NFPA Journal

NFPA Journal®, July/August 2012

By Fred Durso, Jr.

On August 13, 2011, the Indiana State Fair in Indianapolis was in full swing, and a flurry of activity was occurring on the 250-acre (101.2-hectare) site. At the outdoor Hoosier Lottery Grandstand Stage, where the popular country group Sugarland was scheduled to perform at 8 p.m., workers were building a large structure — roughly 107 feet (32.6 meters) long, 57 feet (17.4 meters) wide, and 56 feet (17.1 meters) high — over the stage for suspended spotlights and other sound and lighting equipment.

About a half block from the grandstand stage, at the Indiana State Fairgrounds’ Joint Operations Center, a worker was responsible for contacting the National Weather Service (NWS) for frequent forecast updates while the fair was in progress. Forecasts that day called for potentially severe weather for central Indiana. After one NWS update, the worker jotted down a brief note: “If it organizes, strong winds and possible hail.”

By 6 p.m., Sugarland fans were already claiming their spots in front of the stage and in the nearby  grandstand. It was also around the time that the NWS issued a severe thunderstorm warning for Marion County, which includes Indianapolis, since the impending storm had produced quarter-sized hail and 60-mile-per-hour (97-kilometer-per-hour) winds in other parts of the state. The public safety and logistics director for the Indiana State Fair Commission (ISFC), which oversees fairground operations, sent out an alert via ISFC’s notification system: “These are severe storms. We will experience heavy rain, possible high winds, and some lightning. These storms should be here between 9:00 and 9:30.”

Fair and entertainment officials met at 8 p.m. to discuss operational issues related to the timing of the show, but public safety related to the weather forecast was not discussed. Following a conversation with Sugarland’s management, it was agreed that the show’s start time should be delayed to 8:50 p.m.

After the meeting, ISFC Executive Director Cindy Hoye had a chance encounter backstage with Brad Weaver, a captain with the state police. He was not on duty, but expressed concerns about the dark clouds approaching the fairgrounds from the west. “Ma’am, it’s not my call, it’s not my site, but if it were me, I’d shut it down,” he told Hoye, who then began instructing staff to prepare for the evacuation of the grandstand area. The NWS issued another severe thunderstorm warning at 8:39 p.m.

Under the impression that the event’s emcee was going to tell the crowd to evacuate, Weaver instead heard an unexpected announcement that was dictated to the emcee by Hoye: “We are all hoping for the best that the weather is going to bypass us but there [is] a very good chance that it won’t … if there is a point during the show where we have to stop the show on stage, what we would like you [to] do is calmly move towards the exits.”

Weaver gazed at Hoye. “We need to call this off,” he demanded. Hoye agreed. They headed toward the stage to make the announcement as lightning illuminated the dark sky.

They never made it back to the stage. At 8:46 p.m., a nearly 60-mile-per-hour wind gust slammed into the venue, kicking up clouds of dust. The large blue roof tarp that covered the stage rigging filled with wind like a giant sail, and a moment later ripped free, billowing up above its metal framework. In the next moment, the metal truss columns that supported the rigging began to twist and buckle; as the nearly 12,000 attendees gasped or screamed, the entire structure collapsed onto the stage and onto the spectators and stagehands who’d been located closest to it. The collapse would claim the lives of seven people and injure dozens.

As part of their response to the tragedy, state officials initiated investigations on the structure itself and on the emergency management practices before and during the event. The investigations produced two reports — one of which provided most of the event details cited above — and the findings, released in April, indicate shortfalls that seem to match other safety deficiencies that have resulted in recent injuries or deaths at assembly occupancies and non-assembly buildings. (See “Ready for Anything.")

Regarding the structure, it was determined that a wind gust of nearly 60 mph was far beyond the structural limitations of the rigging. The temporary structure had a “lateral force resisting system” intended to keep it in place using cables attached to concrete barriers in the ground, but the wind was strong enough to cause the barriers to shift, allowing the truss columns to bend and ultimately collapse. It was also revealed that the state’s codes at the time did not regulate the design or inspection of these kinds of temporary structures.

Shortcomings were also identified for emergency management practices and decision making. For example, public safety agencies with around-the-clock presence at the event, such as the Indianapolis Fire Department, were not on the distribution list for the ISFC notification alerts. Information also had a hard time getting to key management personnel; the severe thunderstorm warning issued by the NWS at 8:39 p.m., for example, was never received by either Hoye or Weaver.

As a result of the Indiana State Fair incident, an NFPA task group now has additional information to review as it considers the best way to establish decision-making protocols for venue managers who apply the Life Safety Evaluation (LSE), an important component of NFPA 101®, Life Safety Code®, that addresses an array of fire and non-fire emergencies and crowd safety issues. The task group was formed in 2010, following work on the 2012 edition of NFPA 101, to look at the operational aspects relating to the LSE. Complementing its current efforts is a new research project by the Fire Protection Research Foundation/NFPA Code Fund on expanding the use of the LSE for non-fire emergencies and non-emergency situations.

“The Indiana Fair incident is changing the way people think about emergency preparation and response, similar to what occurred with building safety after The Station nightclub [fire in Rhode Island in 2003 that killed 100 people],” says Harold Hansen, director of Life Safety and Security for the International Association of Venue Managers (IAVM) and a member of the Life Safety Code’s Assembly Occupancies and Membrane Structures Committee. “The Indiana State Fair [incident] will provide us the opportunity to raise the bar another notch. Some of these efforts were in the works before the collapse, but it has now forced people to learn to plan better.”  

Boosting awareness of the life safety evaluation
The ISFC did take emergency planning into account prior to the start of the fair, according to the report “An Independent Assessment of the August 13, 2011 Indiana State Fair Collapse Incident,” produced by Witt Associates, a public safety and crisis management consulting firm hired by the state of Indiana. A month before the collapse, the Indianapolis Division of Homeland Security designed a tabletop exercise at the ISFC’s request that addressed responses to public safety threats. One of the scenarios, coincidentally, asked participants about a response to an inclement weather forecast during the Sugarland show.

Following the tabletop exercise, the Division of Homeland Security recommended that the fairgrounds’ staff review and revise shelter-in-place procedures during extreme weather events, but these and other recommendations weren’t implemented before the state fair. The Witt report acknowledges the ISFC’s emergency response plan and an emergency procedures guide, but admits they were not fully developed, since there wasn’t a “clear understanding” of the applicability of the plan or procedures, nor a protocol for canceling or delaying an event at the Grandstand Stage during an emergency. It was also unclear who had ultimate authority for public safety during emergencies at the fair. ISFC, for example, thought the state police would take charge, while the state police thought ISFC would oversee a response.

Complicating matters were structural inadequacies that contributed to the roof and truss collapse at the Grandstand Stage. The “Indiana State Fair Commission August 13, 2011 Collapse Incident Investigative Report,” produced by Thornton Tomasetti, an investigation, design, and analysis firm, notes that the structure was incapable of withstanding minimum code-specified wind speeds (68 miles per hour) or the wind speed at the time of collapse (approximately 59 miles per hour). Moreover, the state’s building code lacked requirements for the appropriate design, review, permitting, and inspection of such temporary structures, states the report.

Members of the Indiana Fire Prevention and Building Safety Commission, which was formed after the collapse, approved a series of regulations in May that now require the inspection of temporary rigging, as well as a buffer zone near stages. “We’ve been very busy,” says Indiana State Fire Marshal James Greeson. “We’re reaching out to various festival and fair associations, various cities and towns, and county officials to ensure that places that haven’t applied for an amusement or entertainment permit in the past [are expected to].” Last year, the Indiana Department of Homeland Security issued nearly 2,000 amusement and entertainment permits; roughly 800 of these events included stages.

Developing an all-encompassing safety review for both permanent and temporary structures in assembly occupancies is at the core of the LSE. First appearing in the 1994 edition of the Life Safety Code (the specifics are in Annex A of the 2012 edition), the LSE provides significant guidance on safety considerations related to fire, storms, collapses, and related hazards, as well as crowd behavior. While used by authorities having jurisdiction, other parties with a stake in event planning — building designers, event managers, and other local agencies, for example — could also benefit from an evaluation that coordinates everyone’s effort before and during an event. For instance, the LSE lists more than 100 factors that should be addressed annually, or more frequently, including a response to severe weather conditions as well as an analysis on the sufficiency of a venue’s various systems, including the alarm and communications systems. It also requires a deep understanding of the nature of the events taking place; the response and planning elements will vary among different kinds of events, such as a boat show and a rock concert, since crowd behaviors and responses to emergencies are directly related to what is going on at the event.

While some might think the LSE is only for very large venues holding tens of thousands of people, it actually applies to a wide variety of assembly occupancy uses. These include any assembly occupancy holding more than 6,000 people; any assembly occupancy holding more than 250 people where festival seating is utilized; and any assembly occupancy taking advantage of the special rules for smoke-protected assembly seating. These rules apply equally whether the venue is indoors or outdoors, if it is a permanent or temporary structure, or if it is a mix of staging and structure.

Another valuable component of the LSE is the need to discover and address operational shortfalls at venues, particularly the kind that have led to recent injuries and deaths at stadiums across the country. Last summer, for example, a fan died from injuries he sustained when he fell over a railing while trying to catch a baseball at Rangers Ballpark in Arlington, Texas. The park has since made safety upgrades to railings and has implemented signs that prohibit leaning on or standing against railings. [For more on the issue of rail heights and fan safety, see “Monster Concern,” part of our feature on Fenway Park.]

The Rangers Ballpark incident and the Indiana stage collapse were described in some media accounts as “unavoidable” accidents that “were not covered by the codes.” In fact, the codes, in particular NFPA 101, do cover these scenarios; provisions of the Life Safety Code have been offering specific rules for assembly occupancies since 1929, while the LSE has been maturing since 1994. The LSE can make venue owners stop and think about the nature of their events, what might go wrong, how the crowd might react, and, perhaps most important, who the decision makers are that determine the level of response and intervention. A range of entities are involved in this process, including the venue manager, the event promoter, and local law enforcement. Even the usher staff is viewed as the eyes and ears for an event, and they can often intervene before a problem or issue escalates. The LSE states that clear contractual arrangements need to be established among the myriad groups involved in an event, and that ultimate decision-making authority to delay or stop an event needs to be clearly defined well before the event begins.

Such awareness would benefit other venues worldwide with flawed or incomplete emergency preparedness plans, says IAVM’s Hansen, who offered his expertise during the Witt Associates investigation of the state fair collapse. “The LSE gets used, but I don’t think it’s been applied or used effectively enough because of confusion by code officials and authorities having jurisdiction,” he says. Hansen cites some confusion over which aspects of the LSE should be addressed by event managers and code enforcement officials, the latter typically analyzing a structure’s physical features. “The venue operations and production folks are also not understanding it well enough to make it a useful tool.”

NFPA’s handbooks and other technical resources can help users avoid confusion, and Hansen says additional help is on the way. In 2010, the Technical Committee on Assembly Occupancies formed the Operational Requirements Task Group, which aims to clearly define the role of venue operators, before and during events, through the development of new operational guidelines. In the event of a severe storm, for example, these provisions could help users determine the relationship between the proximity of a storm cell and when a facility manager should initiate a response. “We haven’t changed the need for the LSE, but we’ve tried to provide an outline and further guidance for what it needs to address,” says Hansen, who sits on the task group. The committee will weigh in on the task group’s proposals at its next meeting in August, with the intent of developing a special manual or additions to the 2015 edition of the Life Safety Code.  

Life safety 2.0
Another bullet point on the committee’s agenda is an analysis of the new Fire Protection Research Foundation/Code Fund project “Defining Emergency and Non-Emergency Use of Buildings by Occupants.” The Life Safety Code contains provisions that address protection from both fire and non-fire emergencies, though the extent of the code’s use for the latter is unclear. A variety of non-fire scenarios that are occurring at both assembly and non-assembly occupancies — crowd crushes at Black Friday retail events, trampling deaths at religious pilgrimages, and injuries resulting from celebrity meet-and-greets at malls, to name a few — are examples of how the LSE could help prevent seemingly positive events from going awry. At their August meeting, the Assembly Occupancies Committee, along with the Mercantile and Business Occupancies Committee, will discuss a literature review developed for this project that identifies the number and extent of such incidents.

Addressing all aspects of live events through standardization has also gotten the attention of the entertainment industry. Following the release of the state fair investigation reports, a safety summit was held in Indianapolis in April that brought together U.S. fire service officials and industry insiders on expanding the use of the Event Safety Guide (also known as the “Purple Guide”), a highly utilized manual in the United Kingdom. Produced in 1999, the guide addresses all aspects of event safety at venues while providing guidance on collaborating with emergency services.

Leading the charge in creating a U.S. version of that guide is the Event Safety Alliance, which was formed after the Indiana collapse and includes 400 industry leaders interested in standardizing safety features at live events. “We’re working on rewriting the document to include U.S. codes and standards,” says Jim Digby, the alliance’s executive director and director of touring and production management for the rock group Linkin Park. He spoke with NFPA Journal following the band’s June concert in Bucharest, Romania. “We hope to develop a U.S. version that points to NFPA and other existing codes.”

This apparent collaboration among many parties with a vested interest in crowd safety is initiating a new emphasis on crowd safety, according to IAVM’s Hansen. “We need to build a commitment with everyone — from the designers that apply the codes, to the management and operations staff, to the AHJs who inspect [these facilities], to the event performers — to emphasize we’re going to take life safety seriously,” he says. “It needs to be a universal, across-the-board commitment. I see it coming together, and I’m excited about it.”

Fred Durso, Jr., is staff writer for NFPA Journal.

SIDEBAR
Ready for Anything
From Justin Bieber crowd crazes to music festival mishaps, recent events worldwide underscore the critical need to address inadequacies in emergency management and crowd control

2011
Severe weather at music festivals
The Indiana State Fair tragedy was only one example last year of Mother Nature quickly turning concerts into calamitous situations. Heavy winds, for instance, toppled tents, lighting scaffolds, and video screens at a Belgian music festival five days after the Indiana event, killing five and injuring more than 140. Strong gusts also brought down a stage at the Ottawa Bluesfest in Canada last July, resulting in multiple injuries. Though nobody was hurt, a storm during a festival in Tulsa, Oklahoma, caused a lighting rig to slam to the ground prior to a scheduled performance.

2010
Crowd crush at music festival
Attendance at the Love Parade, an electronic music festival in Duisberg, Germany, swelled to more than 1 million people, according to news reports, surpassing the 300,000 reportedly permitted at the site, a former freight railway station. A knot of attendees eventually formed near a portion of a parade route that passed by the main entry ramp to the festival area. To ease the knot, festival organizers blocked the entrance to the ramp — which also served as the event’s primary exit — with the intent of thwarting attendees from entering in nearby tunnels. Instead, the influx of visitors toward the ramp eventually created a crowd crush that killed 21 people and injured more than 500.

2009
Crowd incident at celebrity appearance
Some 3,000 fans apparently became delirious with Justin Bieber fever while awaiting the teen pop singer’s public appearance at the Roosevelt Field Mall in Garden City, New York. Screaming fans began pushing and shoving, resulting in the hospitalization of five people for minor injuries. Two members of Bieber’s record label and management were criminally charged for not adhering to a police request to send a Twitter message urging the crowd to disperse. Charges were later dropped, and the men instead pled guilty to fire code violations, according to the AP.

2008
Black Friday retail event
The promise of sales lured more than 2,000 would-be shoppers to the Wal-Mart in Valley Stream, New York. Minutes before the 5 a.m. opening, unruly customers waiting outside began banging and pushing on the sliding-glass doors, which eventually buckled under the pressure. A seasonal worker was trampled and killed as frenzied shoppers stormed the store. “When they were saying [shoppers] had to leave, that an employee had been killed, people were yelling, ‘I’ve been in line since yesterday morning,’” one witness told the Associated Press (AP). “They kept shopping.” Officials attributed the death to the store’s inadequate security. Following the incident, the National Retail Federation issued “crowd management guidelines” that recommend employee training for handling throngs of shoppers.

2006
Crowd incident at religious ceremony
Hajj, the annual pilgrimage to Mecca, Saudi Arabia, has been the scene of numerous crowd incidents resulting in injuries and deaths. During the final days of Hajj in 2006, for example, pilgrims participated in a ritual that has them toss stones at specific walls. More than 300 people were killed and hundreds were injured in a crowd crush that began when a swarm of pilgrims improperly exited a stone-throwing site and disrupted the flow of visitors entering the area from a nearby bridge.

— Fred Durso, Jr. 

SIDEBAR
The Responder Angle
While the Life Safety Evaluation is geared toward designers, managers, and inspectors of event facilities, it also references a number of areas that are critically important to responders. The Witt Associates report produced on the Indiana State Fair collapse incident, as well as the tabletop exercise conducted a month before the incident by the Indianapolis Division of Homeland Security, addressed a number of these issues, including pre-incident planning, a unified incident management system, and a coordinated incident response. These are just some of the elements of emergency response that are covered by NFPA codes, including:

NFPA 1561, Emergency Services Incident Management System
This standard outlines an incident management structure that can be used for any type of event.

NFPA 1620, Pre-Incident Planning
This standard details the methodology and data collection forms that can be used before an incident to develop customized response plans that address a range of potential hazards.

NFPA 610, Emergency and Safety Operations at Motorsports Venues
This guide includes detailed approaches for providing protection to the public where attendance is in the tens of thousands in open venues exposed to the weather.