smoke detectors in these locations was an ineffective substitute for protecting the integrity of
smoke and fire barriers. This fire clearly illustrates that smoke and fire spread through mechani-
cal system plenums, ducts, and shafts is substantial even without the aid of operating fans.12

10 Fitzgerald, R. W. (1981), “Structural Integrity During Fire,” in Fire Protection Handbook, 15th ed., McKinnon, G. P., ed.,
Quincy, MA: National Fire Protection Association, p. 5-62.

11 Actual conditions in most fires produce heat release curves similar to the standard exposure up to the point where oxygen,
i.e., ventilation, becomes restricted by fire product release, i.e., smoke and heated gases. However, at this point, actual fires
usually diminish in size unless ventilation improves or a renewed oxygen supply is established. Once refreshed with a new
air supply, most fires will resume growth, reach a peak, and then diminish as the fuel supply is consumed.

12 HVAC fans were shut down at night and on weekends, and were not operating at the time of the fire.

USFA-TR-049/February 1991 25

19. Features to limit exterior vertical fire spread must be incorporated in the design of highrise
buildings.

Exterior vertical fire spread or autoexposure can be a significant fire protection problem in con-
struction of highrise buildings if interior fire growth is unrestricted. Because of the difficulty
with retrofitting exterior features to restrict fire spread, the installation of automatic sprinklers
to restrict fire growth is the most simple approach to managing this risk in existing buildings.
Exterior features to prevent fire spread must usually be designed and built into new build-
ings. Many modern (international style) and post-modern building designs present difficult
exterior fire spread challenges because of their smooth exterior facades and large glazing areas.
Variegated exterior facades and larger noncombustible spandrels significantly reduce exterior
fire spread effects by increasing the distance radiant and conductive heat must travel to stress
exterior windows and to heat materials inside the windows on floors above the fire.

COnClUsIOn
The ultimate message delivered by this fire is the proof that automatic sprinklers are the most effec-
tive and reliable means at our disposal to protect highrise buildings. When all other systems failed,
automatic sprinklers were successful in controlling the fire. The Philadelphia Fire Department was
confronted with an essentially impossible situation and did a commendable job of managing the
incident. The loss of three firefighters is a tragedy that will always be remembered by the Philadelphia
Fire Department. Analysis of the situation reveals, however, that the toll could have been much
worse, had it not been for the courage, skills, and experience of this department. Several extremely
difficult decisions were made under the most severe conditions. This fire will also be remembered
for the lessons that it brings with respect to fire protection systems. To work effectively, such systems
must be properly designed, installed, and maintained. When those requirements are not satisfied,
the results can be devastating, as clearly demonstrated by this incident.

sOURCes OF InFORMaTIOn
In addition to references to codes and standards cited in the text, news media accounts of the fire,
and interviews with officials of the Philadelphia Fire Department, the following resources were used
in the preparation of this report:

Alert Bulletin: Pressure Regulating Devices in Standpipe Systems (May 1991). Quincy, MA: National
Fire Protection Association.

Butters, T., and T. Elliott (March 1991). “How the Philadelphia FD Handled the Worst Highrise Fire
in the City’s History,” IAFC On Scene, March 15, 1991.

Eisner, H., and B. Manning (August 1991). “One Meridian Plaza Fire,” Fire Engineering, August 1991.
pp. 50-70.

Factory Mutual Engineering Corporation (March 1990). Highrise Buildings, Loss Prevention Data
Sheet 1-3. Boston, MA: Factory Mutual Engineering Corporation.

Factory Mutual Engineering Corporation (December 1986). Pressure Reducing Valves for Fire
Protection Service, Loss Prevention Data Sheet 3-11. Boston, MA: Factory Mutual Engineering
Corporation.

26 U.S. Fire Administration/Technical Report Series

Klem, T. J. (May 1991). Preliminary Investigative Report: One Meridian Plaza, Philadelphia, PA,
February 23, 1991, Three Fire Fighter Fatalities. Quincy, MA: National Fire Protection Association.

Klem, T. J. (September/October 1991). “Highrise Fire Claims Three Philadelphia Fire Fighters,”
NFPA Journal, Sept/Oct 1991. pp. 64- 67, 89.

Linville, J. L., ed. (1991). Fire Protection Handbook, 17th ed. Quincy, MA: National Fire Protection
Association.

McKinnon, G. P., ed. (1981). Fire Protection Handbook, 15th ed. Quincy, MA: National Fire Protection
Association.

One Meridian Plaza: 12-Alarm Highrise Fire (1991), Philadelphia, PA: Philadelphia Fire Films.
Videotape.

aPPenDIx a

Elevation Drawing of the Building and 22nd Floor Plan,
Floor of Origin

NORTH ELEVATION
1414 South Penn Square

One Meridian Plaza

28 U.S. Fire Administration/Technical Report Series

appendix a (continued)

O
ne

M
er

id
ia

n
P

la
za

nd
F

lo
or

77
2-

11
-1

0-
92

-1
R

11
-2

3-
92

Appendix B

Building Emergency Instructions

Appendix C

Philadelphia Fire Department
Highrise Emergency Procedures

USFA-TR-049/February 1991 31

Appendix C (continued)

32 U.S. Fire Administration/Technical Report Series

Appendix C (continued)

USFA-TR-049/February 1991 33

Appendix C (continued)

34 U.S. Fire Administration/Technical Report Series

Appendix C (continued)

USFA-TR-049/February 1991 35

Appendix C (continued)

Appendix d

Factory Mutual Engineering Corporation
Pressure Reducing Valve Loss Prevention Data Sheet

USFA-TR-049/February 1991 37

Appendix d (continued)

38 U.S. Fire Administration/Technical Report Series

Appendix d (continued)

Appendix e

Philadelphia Fire Department
Pressure Regulating Device Fact Sheet

40 U.S. Fire Administration/Technical Report Series

Appendix e (continued)

USFA-TR-049/February 1991 41

Appendix e (continued)

42 U.S. Fire Administration/Technical Report Series

Appendix e (continued)

USFA-TR-049/February 1991 43

Appendix e (continued)

44 U.S. Fire Administration/Technical Report Series

Appendix e (continued)

USFA-TR-049/February 1991 45

Appendix e (continued)

46 U.S. Fire Administration/Technical Report Series

Appendix e (continued)

Appendix F

Philadelphia Fire Department Block Inspection Program

48 U.S. Fire Administration/Technical Report Series

Appendix F (continued)

USFA-TR-049/February 1991 49

Appendix F (continued)

50 U.S. Fire Administration/Technical Report Series

Appendix F (continued)

USFA-TR-049/February 1991 51

Appendix F (continued)
E.
1.

52 U.S. Fire Administration/Technical Report Series

Appendix F (continued)
6.

USFA-TR-049/February 1991 53

Appendix F (continued)

54 U.S. Fire Administration/Technical Report Series

Appendix F (continued)

Appendix G

Philadelphia Fire Code Amendments Adopted after the
One Meridian Plaza Fire

56 U.S. Fire Administration/Technical Report Series

Appendix G (continued)

USFA-TR-049/February 1991 57

Appendix G (continued)

58 U.S. Fire Administration/Technical Report Series

Appendix G (continued)

USFA-TR-049/February 1991 59

Appendix G (continued)

60 U.S. Fire Administration/Technical Report Series

Appendix G (continued)

USFA-TR-049/February 1991 61

Appendix G (continued)

aPPenDIx H

Photographs

Numerous slides and photographs are included with the master report at the United States Fire
Administration. The photographs presented on the following pages were taken by Charles Jennings
after the fire, except where otherwise noted.

USFA-TR-049/February 1991 63

Philadelphia Inquirer photo by Michael S. Wirtz

Exterior view of One Meridian Plaza and fireground operations in the early
morning hours of February 24, 1991. Fire involves the 22nd, 23rd, 24th,

and part of the 25th floors. Note the heavy stream played on the
exterior from an adjacent building.

appendix H (continued)

64 U.S. Fire Administration/Technical Report Series

Ph
ila

de
lp

hi
a

In
qu

ire
r

ph
ot

o
by

M
ic

ha
el

M
al

A
er

ia
l

vi
ew

o
f

x
te

ri
o

r
fi

re
fi

gh
ti

n
g

o
p

er
at

o
n

s
af

te
r

d
aw

n
o

n
F

b
ru

ar
y

2
4

, 1
9

9
1

appendix H (continued)

USFA-TR-049/February 1991 65

Ph
ila
de
lp
hi
a
In
qu
ire
r
ph
ot
o
by
M
ic
ha
el
M
al
ly

Ex
te

ri
o
r
fi
re
fi
gh
ti
n
g

ef
fo

rt
s

fr
o

m
t

h
e

G
ir

ar
d

B
u

il
d

in
g

#
1

, e
as

f
O

n
e

M
er
id
ia

n
P

la
za

.
T

h
e

tw
o

b
u

il
d

in
gs

a
re

c
o

n
n

ec
te

d
o

o
w

er
fl

o
o

rs
.

appendix H (continued)

66 U.S. Fire Administration/Technical Report Series

appendix H (continued)
Ph
ila
de
lp
hi
a
In
qu
ire
r
ph
ot
o
by

R
ic

k
B

ow
m

m
o

ke
p

o
u

rs
f

o
m

O
n

e
M

er
id

ia
n

P
la

za
a

s W
il

li
am

P
en

n
l

o
o

k
s

o
n

f
ro

m
a

to
p

P
h

il
ad

el
p

h
ia

C
it

y
H

al
l

th
e

m
o

rn
in

g
o

f
Fe

b
ru
ar
y
2
4
, 1
9
9
1

, a
ft

er
i

n
te

ri
o
r
fi
re
fi
gh
ti
n
g
ef
fo
rt
s

h
av

e
b

ee
n

s
u

sp
en

d
ed

USFA-TR-049/February 1991 67

appendix H (continued)
Ph
ila
de
lp
hi
a
In
qu
ire
r
ph
ot
o
by
M
ic
ha
el
M
al
ly

V
ie

w
o

f
d

el
u

ge
s

et
o

p
er

at
in

g
fr

o
m
O
n

e
C

en
tr

e
Sq

u
ar

68 U.S. Fire Administration/Technical Report Series

appendix H (continued)

Exterior view of building looking south from City Hall Plaza.

USFA-TR-049/February 1991 69

appendix H (continued)

Exterior view of south side of building.

70 U.S. Fire Administration/Technical Report Series

appendix H (continued)

T
h

is
s

ta
ir

w
ay

c
o
n
n
ec
te

d
t

h
e
O
n
e
M
er
id
ia
n
P
la

za
B

u
il

d
in

g
w

it
h

t
h

e
ad

ja
ce

n
t

o
ffi

ce
b

u
il
d
in
g.

USFA-TR-049/February 1991 71

appendix H (continued)

H
er

e
an

d
i

n
t

h
e

n
ex

t
tw

o
p

h
o

to
s

ex
te
ri
o

r
gr

an
it

e
p

an
el

s
fr

o
m
t
h

e
ea

st
s

ta
ir

t
o

w
er

e
d

is
lo

d
ge

d
d

u
e

to
t

h
e

h
er

m
al

p
an

si
o

n
o

f
th

e
st

ee
l

fr
am

e
o

f
th
e
b
u
il
d
in
g.

72 U.S. Fire Administration/Technical Report Series

appendix H (continued)

USFA-TR-049/February 1991 73

appendix H (continued)

74 U.S. Fire Administration/Technical Report Series

appendix H (continued)

Ph
ot

o
by

J
am

es
D

av
id

O
n
e
o
f
th

e
ar

ea
s

o
f

fi
re

p
en

et
ra

ti
o

n
o
n
t
h
e

3
0

th
fl

o
o

r
w

h
er

e
a

si
n

gl
e

sp
ri

n
k

le
r

h
ea

d
a

ct
iv

at
ed

t
o

s
to

p
t

h
e

u
p

w
ar

d
e

x
te

n
si

o
n

o
f
th

e
fi

re
.

USFA-TR-049/February 1991 75

appendix H (continued)

Close-up of crack in concrete floor, 28th floor.

76 U.S. Fire Administration/Technical Report Series

appendix H (continued)
H
er
e
an
d
i
n
t
h
e
n
ex

t
th

re
e

p
h

o
to

s
ar

e
in

te
ri

o
r

vi
ew

s
o

f
fl

o
o

r
ar

ea
s

af
te

r
th

e
fi

re
.

N
o

te
t

h
e

to
ta

l
co

n
su

m
p

ti
o
n
o
f
th

e
av

ai
la

b
le

el
a

n
d

s
ag

gi
n

g
o
f
th

e
fl

o
o

r
d

ec
k

o
f

u
p
t
o
t
h
re
e

fe
et

b
et

w
ee

n
c

o
lu

m
n

USFA-TR-049/February 1991 77

appendix H (continued)

78 U.S. Fire Administration/Technical Report Series

appendix H (continued)

USFA-TR-049/February 1991 79

appendix H (continued)

80 U.S. Fire Administration/Technical Report Series

appendix H (continued)

D
et

ai
l

o
f

ty
p

ic
al

T
yp

e
1

B
c

o
n

st
ru

ct
io

n
, 6

th
fl
o
o

r.
N

o
te

t
h

e
sp

ra
y-

ap
p

li
ed

fi
re

p
ro

o
fi

n
g

an
d

f
ra

m
in

g
fo

r
gy

p
su

m
w

al
lb

o
ar

d
.

USFA-TR-049/February 1991 81

appendix H (continued)

Fi
re

t
o
w
er
b
et
w
ee

n
2

5
th

a
n

d
2

6
th

fl
o

o
rs

.
N

o
te

h
ea

vy
fi

re
a

n
d

s
m

o
ke

d
am

ag
e.

82 U.S. Fire Administration/Technical Report Series

appendix H (continued)

O
cc

u
p

an
t

u
se

s
ta

n
d

p
ip

e
h

o
se

c
ab

in
et

o
n

2
6

th
fl
o
o
r.

USFA-TR-049/February 1991 83

appendix H (continued)

St
an

d
p

ip
e

h
o

se
o

u
tl

et
w

it
h

p
re

ss
u

re
r

ed
u

ci
n

g
va

lv
e

(P
R

V
),

2
6
th
fl
o
o
r.

84 U.S. Fire Administration/Technical Report Series

appendix H (continued)

Photo by James David

Electrical shaft enclosure on the 30th floor, showing side-by-side risers for
the two power supplies, both damaged by fire penetration at the plenum

level of the adjoining office space.

USFA-TR-049/February 1991 85

appendix H (continued)

Se
ct

io
n

o
f

5
-i

n
ch

h
o

se
t

h
at

w
as

r
u

p
tu

re
d

b
y

fa
ll

in
g

d
eb

ri
s

o
u

ts
id

e
th

e
b
u
il
d
in

g.
H

o
se

l
in

es
f

ee
d

in
g
th
e

st
an

d
p

ip
es

a
n

en
te

ri
n

g
th

e
st

ai
rw

ay
s

w
er
e
d

am
ag

ed
s

ev
er

al
t

im
es

a
n

d
h

ad
t

o
b

e
re

p
la

ce
d

a
t

gr
ea

t
ri

sk
t

o
fi

re
fi

gh
te

rs
.

(S
h

o
ri

n
g

b
o

ar
d

s
w

er
e

la
te

r
u

se
d

t
o

p
ro

te
ct

t
h
e
h
o
se
l
in

es
.)

86 U.S. Fire Administration/Technical Report Series

appendix H (continued)

St
re

et
i

n
f

ro
n

t
o

f
th
e
b
u
il
d
in
g
fr
o
m
f
ro
n
t

st
ep

s
sh

o
w
in
g

st
ra

n
d

ed
a

u
to

s
an

d
d

eb
ri

s
in

s
tr

ee
t.

USFA-TR-049/February 1991 87

appendix H (continued)

R
o

o
ft

o
p

h
el

ip
o

rt
.

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