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 department 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 high-rise buildings, particularly those not protected by automatic sprinklers, should reflect the potential need to employ heavy firefighting streams, which may require higher flows and pressures.

6. 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 be to gather information about buildings and occupancies 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.

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 firefighters at the scene of an emergency. Recognizing and recording information about pressure 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.

Occupants and central station operators must always treat automatic fire alarms as though they were actual fires. especially in high-rise 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 attitude 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).