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Summary
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Board and Care Fire,
Mississauga, Ontario
8 People Killed
Tuesday, March 21, 1995
NFPA Report by Ed Comeau
Summary
On Tuesday, March 21, 1995, at approximately 7:40 p.m., a
fire occurred in a one-story board and care facility in
Mississauga, Ontario. The fire resulted in eight fatalities
and 12 injuries. Three people died at the time of the fire
and one died five days later. The remaining four fatalities,
determined to be related to the fire, occurred over a span
of eight months.
The 70 occupants ranged in age from 60 to 101 years old.
Many of the occupants had some degree of mental or physical
impairment that could have impeded their ability for self
rescue. Of the 70 occupants, 20 used wheelchairs, 17 used
canes or walkers, and 15 suffered from varying degrees of
mental impairment.
The building was a one story structure that was partially
sprinklered in the basement area only. The resident's rooms
were equipped with heat detectors, as were the hallways,
which were connected to an alarm system. The alarm system
was connected to an alarm monitoring company.
The fire was determined by the Ontario Fire Marshal's
office to have been caused by smoking materials which
ignited clothing in a closet in one of the rooms. The room
was occupied by two people at the time of the fire, which
occurred at 7:39 pm. One of the occupants of the room called
the fire department via 911 and reported the fire. She then
was able to escape from the room via an exterior window. The
other occupant, who was confined to a wheelchair, was not
able to escape.
Six of the other fatalities were found in their rooms.
One other victim, who was confined to a wheelchair, was
found in the hallway, having become overcome by smoke while
attempting to escape.
Smoke was able to spread to the other rooms through the
void space above the rooms. The corridor walls and the walls
between the individual units did extend above the ceiling to
the underside of the roof diaphragm. However, smoke was able
to penetrate into this void space via unprotected openings
in the ceiling in the room of origin and then into the other
areas through unsealed penetrations in the various
walls.
In addition to the void space, smoke also penetrated into
the rooms through the corridor doors to the individual
units. In several of the rooms, the occupants died from
smoke inhalation even though the door to their rooms were
closed.
The following are considered significant factors that
contributed to the outcome of this incident:
- The lack of sprinkler protection (except for the
basement);
- The failure to close the door to the room of fire
origin following detection of the fire;
- The combustible room contents; and
- The lack of staff training and fire drills.
This is the second fire to have occurred in a Mississauga
facility housing elderly people with serious loss of life.
In 1980 another fire in a nursing home killed 25 occupants.
There are a number of common factors between the two fires,
which include lack of an automatic sprinkler system and
failure to close the door to the room of origin.
There have been seven fatal board and care fire
investigated by NFPA since December, 1984. These seven
incidents have resulted in a total of 50 fatalities over a
period of 3-1/2 years. The other six incidents include:
A related article on board
and care fires was written by Ed Comeau for NFPA Journal
and can also be seen on-line.
©
1995 National Fire Protection Association, Quincy, MA
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