on i t di E l a i ec p S
A publication for the staff of Hartford Hospital
December 8, 2011
Vol. 67 No. 46
The 50th Anniversary of the Tragic Hartford Hospital Fire: Remembering Lives Lost, Living More Safely With Lessons Learned
“When Doors Opened, Death Entered.” Friday, Dec. 8, 1961, was one of the darkest days in the history of Hartford Hospital. Early in the afternoon, smoldering cigarette ash in a trash chute in the High Building created a terrifying fireball that blew out of a faulty trash chute door on the ninth floor, creating what investigators later called “a wall of flame.” In all, 16 individuals died: seven patients, five visitors and four employees.
The tragic fire left a legacy of horror, but also became the single most valuable safety lesson in hospital history. Lessons learned here that day have forever changed fire safety at Hartford Hospital, and at hospitals throughout the country. This Thursday is the 50th anniversary of that horrific event. We remember those who died; express our gratitude for those whose brave actions saved lives that day; and remain committed to improving safety at hospitals everywhere.
See Back Page For A Schedule of Today’s Events
What Happened? A Cigarette And A Trash Chute In 1961, society was still two years away from the Surgeon General’s finding that “smoking is hazardous to your health.” Patients and staff alike smoked openly in patient rooms and hospital corridors. It only took one of those cigarettes, wrongly disposed of in a hospital trash chute, to ignite the inferno that killed 16 people that December day 50 years ago. The trash and linen chutes were 150foot vertical terracotta-block shafts that stretched upward from the basement to the roof. Each nursing unit had round doors in the hall accessing them.
The trash chute doors read “Burnable trash only.” Those words may have given the impression that the trash chute discharged directly into the incinerator, but it did not. On any given day, more than 5,200 tons of debris was dumped in the trash chute, and it piled up in the basement until chute attendants - evening shift employees - moved it into the incinerator.
“Flames entered any door that was open, and anyone exposed to it died. Anyone behind a closed door survived.”
On the afternoon of Dec. 8, someone dropped a lit cigarette into the trash chute, thinking it was going into the incinerator. Instead, it fell into tons of debris - some of it highly combustible. For 10 minutes or so, a smoky fire smouldered, generated gases that accumulated in the upper chamber of the chute.
All seven patients who died were in their rooms. Of the five visitors who died, three were in patient rooms and two were in the corridor. Two of the employees who died were in patient rooms, and two were in the hall.
When someone opened a trash chute door, oxygen was introduced to the mix, and the gases exploded into flames that roared 150 feet skyward like a rocket. The pressure from the explosion blowtorched fire out an open trash chute door on the eighth floor, and through a weak-hinged chute door on the ninth. A quick thinking employee on the eighth floor kicked the door closed, but on the ninth, the flames became a fireball that blasted through vents and open doors. The fire raged for an hour, feeding on combustible ceiling tile made of a substance akin to sugar cane, and spread flame and smoke along the corridor between the fire doors.
Local firefighters responded to the three-alarm blaze with dozens of fire trucks. They quickly realized that the city’s tallest ladder - 100 feet - was half a story too short to reach the ninth floor. Hartford fireman Dick Tajirian stood at the top of the ladder, four feet shy of the window, and leapt, caught the window, and crawled inside. He raced down the hall, and closed doors to six patient rooms, probably saving the lives of those inside.
Employees helped firefighters feed hoses up the nine flights of stairs, and carried patients out of the building, many in wheelchairs. The evacuation took more than nine hours. Out of 782 patients, all but a third were discharged from the lobby; those too sick to go home were moved to the lower floors or sent to other hospitals. In the following days, the hospital sent physicians to visit every patient discharged to home during the fire to determine whether anyone needed to be readmitted. No one did.
Closed doors held back the fire.
Lessons Learned: Hospitals Everywhere Are Safer Now When the smoke cleared, Dr. T. Stewart Hamilton, president and CEO, organized staff tours of the fire-ravaged unit. He wanted employees to see the destruction and to understand the terrible cost of such an event. In an era before “transparency” was a watchword, Hamilton openly shared the results of the fire investigation. He also brought in national fire experts to advise the hospital in redesigning its buildings, its procedures and its on-site fire response so that such a catastrophe could never happen again. This resulted in a number of significant safety improvements that have become national hospital standards. Here are some of the fire code changes implemented following the Hartford Hospital fire: •
Gravity chutes (trash and laundry) must open only in a contained, fireproof room with a self-closing steel door.
Chute doors must be self closing with positive latching devices.
The chute must have sprinklers on every other floor providing fire protection from any blockage within the chute which may be burning.
Automatic sprinkler protection must exist throughout all hospital buildings. (Prior to the fire, Hartford Hospital was not required to have sprinklers because it was brick.)
Smoke barrier doors will be held open by devices which automatically release upon a fire alarm. (Previously, staff had to physically close the doors.)
Smoke barrier doors shall not be wider than 48 inches, and adjacent doors much swing in the direction opposite one another. (Before the fire, single 96-inch doors were pulled across a hall to act as a smoke barrier. They created monumental exiting hazards.)
All interior finishes shall have flame spread ratings of either class A or B. (All wallpaper, paneling, ceilings, etc.
must have an extremely low flame-spread ratio and produce little smoke. This prohibits the use of materials such as the sugar-cane ceiling that burned so readily at HH.) •
All patient room doors must have positive latching hardware. (Previously, they had friction latches that could pop open with the pressure force created by a hallway fire.)
Today, We Remember “The Fire”
Today - December 8, 2011 - we mark the 50th anniversary of the Hartford Hospital fire. We will have a Grand Rounds at 8 a.m. reviewing the event and its impact, and a press conference at 11 a.m. Beginning at 2 p.m. at Heublein Hall in the ERC, we will offer a preview of “The Hartford Hospital Fire of 1961,” a documentary that will be broadcast in January on Connecticut Public Television. We also will announce plans to create a permanent memorial on our campus to the victims and to the public safety personnel and staff who responded. We invite you to attend.
We will have a memorial service to remember those who lost their lives in the fire. At 2:38 p.m. – the time the fire broke out – we will read their names, strike a bell once for each of the deceased and observe a hospital-wide minute of silence. Here are the seven patients, five visitors and four employees who perished: Nancy Coniglione, patient Henrietta Conover, visitor Jennie Dunn, patient Adelene Fainter, visitor C. Frederick Greenleaf, patient Laura Greenleaf, visitor Grace Hatch, employee Dr. Norman Hedenstad, resident
Gladys Kokaska, patient Ruth LaPenta, patient Theresa Mascaro, visitor Diane Pape, patient Angeline Siegel, visitor Charles Siegel, patient Sadie Ward, employee Marion Winget, nurse