Brazil Nightclub Fire and Disaster Prevention

Posted on January 28, 2013 | in Error-Proofing, Lean Tools, Root Cause Analysis, Safety, Small Business | by

Brazil Nightclub Fire Kiss

 

Wow. A horrendous nightclub fire in Brazil has left 230+ patrons dead.

This is a complete disaster and horrible situation. My thoughts go out to the victims and their families.

I’m not a news agency and I have never been to Brazil, so I’m not going to pile on. However, what in the heck went wrong?

– The band performing at the nightclub used pyrotechnics inside. I don’t care how safe they are or how well the users have been trained in setting them off, this always seems like a bad idea.

– It took some time for the band and patrons to realize the club was on fire, and once they did chaos ensued.

– There was only one way out of the club – the front door – and no emergency exits (according to the CBS News report).

– No communication means between the back of the club and the security officers out front. The guards were trying to prevent patrons from fleeing because they needed them to pay their bar tabs before leaving, thusly causing an escape bottleneck.

– Smoke filling the club suffocated victims – was there no ventilation system?

– Between the smoke suffocation and the escape bottleneck, the killed victims’ bodies were piling up at the entrance, making it even harder for others to escape safely and for emergency responders to get inside and help.

– A security guard gave a band member a fire extinguisher to use on the fire…but either it didn’t work or he didn’t know how to use it.

– The club had been filled beyond its capacity for a party.

– In addition to the ceiling, the soundproofing material used for deadening echoes caught fire and spread toxic fumes through the air. Soundproof does not equal fireproof, evidently.

This is not to make light of the situation. This is a huge disaster and in many ways it could have been prevented – no indoor pyrotechnics, reduced flammable components, functional fire extinguishers, lights for emergency exits, more emergency exits…

Clubs continually push the limits on what maintains a safe atmosphere. It’s sad that improvements come as a result of being reactive and not proactive in situations like these.

(Thanks to Courtney Khondabi of WOWK in Charleston, WV for the heads-up on these developments.)

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5 Responses to “Brazil Nightclub Fire and Disaster Prevention”

  1. Mark Graban says:

    USA Today had a column that compared the Brazil tragedy to the one in Rhode Island.

    http://www.usatoday.com/story/opinion/2013/01/27/john-barylick-on-lessons-of-brazil-nightclub-fire/1868455/

    This is similar to healthcare errors and patient harm – it’s usually not just ONE problem, but multiple problems that all line up together (look up “swiss cheese effect”).

    It seems people don’t learn lessons from other tragedies. Allegedly, bouncers in both fires kept patrons from getting out certain exits. One allegation was that they didn’t want to let people out without paying… that’s crazy. I’d like to see the incentive structure or management system that makes greed win out over basic humanity and survival instinct.

    Hospitals aren’t real good at learning from the mistakes of others… case in point the Dennis Quaid twins being overdosed in Los Angeles from basically the SAME set of problems that lined up to kill some babies earlier in Indianapolis. It’s easy to say that shouldn’t have happened in Indianapolis, but it certainly shouldn’t have happened again to the Quaid twins (who thankfully survived). Indianapolis is to Rhode Island as Los Angeles is to Brazil. Sad.

    http://www.leanblog.org/2009/05/dennis-quaid-and-medical-mistakes/

    Why are we unwilling to learn from past mistakes made by others? We don’t hear about them? We’re arrogant and think it won’t happen to us?

    • Chad Walters says:

      With regard to the club bouncers forcing folks back in to pay, I’m inclined to think they were unaware there was a fire. Was there a sprinkler system installed? What about a fire alarm? There are a lot of questions yet to be answered, but I doubt they would stop folks exiting a burning building.

      • Mark Graban says:

        You don’t think customers were screaming, “Let us through, there’s a fire!!!!!” ?

        • Chad Walters says:

          I’m quite certain they would have been. However, I could also see bouncers being skeptical of such claims. It’s hard to know exactly what happened without being there, but it’s easy to see bouncers thinking “Oh yeah, sure, there’s a fire…like that would ever happen…”

  2. I am a brazilian lean consultant.
    The summary of the origim of this tragic happening:
    lach of 5S and of respect. A lot of greed!

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