Evacuation Analysis of the Kiss Nightclub Disaster Natalia Flores Quiroz

Evacuation Analysis of the Kiss Nightclub Disaster

Natalia Flores Quiroz

Supervisor: Prof. Edwin Galea

Master’s Dissertation submitted in order to obtain the academic degree of Master of Science in Fire Safety Engineering

Department of Flow, Heat and Combustion Mechanics Chair: Faculty of Engineering and Architecture Academic Year 2017-2018

ACKNOWLEDGEMENTS

I am especially grateful to my supervisors, Professor Ed Galea for giving me the opportunity and the resources to work in this project and ZhaoZhi Wang for his time and support during the writing of this thesis. Their guidance and constructive suggestions were fundamental in the outcome of this study.

Thanks to the Fire Safety Engineering Group (FSEG) of the University of Greenwich for providing their analysis of the fire and evacuation which served as the base model for this project and for providing access to the buildingEXODUS software and their servers to run the many simulations required for this project.

My gratitude is also extended to: Jaime Moncada for his help at the beginning of this research and for the material he shared with me, Lazaros Filippidis for his support with the buildingEXODUS software and Allison Ribeiro for his help to translate and look for information in Portuguese.

I would also like to thanks to all the people who encourage me to be in this program, in particular to Nelson Gómez, Alejandro Ramírez, Marcial Salaverry, Patricia Castro and Iván Ortiz.

Finally, my warmest thanks go to my family, Andrés, Violeta, Martín, Angela and Felipe, for their continuous encouragement unconditional support and love throughout this process.

iii

ABSTRACT

On 27 January of 2013 a fire broke out in the Kiss nightclub in Santa Maria, Rio Grande do Sul, Brazil. The fire was one of the most deadly nightclub fires in recent times, which resulted in the loss of 242 young people.

In this thesis the conditions in which the nightclub was the night of the fire are presented and a comparison with the legal requirements is conducted. This allows to identify the breaches that the nightclub had and that could have impacted the evacuation results. The effect of the different breaches on the evacuation results are investigated by simulating 14 scenarios using the buildingEXODUS evacuation software based on the reconstruction of fire and evacuation performed by the Fire safety engineering Group (FSEG) of the University of Greenwich. Aspects such as exit routes conditions, population, signage, staff training and number of exits are analyzed in these scenarios.

The study reveals that the factors that impact the reduction of the fatalities compared with the reconstruction scenario (producing an average of 241.1 fatalities), from the highest to the lowest, are: the clearance of the evacuation route by removing the metal barriers (79.30%); an efficient signage system directing people to the exits rather than moving towards the toilets (69.02%); not exceeding the certified population (50.81%); two exit doors remotely located (37.74%); well trained staff (26.92%) and wider final exits (4.98%).

Furthermore, if the Kiss Nightclub had been in compliance with all the regulations related with the evacuation, the number of fatalities would have been reduced almost to zero. However, even with a compliant configuration people spend a large amount of time waiting in congestion (with an average of waiting time to evacuation time ratio of 62.9%) and approximate 10 ‘moderate to life threating’ injuries are produced, which means that the evacuation is still sub- optimal. These results are derived using the fire environment derived from the fire simulation conducted by FSEG as part of their fire and evacuation reconstruction analysis.

The findings made in this thesis not only provide information regarding the factors that influence the evacuation results of the Kiss Nightclub, but also contribute to a better understanding of the importance of the evacuation requirements in nightclubs.

CONTENTS ACKNOWLEDGEMENTS ...... iii ABSTRACT ...... iv FIGURES ...... viii TABLES ...... x 1 INTRODUCTION ...... 1 1.1 Motivation ...... 1 1.2 Research Objectives and Questions ...... 1 1.3 Layout of the Thesis ...... 2 2 KISS NIGHTCLUB FIRE ...... 3 2.1 Building ...... 3 2.1.1 Building Layout ...... 3 2.1.2 Building Materials ...... 5 2.1.3 Changes in the Building ...... 6 2.2 Fire Safety Measures ...... 7 2.2.1 Capacity ...... 7 2.2.2 Exit Routes ...... 7 2.2.3 Fire Protection ...... 9 2.2.4 Firefighters Inspections ...... 10 2.3 Fire in the Nightclub ...... 12 2.3.1 Cause of Fire ...... 12 2.3.2 Attempt to Control the Fire ...... 12 2.3.3 Fire Spread ...... 13 2.3.4 Evacuation ...... 16 2.3.5 Emergency Responders ...... 17 2.3.6 Casualties ...... 18 2.4 Summary ...... 20 3 FIRE SAFETY REQUIREMENTS ...... 22 3.1 Building Classification ...... 22 3.2 Materials ...... 24 3.2.1 Requirements ...... 24 3.2.2 Analysis ...... 24 3.3 Capacity ...... 24 3.3.1 Requirements ...... 24 3.3.2 Analysis ...... 24 3.4 Emergency Exits ...... 25 3.4.1 Requirements ...... 25 3.4.2 Analysis ...... 26 3.5 Extinguishing System ...... 27

v Contents

3.5.1 Requirements ...... 27 3.5.2 Analysis ...... 28 3.6 Detection and Alarm System ...... 29 3.6.1 Requirements ...... 29 3.6.2 Analysis ...... 29 3.7 Signage and Emergency Lighting ...... 30 3.7.1 Requirements ...... 30 3.7.2 Analysis ...... 31 3.8 Summary ...... 31 4 COMPLIANCY ISSUES ...... 32 4.1 Materials ...... 32 4.2 Population ...... 32 4.3 Emergency Exit ...... 32 4.4 Fire Extinguishers ...... 33 4.5 Fire Alarm System ...... 33 4.6 Signage and Emergency Lighting ...... 33 4.7 License to Operate ...... 33 4.8 Trained Staff ...... 33 4.9 Use of Pyrotechnics ...... 33 4.10 Summary ...... 34 5 INVESTIGATION METHOD ...... 35 5.1 BuildingEXODUS ...... 35 5.2 Coupled Fire and Evacuation Analysis Technique ...... 35 5.3 Incident Reconstruction ...... 36 5.4 Investigation Method ...... 38 6 EVACUATION ANALYSIS ...... 39 6.1 Evacuation Scenarios ...... 39 6.1.1 Scenario N°1: Reconstruction Scenario ...... 40 6.1.2 Scenario N°1.2: Signage System ...... 40 6.1.3 Scenario N°2: Wider Exit Door ...... 40 6.1.4 Scenario N°3: Nominal Capacity ...... 40 6.1.5 Scenario N°4: Trained Staff ...... 40 6.1.6 Scenario N°5: Two Exit Doors ...... 41 6.1.7 Scenario N°6: Clearance of the Evacuation Route ...... 41 6.1.8 Scenario N°7: Compliance with All Regulations ...... 41 6.2 Evacuation Simulations ...... 41 6.2.1 Scenario N°1: Reconstruction Scenario ...... 42 6.2.2 Scenario N°1.2: Signage System ...... 43 6.2.3 Scenario N°2: Wider Exit Door ...... 43

Contents

6.2.4 Scenario N°3: Nominal Capacity ...... 45 6.2.5 Scenario N°4: Trained Staff ...... 45 6.2.6 Scenario N°5: Two Exit Doors ...... 46 6.2.7 Scenario N°6: Clearance of the Evacuation Route ...... 48 6.2.8 Scenario N°7: Compliance with All Regulations ...... 49 6.3 Evacuation Results ...... 51 6.3.1 Statistics Results ...... 51 6.3.2 Scenario N°1.2: Signage System ...... 53 6.3.3 Scenario N°2: Wider Exit Door ...... 53 6.3.4 Scenario N°3: Nominal Capacity ...... 53 6.3.5 Scenario N°4: Trained Staff ...... 54 6.3.6 Scenario N°5: Two Exit Doors ...... 54 6.3.7 Scenario N°6: Clearance of the Evacuation Route ...... 55 6.3.8 Scenario N°7: Compliance with All Regulations ...... 55 6.4 Main Findings ...... 56 6.5 Recommendations ...... 59 6.6 Limitations ...... 59 6.7 Summary ...... 59 7 CONCLUSIONS ...... 61 8 FURTHER WORK ...... 64 8.1 Full Analysis ...... 64 8.2 Signage ...... 64 8.3 Fire Spread ...... 64 8.4 Extend the Solution Domain ...... 64 8.5 Comparison with Regulations from other Countries ...... 64 REFERENCES ...... 65 Fires in Nightclubs ...... 69 Numerical Reconstruction ...... 70 Simulation Results ...... 75

vii

FIGURES

Figure 2-1: Location Kiss Nightclub (Source BBC [7]) ...... 3 Figure 2-2: Kiss Nightclub layout (Source IGP-RS [8]) ...... 3 Figure 2-3: 3D sketch of the Nightclub before the fire (Source IGP-RS [9]) ...... 4 Figure 2-4: Polyurethane foam on the above the stage (Source IGP-RS [9]) ...... 5 Figure 2-5: KISS Nightclub prior to the fire [15] ...... 6 Figure 2-6: KISS Nightclub prior to the fire [15] ...... 7 Figure 2-7: Extract Bulletin of establishments and activities [19] ...... 7 Figure 2-8: Kiss Nightclub Facade (Source: Google Street View [22] ...... 8 Figure 2-9: View of the exit doors of the Nightclub (Source O Globo [23]) ...... 8 Figure 2-10: Metal bars placed in the evacuation route (Source IGP-RS [9][23]) ...... 9 Figure 2-11: Fire prevention and protection license [19] ...... 12 Figure 2-12: Beginning of the Fire at Kiss Nightclub (Source Dailymail UK [35]) ...... 12 Figure 2-13: Screenshots from a video recorded the night of the fire. From left to right the images are at 0s; 5s; and 15s of this video [38] ...... 13 Figure 2-14: Screenshots from a video recorded the night of the fire. From left to right at 20s; 25s; and 40s [38] ...... 13 Figure 2-15: Screenshots from a video recorded the night of the fire. From left to right at 60s; 65s; 74s [38] ...... 14 Figure 2-16: Screenshots from a video of the experimental simulation - Configuration [39] .... 14 Figure 2-17: Screenshots from a video of the experimental simulation - Ignition [39] ...... 15 Figure 2-18: Screenshots from a video of the experimental simulation – Smoke spread [39] ... 15 Figure 2-19: KISS Nightclub after the fire. (Source: O Globo [23]) ...... 16 Figure 2-20: KISS Nightclub after the fire. (Source: O Globo [23]) ...... 16 Figure 2-21: Exit Routes (Source O Globo [47]) ...... 17 Figure 2-22: Firefighters and civilians trying to rescue people [35] ...... 18 Figure 2-23: Fatalities in the nightclub [54] ...... 19 Figure 2-24: Dead people in the toilet [54] ...... 19 Figure 3-1: NBR 9077 – Table 1 [64] ...... 22 Figure 3-2: NBR 9077 – Table 2 [64] ...... 23 Figure 3-3: NBR 9077 – Table 3 [64] ...... 23 Figure 3-4: NBR 9077 – Table 4 [64] ...... 23 Figure 3-5: NBR 9077 – Table 5 [64] ...... 25 Figure 3-6: NBR 9077 – Table 7 [64] ...... 26 Figure 3-7: NBR 9077 – Table 6 [64] ...... 27 Figure 3-8: Fire extinguisher with similar characteristics as the ones in Kiss Nightclub [68] ..... 28 Figure 3-9: Fire extinguisher location (the layout of the club from [8]) ...... 29 Figure 3-10: NBR 9077 – Table 8 [64] ...... 30 Figure 5-1: Sub-models in buildingEXODUS ...... 35 Figure 5-2: SMARTFIRE set up of the Kiss Nightclub in the fire simulation [2]...... 36 Figure 5-3: Fire hazard zones prescribed within both the fire and evacuation models identified by dashed lines and walls (several key zones are indicated by their zone number)[2]...... 37 Figure 5-4: Evacuation simulation setup in the reconstruction [2]...... 37 Figure 5-5: Evacuation routes near the exit (dashed line representing the path for entering the nightclub hall in the reconstruction [2]...... 38 Figure 6-1: Left two exit doors in the front. Right exit door in the front and in the back ...... 41

viii Figures

Figure 6-2: Geometry of the Nightclub in buildingEXODUS for Scenario N°1 ...... 42 Figure 6-3: Scenario N°1.2 ...... 43 Figure 6-4: Scenario N°2.1 ...... 44 Figure 6-5: Scenario N°2.2 ...... 44 Figure 6-6: Scenario N°3. (Left) Scenario N°3.1; (right) Scenario N°3.2 ...... 45 Figure 6-7: Response times of occupants for Scenario N°4 ...... 45 Figure 6-8: Scenario N°5.1 Two exit doors (Door 1 and Door 2) in the front ...... 46 Figure 6-9: Scenario N°5.3 One exit (Door 1) door in the front and one (Door 2) in the back ... 47 Figure 6-10: Scenario 6.1 ...... 48 Figure 6-11: Scenario N°6.2 ...... 49 Figure 6-12: Number of occupants and their response times ...... 50 Figure 6-13: Scenario N°7 ...... 50 Figure 6-14: Screenshots from the simulation of Scenario N°4.2. From left to right the images are at 25s; 31.5s; and 40s of this video ...... 54 Figure 6-15: Number of Fatalities ...... 57 Figure B-1: Geometry of the Kiss Nightclub...... 70 Figure B-2: Timeline of the Kiss Nightclub fire ...... 71 Figure B-3: Fire hazard zones prescribed within both the fire and evacuation models identified by dashed lines and walls (several key zones are indicated by their zone number) ...... 72 Figure B-4: Initial location of the 1200 occupants ...... 72 Figure B-5: Evacuation routes near the exit (broken line representing the path for entering the nightclub hall ...... 73 Figure B-6: Hazard zone list ...... 73 Figure B-7: Predicted death locations from a single evacuation simulation ...... 74

TABLES

Table 2-1: Areas of each zone of the Kiss Nightclub ...... 4 Table 2-2: Construction Materials [11] ...... 5 Table 3-1: Population ...... 25 Table 3-2: Exit doors and accesses required width ...... 26 Table 6-1: Summary of the evaluated Scenarios...... 39 Table 6-2: Scenario N°1 Parameters ...... 43 Table 6-3: Parameters for Scenario N°2.1 and N°2.2 ...... 44 Table 6-4: Parameters for Scenario N°4 ...... 46 Table 6-5: Parameters for Scenario N°5.1 and N°5.2 ...... 47 Table 6-6: Parameters for Scenario N°5.3 and N°5.4 ...... 48 Table 6-7: Parameters for Scenario N°6.1 and N°6.2 ...... 49 Table 6-8: Parameters for Scenario N°7 ...... 51 Table 6-9: Average evacuation time and fatalities from 500 simulations repetitions ...... 52 Table 6-10: Average results for survivors from 500 simulation repetitions ...... 52 Table 6-11: Average results for fatalities from 500 simulation repetitions ...... 53 Table 6-12: Improvement of the survivability with respect to the Reconstruction (Scenario N°1), based on the improvements proposed to comply the regulations ...... 57 Table 6-13: Improvement of the survivability with respect to the use of signage for each scenario ...... 58 Table 6-14: PET, CWT and CWT Ratio of survivors ...... 58 Table A-1: Fires in Nightclubs ...... 69

x Chapter 1. Introduction

1 INTRODUCTION

1.1 Motivation The concern about Life Safety in buildings in a fire condition has been present for a long time. The study of important fires involving loss of lives has led to the preparation of standards addressing issues such as stairways, fire escapes, and egress routes. The importance of adequate exits and fire safety features was demonstrated after the Cocoanut Grove fire in Boston in 1942 where 492 fatalities occurred [1].

From then on, many fires in Nightclubs have occurred [1]. When reviewing the information about these nightclub fires, it is possible to notice that several of them, especially those that occurred since 2000, have a number of similarities (See Appendix A for details).

The first similarity is the cause of the fire. In many cases the use of pyrotechnics or torches for the different shows were the ignition source (e.g.: Lame Horse, República Cromañón, The Station Nightclub). The second one is the use of combustible materials for acoustic soundproofing (e.g.: Colectiv Nightclub, República Cromañón, The Station Nightclub). The third one is the overcrowding. In some of the nightclubs there was the double of their maximum capacity (e.g.: República Cromañón). The fourth one is the insufficient number of exit doors or the fact that they were blocked (e.g.: República Cromañón, The Station Nightclub, Colectiv Nightclub). Finally, it is the deficient or inexistent fire protection system (e.g.: The Station Nightclub). Other aspect of interest, which is not well documented, are the conditions, level of alcohol or drugs, for example, of the occupants at the moment of the fire and the knowledge that they had of the place.

Analyzing the factors that led to the large number of deaths of this disaster will allow not only to determine on which level each of them influence the evacuation of the Kiss Nightclub, but also to improve the understanding of fires in nightclubs which hopefully help to avoid tragedies similar to this one in future.

1.2 Research Objectives and Questions It is of common knowledge that the Kiss nightclub was non-compliant with several regulations on the night of the fire. This Master’s thesis seeks to address the following question:

Would the number of fatalities in the nightclub be reduced if it had been compliant with the fire safety regulations?

In order to answer this key question, the following additional questions must be addressed:

What were the conditions of the nightclub the night of the fire?

To establish, as best as possible, the conditions at the time of the incident, it is necessary to review evidences from: newspapers; testimonies from survivors, firefighters, engineers and architects, employees; videos and papers.

Chapter 1. Introduction

What were the relevant fire safety requirements for the nightclub?

The Brazilian fire safety requirements in relation to evacuation and fire safety protection, in particular within the state of Rio Grande do Sul, will be reviewed. Based on the classification of the building, the fire safety requirements will be established.

Which fire safety regulations were not being satisfied by the nightclub the night of the fire?

By comparing the situation of Kiss Nightclub in the night of the fire and the fire safety requirements, breaches will be identified.

What is the likely impact of the breaches on the number of casualties and injuries?

To answer this question the reconstruction fire and evacuation simulation performed by the Fire Safety Engineering Group (FSEG) of the University of Greenwich [2] will be reviewed. In order to investigate the impact of the regulatory noncompliance several modifications to this reconstruction will be suggested. These modifications are focused only on the aspects that are related with the evacuation, rather than the fire. Factors that intervene with the fire development are not part of this study.

Using the reconstruction scenario performed by the FSEG as a base [2], the different proposed scenarios will be modelled using the buildingEXODUS [3][4][5][6] evacuation simulation software to determine the impact of each of the breaches to the outcome.

Finally, by simulating the scenario that merge all the modifications the main question can be answered.

1.3 Layout of the Thesis Chapter 1 (Introduction): Provides a brief introduction of fire in nightclubs. Research questions and objectives of this thesis are outlined.

Chapter 2 (Kiss Nightclub Fire): Describes the conditions in which the nightclub was the night of the fire. Aspects such as constructive features, fire safety measures, the origin of the fire and its spread, how people react and the consequences of this disaster.

Chapter 3 (Fire Safety Requirements): Presents extracts from the Brazilian regulations related with fire safety. Topics like capacity, emergency exits and active fire protection are reviewed and specific requirements are analyzed.

Chapter 4 (Issues Breaking Regulations): Establishes the breaches that are found by comparing the conditions at the time of the incident with the requirements previously stated in Chapter 3.

Chapter 5 (Investigation Method): Describes the computational tools that are used for the reconstruction fire and evacuation performed by FSEG and in this study as well.

Chapter 6 (Evacuation Analysis): Describes the features of the different scenarios that are analyzed. The scenarios are modeled in buildingEXODUS, with modifications to the reconstruction scenario. The simulation results are analyzed and the main findings are presented.

Chapter 7 (Conclusions): The conclusions of this study are presented and questions raised in Chapter 1 are answered.

Chapter 8 (Further Work): Future work identified during this study is suggested.

Chapter 2. Kiss Nightclub Fire

2 KISS NIGHTCLUB FIRE

2.1 Building

2.1.1 Building Layout The Kiss Nightclub was located in Rua dos Andradas 1925, Santa Maria in Rio do Sul, Brazil (Figure 2-1) [7].

Figure 2-1: Location Kiss Nightclub (Source BBC [7])

According to the official layout of the nightclub (Figure 2-2), the building was 26.95 meters length and 23.68 meters wide, an area of 638 m2 [8]. The maximum travel distance to the exit door is around 30 meters. Figure 2-3 is a 3D view of the club that was produced by the Instituto Geral de Perícias do Rio Grande do Sul [9].

Figure 2-2: Kiss Nightclub layout (Source IGP-RS [8])

Chapter 2. Kiss Nightclub Fire

A summary of the different areas of the building are shown in Table 2-1.

Table 2-1: Areas of each zone of the Kiss Nightclub

Employees Area m2 Customer Area m2 Other Areas m2 DJ 19.85 Reserved 50.37 Toilet-Front 18.37 Bar 8.31 Hall 94 Toilet-Front 15.19 Bar 23.42 Dance Floor 1 123.77 Toilet-Back 20.33 Bar 10.63 Dance Floor 2 93.32 Toilet-Back 13.48 Office 3.76 Lobby 3.56 Circulation 22.43 Kitchen 7.92 Lobby 23.86 Circulation 9.81 Storage 5.59 Proscenium 8.98 Lift Platform 1 Dressing room 10.74 Proscenium 15 Lift Platform 1 Office 6.56 Total 412.86 Total 101.61 Cashier 8 Cloakroom 9.39 Total 114.17

According to employee’s testimony the official layout was modified, without any guidance of architects or engineers, this situation was not informed [10].

Figure 2-3: 3D sketch of the Nightclub before the fire (Source IGP-RS [9])

Chapter 2. Kiss Nightclub Fire

2.1.2 Building Materials The materials used in the nightclub shown in Table 2-2, were taken from the architectonic project of the building [11].

Table 2-2: Construction Materials [11]

Area Floor Walls Ceiling Stage Decks

Ceramic Coating Precast concrete height h=2 m 41x41 slab coated with cm. plastering mortar Toilets and painted with Brick wall coated wall paint. with smooth plastering mortar, and painted with Kitchen Ceramic wall paint. Floor 41x41 Brick wall coated cm with smooth Wooden Masonry

plastering mortar, Gypsum board false structure walls with a Dance Floor and painted with ceiling coated with protected ceramic tile wall paint. spackling paste and by a layer of flooring cetol. 41x41 cm Drywall partitions painted with wall paint. Administrative coated with Area spackling paste and painted with wall Other Areas paint

As seen in Figure 2-4, polyurethane foam covered the stage lining and the air conditioning duct. The employees indicated that at first the foam was placed in the walls, but since the acoustic problem persisted, it was removed and a stone wall was built. That is when it was decided to place it on the ceiling above the stage [12].

Figure 2-4: Polyurethane foam on the above the stage (Source IGP-RS [9])

Chapter 2. Kiss Nightclub Fire

The polyurethane foam is combustible, highly flammable and toxic, two types of foam were collected from the Kiss Nightclub. The technical report N° 15209/2013 concluded that both foams contained in their composition polyurethane, the first thermal decomposition occurred at 200° C; the second at 300° C and above 450° C the foam was practically decomposed. The burning of the foam, in addition to the production of other toxic gases, also effectively produced the hydrocyanic acid [10].

It is important to mention that the Engineer in charge of the acoustic project recommended gypsum layer below the slab, glass wool and another layer of gypsum, this would have provided a fire resistance of 30 minutes [13].

2.1.3 Changes in the Building After the operation license was granted, several changes were made in the building. According to the testimony of the people who performed the modifications, all these requests were made by the owner. There were no project or drawings for these alterations; only the owner gave the instructions [14]. Figure 2-5 and Figure 2-6 show the club interior before the fire.

 Beginning 2011 the façade of the building was covered with wood, windows were not blocked.  May 2011 metal barriers were placed in the stage at the entrance of the building.  June 2011 more metal bars were placed in the stage, at the cashier access and in the main access.  October 2011: Corridor next to the stage, partition of the male bathroom, more metal barriers on the cashier.  December 2011 the stage was moved from the front to the back of the nightclub.  End 2011 the acoustic engineer notice that the east wall was covered with “sound insulation foam” and he requested to removed it and to build a masonry wall.  2011 windows were closed.  June 2012 foam was placed on stage ceiling and in the rear wall.

Figure 2-5: KISS Nightclub prior to the fire [15]

Chapter 2. Kiss Nightclub Fire

Figure 2-6: KISS Nightclub prior to the fire [15]

2.2 Fire Safety Measures

2.2.1 Capacity A considerable amount of information can be found on the literature about the actual capacity of the nightclub, but official documents indicated that the maximum capacity is of 1000 people (see Figure 2-7), which was corroborated by the owner of the nightclub [16] and the firefighters [17].

Experts from the “Instituto Geral de Perícias do RS” indicated that the capacity of the building according to its area is 740 people in public areas and 29 in the service area, giving a total of 769 persons [18].

Figure 2-7: Extract Bulletin of establishments and activities [19]

2.2.2 Exit Routes According to the layout, the nightclub had two exit doors, one next to the other, with a total of 3.6 meters wide according to the drawings, which does not match with what is seen on Figure 2-8 and Figure 2-9. In the literature it is even mentioned a wide of 2 meters [20]. Official information from the Estado do Rio Grande do Sul Police indicate that the nightclub´s door had only 2.56 meters that correspond to 4.6 passing units [18].

Chapter 2. Kiss Nightclub Fire

In the report prepared by the experts of the IGP the two access and discharge doors, located between the hall and the folding door, which gives access to the street, measured, respectively, 1.75 m on one side and 1.30 m from another, in total 3.05 m [21].

Figure 2-8: Kiss Nightclub Facade (Source: Google Street View [22]

Obstacles delayed the evacuation of the nightclub. At three locations there were metal bars (see Figure 2-3 and Figure 2-10). Moreover, in some cases people must go through three different doors to escape. Police even used the word “maze” to describe the interior of Kiss [9].

Figure 2-9: View of the exit doors of the Nightclub (Source O Globo [23])

Chapter 2. Kiss Nightclub Fire

Figure 2-10: Metal bars placed in the evacuation route (Source IGP-RS [9][23])

2.2.3 Fire Protection The Nightclub fire prevention and protection license had expired on August 10 of 2012, as it is possible to see in Figure 2-11.

Regarding the active fire protection system, the National Post [24] indicates “Preliminary investigations of the tragedy have revealed that there was no alarm, working fire extinguisher or sprinkler system…”. There was not fire detection either.

Fire Extinguisher

Carlos Alberto Webber, owner of the company that sold fire extinguishers to the Kiss nightclub, said he recharged and sealed the five fire extinguishers of the nightclub on October 19, 2012, having returned the products in person to an employee of the establishment [25].

"They had five 4 kg ABC fire extinguishers in the nightclub, all of them I reviewed and changed the powder annually, and we did a hydraulic test." Every year we called him, telling him that the fire extinguisher were about to expired. We reloaded them in October because they asked us to do it. My employee went to pick them up and the fire extinguishers had been moved and thrown under the bar counter," Webber said [25].

In October 2012, only three fire extinguishers were seen at KISS nightclub, all three of which had defects, such as low pressure, lack of locking to the cylinder (without the pin and without the seal), the manometer indicated "empty". They were without seals and many of them unloaded. Fire extinguishers never remained in the places of their correct installations, it was always necessary to look for them, because no one knew where the fire extinguishers were. The last time Webber attended to KISS, three fire extinguishers were under a kitchen counter. There were arrows on the walls indicating the locations of fire extinguishers, but they were never in those places. One of the owners did not like to have the fire extinguishers on the walls because they made the environment ugly and they damage the decoration of the nightclub [26].

Webber guarantees that he delivered the extinguishers in perfect conditions, with sealing and registration suitable for use. He believes the appliances may have been used after recharging, before the tragedy, without being replaced by the nightclub. He said "These fire extinguishers may have been used, handled, depressurized and were no longer functioning after we delivered. This is beyond our responsibility, and it is the owners responsibility to request a fire extinguisher review if they are not in proper conditions" [25].

Chapter 2. Kiss Nightclub Fire

A musician from a band also gave an interview, stating that someone used a fire extinguisher near the stage at a party in December [25].

In a statement to the Civil Police, the band's vocalist said that he tried to use a fire extinguisher when the fire started, removing the seal and pointing towards the flames on the ceiling, but that the fire extinguisher did not work. He also said that the pressure gauge indicated that the content was low or almost zero [25]. Figure 2-13 shows images from this situation.

Delegate Sandro Meinerz, who participated in the investigation, said only three 4 kg extinguishers were found at the nightclub on the night of the tragedy. One of them, the one used by the singer on stage to try to extinguish the flames, was, in his words, "all black, burned. It's impossible to see anything on the outside of the label", he said. The police did not know where the other two extinguishers were [25].

Emergency Lighting and Signage

Survivor information indicates that if the emergency lighting existed, it did not work. They also report the difficulty in guiding themselves [27], which may indicate absence or deficiency in the signaling and emergency lighting systems.

According to firefighters inspectors [28]:

 Traces of signs of exit signage in the central hall area, dance floor 2, access to toilets and toilets were not find. Only traces of two plastic plates were found in the access to the corridor of the exit boxes of the left portion of the building (items 4.13.3.1 of NBR 9077/2001).  There was no illumination near the floor, so that it remained visible even with high smoke (item 4.13.2.3 of NBR 9077/2001, which refers to item 3.11 of NBR 10898/1999).  There was no illumination for recognizing obstacles that could impede circulation such as metal bars and changes of direction (items 5.1.1 and 5.1.2 of NBR 10898: 1999).  There were no flashing luminaires (flashing lights) or similar equipment at the outputs (Item 5.1.2.2 of NBR 10898: 1999).

Trained Staff

It was requested that the staff have a Prevention and Fire Fighting Training taught by a qualified professional, which enables them to a fast response, in order to extinguish or reduce the fire propagation and its associated damages. But according to the testimony of the personnel they did not receive the training [29].

2.2.4 Firefighters Inspections Fist Time – 2009

According to the testimony of the firefighters that did the inspection [30]:

 Fire extinguishers, emergency lighting, signs and emergency exits were according to the design.  No metal barriers inside the nightclub.  Windows were not sealed.  There were two emergency exits, type double door each of them measure 90 cm wide, which correspond to seven units of passage that allowed the evacuation of 700 people per minute, according to their calculation, which was not correct. However, after three

Chapter 2. Kiss Nightclub Fire

and a half years, the dimensions could have change, due to the various reforms and modifications that the nightclub environment has undergone.  No polyurethane foam for acoustic treatment.  The permission signed in 2009 was granted for 1 year and it was expressly stated that it would lose its validity if any item of fire prevention was modified.

Second Time – August 2011

According to the testimony of the firefighters that did the inspection [31]:

 No metal bars inside or outside the nightclub. This does not match with the declaration presented in 2.1.3.  No polyurethane foam for acoustic treatment.  The stage was not in the back of the nightclub.  Windows were not sealed.

It is also stated that on 08/11/2010 the firefighters department required that Kiss employees receive a Prevention and Fire Fighting Training within 30 days.

The evidence shows that the firefighters gave a false testimony, not facing their responsibility on the consequences that the fire had.

Based on the expert report Nº 12268/2013 the main failures that the fire fighters inspection neglected are the following [32]:

 There were no signs in the exit doors and exit routes in the central hall area, and the second dance floor.  There was no illumination to recognize obstacles (5.1.1 and 5.1.2 NBR 10898:1999).  Width of exit routes. The sum of the spans of the internal doors is 3.05 m, 1.35 m less than the 8 passing units required by NBR 9077:2001. Also the opening of the doors conflicted with the folding doors at the entrance, reducing the width to 4 passing units.  It is not valid to consider an evacuation rate of 100 people per minute on the exit doors (Table 5 NBR 9077:2001), because for that there should be a full compliance of the requirements in the codes.  There were obstacles in the access and exit routes.  They considered that there were 2 exits even though they were located in the same place.

From Figure 2-11, it is possible to see that the person who signed the license was Alex da Rocha, he was one of the two firefighters who were found guilty at a military court of making false declaration [33].

Chapter 2. Kiss Nightclub Fire

Figure 2-11: Fire prevention and protection license [19]

2.3 Fire in the Nightclub

2.3.1 Cause of Fire On January 27 of 2013 at 2:30 am a fire developed at Kiss Nightclub. The fire was originated on the ceiling over the raised stage area due to the use of pyrotechnics intended for outdoor use during the band show (See Figure 2-12). The decision to use it inside the nightclub was mainly because outdoor pyrotechnics are much cheaper than those suitable for indoors use. Moreover, the package of the spark had clear instructions for use, like: “Check before releasing if the place is open or outdoors", or "Fireworks must be kept within 10 meters of people, houses, hospitals, electricity, vehicles, fuels, flammable products, explosives”[34].

Figure 2-12: Beginning of the Fire at Kiss Nightclub (Source Dailymail UK [35])

2.3.2 Attempt to Control the Fire According to witnesses, at the earliest stage of the fire a staff member and the singer of the band tried to extinguish the fire, but the fire extinguisher did not work, the singer tried to put the fire down by throwing two small bottles of mineral water [36]. This situation can be seen in Figure 2-13.

The staff member said that when he got the fire extinguisher, he realized it was without the plastic seal because there was only the metal pin. He said he pulled the pin and directed the hose into the focus of the flames, having squeezed the trigger about three times. He handed the fire extinguisher to the singer, who triggered a few more times, but did not succeed [26].

Chapter 2. Kiss Nightclub Fire

2.3.3 Fire Spread The fire started near the air conditioning system, which accelerate the dispersion of the smoke. Due to the presence of polyurethane foam, the lack of smoke extraction system [37] and the fact that all windows were sealed as indicated in Section 2.1.3, the smoke rapidly filled the room.

Figure 2-13, Figure 2-14 and Figure 2-15 show a sequence of the situation inside the nightclub during the fire development, the screenshots were taken from a video recorded that night. It is possible to see that at the beginning people are trying to use the fire extinguishers to put the fire down. After 30 seconds the fire has grown and smoke starts to fill the room. At 60 seconds the images are blurry and after 2 minutes the images turned black.

Figure 2-13: Screenshots from a video recorded the night of the fire. From left to right the images are at 0s; 5s; and 15s of this video [38]

Figure 2-14: Screenshots from a video recorded the night of the fire. From left to right at 20s; 25s; and 40s [38]

Chapter 2. Kiss Nightclub Fire

Figure 2-15: Screenshots from a video recorded the night of the fire. From left to right at 60s; 65s; 74s [38]

An experimental simulation was performed to see how did the polyurethane foam used in the Kiss nightclub behaved when burned. The configuration is shown in Figure 2-16, a room of 9 m2 was used to represent the nightclub. In the interior the same type of foam used as acoustic coating in the nightclub was placed in the wall and ceiling [39].

Figure 2-16: Screenshots from a video of the experimental simulation - Configuration [39]

In the experiment the same pyrotechnic used by the singer of the band was used, Figure 2-17 shows that once the sparks reached the ceiling it took only 12 seconds for the foam to be burned [39].

Chapter 2. Kiss Nightclub Fire

Figure 2-17: Screenshots from a video of the experimental simulation - Ignition [39]

Figure 2-18 shows the development of the smoke layer inside the room, after 90 seconds the room was full of smoke [39].

Figure 2-18: Screenshots from a video of the experimental simulation – Smoke spread [39]

Figure 2-19 and Figure 2-20 presents the condition of the nightclub after the fire. It can be seen that the combustibles materials that were just a few meters away from the fire did not burn. On the other hand, traces of soot are all over the place. From the experimental simulation and the testimony of survivors, it is possible to say that the nightclub was rapidly filled with toxic smoke from the burning of the polyurethane foam.

Chapter 2. Kiss Nightclub Fire

Figure 2-19: KISS Nightclub after the fire. (Source: O Globo [23])

Figure 2-20: KISS Nightclub after the fire. (Source: O Globo [23])

2.3.4 Evacuation The amount of people that was present that day in the Nightclub is unknown, depending on the source numbers go from 500 [40], 1200 [41] to 2000 [17]. This last value was the one given by the fire department. The bartender at nightclub, said that usually there were about 1200 people at KISS, and in special nights up to 2000 [42]. Finally, from the list of victims in hospitals and that gave testimony to the Civil Police, the number of people that were inside the nightclub that day was not less than 864 [43]. Most of the people that were on the nightclub that day were between 18 and 30 years old.

A staff member used the microphone to warn the public about the fire and ordered everyone to leave immediately, but as the DJ was playing music on that occasion, it made it difficult for the public to hear the warning [26].

The evacuation paths are shown on Figure 2-21, the one with green arrows represent the exit route that people should have followed, while the red arrows show the routes that people actually followed. In the first stages of the fire, the occupants went directly to the only exit door of the nightclub. Due to the lack of visibility and the large amount of people waiting to get out, some persons went to the toilets located at the front of the building. Testimonies indicate that they might mistook the toilet sign for an exit sign [44] or that they went there looking for windows [45].

Chapter 2. Kiss Nightclub Fire

The presence of metal bars, (see Figure 2-3 and Figure 2-10), and the fact that the security guards thought that people wanted to leave without paying made the evacuation of the nightclub even harder. The survivors said that [46]:

 Metal bars got in the way, Kiss nightclub was a "real labyrinth". A taxi that was in front of the nightclub also made evacuation difficult. As she tried to leave, a security guard held her by the waist, not letting her leave immediately. After she was able to leave, she looked back and saw that they had open the front door and many people started to leave. This took about 2 or 3 minutes: the smoke was already on the street and people were getting sick inside the nightclub.  Upon arriving at the main door, she was stopped by a security guard, who told the audience: "calm, calm, nobody leaves". Then the security guards pulled the main door, closing it completely, when a security guard said they should pay the commission before leaving. After that, a man hit the security guard, knocking him to the ground. So people were able to open the main door by force, dragging the security guards out of the nightclub, where people began to fall on top of each other. An uneven ramp at the exit made it difficult to get out.  The security guards kept the doors closed for about 10 seconds, as they thought people wanted to leave without paying. However, as soon as someone shouted "fire", the security guards immediately opened the doors.

Figure 2-21: Exit Routes (Source O Globo [47])

2.3.5 Emergency Responders The first emergency responders got to the nightclub at around 3 am [48]. The Lieutenant of the Military Brigade said that around 3:04 am on 01/27/2013, he was requested, via radio, to provide support to firefighters in Kiss nightclub, they immediately went to the scene.

The Commander of Socorro indicated that the night of 01/27/2013, at 3:18 am he received several phone calls reporting the fire at the Kiss nightclub. At 3:23 am., the team arrived at the scene [49].

Chapter 2. Kiss Nightclub Fire

When they arrived at the site, there were approximately 600 to 700 people in front of the establishment, which made the work of the firemen even more difficult. Initially, he realized that firefighters alone would not be able to rescue all the victims inside the nightclub. Since there was no fire, they accepted the help of four strong young men who were already there. At first they tried to dissuade them from taking part in the rescue, but they did not accept it because they said they had friends and family inside the club. He said that with his team, they went inside the establishment and they pulled the people until the access of the inner door. From there, the men pulled people out [49].

A young man that help with the rescue of people stated that [50]:

 A firemen asked him to enter and remove the people from the interior of Kiss. He crawled in with his wet T-shirt over her nose and mouth. He also reported that at some point he picked up the firemen's hose and went in to put out the fire. He tried to get an oxygen mask and his cylinder that were in the truck cabin. He dressed, but a fireman had him take it out and put the equipment back in the truck. He took out about 15 people from within Kiss and, as he remembers, firefighters only helped the victims, as they did not enter the nightclub. He was helping for about three hours.  Upon being re stated, on 03/11/2013, he clarified that "some civilians came to help and ended up dying inside the building; these civilians were in the nightclub, left and then returned to save the victims and also ended up dying; the Firemen not only allowed, but encouraged them to go inside and rescue people.”

There are videos, witness reports and firefighters own statements that confirm the declaration . As a result of that, at least 5 people died because they entered the interior of the nightclub without the adequate personal protective equipment, in order to save friends, family and friends [51].

Figure 2-22: Firefighters and civilians trying to rescue people [35]

2.3.6 Casualties A total of 234 people died on scene, 145 were hospitalized, and another 623 people received treatment throughout the first week following the incident. Eight of the hospitalized people later died [52].

Most of the people who died in the fire were young people between ages 18 and 30 years old who went to the party, militaries that were rescuing people and nightclub employees were also among the fatalities [53].

Chapter 2. Kiss Nightclub Fire

Figure 2-23: Fatalities in the nightclub [54]

As mention in section 2.3.4 a lot of people went to the toilets instead of going towards the exit door, 180 bodies were found there [35].

Figure 2-24: Dead people in the toilet [54]

Regarding the cause of death and the type of injuries that people had, the Health Minister Alexandre Padhilha stated:

 More than 90 people were hospitalized, Padilha said, including 14 patients with severe burns[55].  20% of the injured had serious burns, which correspond to more than 30% of the body. The majority suffered respiratory intoxication[56].  Most of the injured were suffering from smoke inhalation and only a few were severely burned [57].  Gustavo, (one of the victims), have 70% of his body burned [56].

While Dr. Paulo Afonso Beltrame, a professor at the medical school of the Federal University of Santa Maria who went to the city's Caridade Hospital to help victims stated [57], "Large amounts of toxic smoke quickly filled the room, and I would say that at least 90 percent of the victims died of asphyxiation."

The decomposition of polyurethanes at high temperatures produces narcotic gases such as carbon moxide and hydrocyanic acid which cause a decrease in oxygen supplied to body tissue, with loss of consciousness and ultimately death [58].

Chapter 2. Kiss Nightclub Fire

Toxicological reports based on blood samples of the victims found lethal concentrations of carbon monoxide (86.4%) and cyanide (69.8%) [59].

One of the major problems after the tragedy was the lack of the specific antidote for cyanide. The country received hydrocobalamin, sent by the US almost a week after the tragedy [60].

2.4 Summary The Kiss Nightclub was located in Rua dos Andradas 1925, Santa Maria in Rio do Sul, Brazil. The original project considered mostly non-combustible materials and exit routes obstacle free. This situation changed in 2011, when the official project was modified, without guidance of architects or engineers. The modifications include: covering the façade of the building with wood; metal bars in different parts of the building; use of polyurethane foam as sound insulation; and the sealing of the windows. The nightclub had two exit door, one next to the other with a total width of 3.05m, there were obstacles in the exit route that delayed the evacuation.

The Nightclub fire prevention and protection license had expired on August 10 of 2012, which means that it should not be in operation the night of the fire. According to the official documents the capacity of the nightclub was between 500 and 1000 people.

With respect to the fire protection measures the nightclub, it is possible to say that: it had fire extinguishers, but less than required and some of them did not work; the emergency lighting existed but it did not work; there was an absence or deficiency in the signaling system; there was no detection, alarm, smoke extraction or sprinkler system; the staff did not have a Prevention and Fire Fighting Training.

During the inspection of 2011, the fire fighters neglected that the nightclub presented several breaches, which allowed that the nightclub legally operate for one year, even when it did not comply with the fire safety regulations.

On January 27 of 2013 at 2:30 am a fire developed at Kiss Nightclub, the fire was originated on the ceiling over the raised stage area due to the use of pyrotechnics intended for outdoor use during the band show. A staff member and the singer of the band tried to extinguish the fire, but the fire extinguisher did not work. The nightclub was rapidly filled with toxic smoke from the burning of the polyurethane foam.

There is no agreement on the number of people that were inside the nightclub that day, but according to official information there were not less than 864, most of them were between 18 and 30 years old.

In the first stages of the fire the evacuation the occupants went directly to the only exit door of the nightclub. However due to the lack of visibility and the large amount of people waiting to get out, some persons went to the toilets located at the front of the building.

The presence of metal bars and the fact that the security guards thought that people wanted to leave without paying made the evacuation of the nightclub even harder.

The first emergency responders got to the nightclub at around 3 am, when they arrived at the site, there were approximately 600 to 700 people in front of the establishment, which made the work of the firemen even more difficult. Initially, they realized that firefighters alone would not be able to rescue all the victims inside the nightclub. Since there was no fire, they accepted the

Chapter 2. Kiss Nightclub Fire help of civilians who were already there. At least 5 people died because they entered the interior of the nightclub without the adequate personal protective equipment.

A total of 234 people died on scene, 180 bodies were found in the toilets, at least 90 percent of the victims died of asphyxiation. 145 were hospitalized, and another 623 people received treatment throughout the first week following the incident. Eight of the hospitalized people later died.

Chapter 3. Fire Safety Requirements

3 FIRE SAFETY REQUIREMENTS

In Brazil, the enforcement of fire safety measures is conducted in each state by the Corpo de Bombeiros da Polícia Militar [61]. The decree 37.380 [62] and the law 3301/91 [63] present the general requirements for Fire Prevention. The particular requirements for active fire protection, emergency exits and others may be found in NBR 9077[64], NBR 9441 [65] and NBR 12693 [66].

Extracts of the codes are mentioned in this section, for further information refer to the references.

3.1 Building Classification The fire safety requirements for the means of egress, detection and alarm system, extinguishing systems and others will depend on the classification of the building. The classification of the Nightclub must be done in function of its occupation, surface and constructive features, according with Table 1, Table 2, Table 3 and Table 4, (Figure 3-1 to Figure 3-4), from NBR 9077 code. According to NBR 9077 the classification of Kiss nightclub is F-6, L, P, and Y/X, which means is a social club of area less than 750 m2, less than 6 meters high and where the fire resistance according with the initial project was medium. After installing the polyurethane foam and wood façade this should have changed to low.

Figure 3-1: NBR 9077 – Table 1 [64]

Chapter 3. Fire Safety Requirements

Figure 3-2: NBR 9077 – Table 2 [64]

Figure 3-3: NBR 9077 – Table 3 [64]

Figure 3-4: NBR 9077 – Table 4 [64]

Chapter 3. Fire Safety Requirements

3.2 Materials

3.2.1 Requirements From LEI MUNICIPAL 3301/91 [63]

Art. 17 - The use of easily ignitable materials and / or that emits toxic gases in case of fire, in partitions, coating and finishes is forbidden: I - public meeting establishments, cinemas, theaters, nightclubs and similar;

3.2.2 Analysis Combustible material, such as polyurethane foam should not be used in the nightclub.

3.3 Capacity

3.3.1 Requirements From NBR 9077 [64]

Art. 4.3 Population calculation Art. 4.3.1 The emergency exits are dimensioned according to the population of the building. Art. 4.3.2 The population of each building floor is calculated by the coefficients in Table 5 of the Annex, considering its occupation, given in Table 1 of the Annex of this code. Art. 4.3.3 Only for calculation of the population purpose, in the pavement areas should be included: b) the total covered areas of buildings F-3 and F-6, including fields and similar; (c) stairway, ramp and similar areas, in the case of buildings of groups F-3, F-6 and F-7, when, as a result of their layout, these seats may possibly be used as bleachers. Art. 4.3.4 Exclusively for the calculation of the population, the sanitary areas in occupations E and F are excluded from the pavement areas. From Table 5 NBR 9077: The kitchens and their support areas, in occupations F-6 and F-8, that have their occupation considered as in group D, that is, a person by 7 m2.

3.3.2 Analysis According to Table 5, (Figure 3-5), of NBR 9077 for an F-6 occupancy, 2 persons per square meter should be considered. In Table 2-1 are shown the different areas in the nightclub from the initial project, however, it is known that the building suffered several modifications, which might produce variations in this values.

Table 3-1 presents the population calculation. The factors used come from Table 5 of NBR 9077, which provides information for areas used by the customers and for kitchens and service areas. However, for zones such as: stage; circulation areas and lobbies (which were categorized as Others), there is not data. To obtain an estimation, values for these locations, (indicated with “*”), were taken from NFPA 101 table 7.3.1.2.

Chapter 3. Fire Safety Requirements

Figure 3-5: NBR 9077 – Table 5 [64]

Table 3-1: Population

Factor Area m2 Population (person/m2) Service 148 1/7 21 Customers 361 2 722 Stage 24 1/1.4 (*) 17 Others 60 1/7(*) 8

With this considerations a value of 768 persons is achieved. The result is practically the same as the one calculated by the Experts from the “Instituto Geral de Perícias do RS” of to the 769 people, which for this analysis will be consider as the nominal capacity of the nightclub.

This calculation confirms that the capacity of the nightclub is 231 persons less than what was indicated on the Bulletin of establishments and activities shown in Figure 2-7.

3.4 Emergency Exits

3.4.1 Requirements The requirements for emergency exits are indicated in NBR 9077 [64].

Art 4.3.1. The emergency exits are dimensioned as function of the building population.

Art 4.3.2. The population of each floor of the building is calculated by the coefficients in Table 5 of the Annex of this code, based on the occupancy category given in Table 1 of the Annex of this code.

Art 4.4.1.2. The width of the exits, that is, the accesses, stairs, discharges, and others, is given 푃 by the following formula: 푁 = ⁄퐶 Where: N = number of units of passage, rounded (a unit of passage is equivalent to 0.55 meters)

Chapter 3. Fire Safety Requirements

P = population, according to the coefficient of Table 5 C = capacity of the unit of passage from Table 5

Art 4.5.2.2. The maximum distances to be covered can be found in Table 6 in the Annex.

Art 4.5.3.1. A minimum number of exits for the different occupancy of the hazard, in relation with the height, dimensions and construction features of the building are indicated in the Table Nº7-Anex.

3.4.2 Analysis From Table 7 of NBR 9077 [64], the nightclub is required to have 2 exit doors. However it is not clear if it is accepted that the two of them are located next to each other.

Figure 3-6: NBR 9077 – Table 7 [64]

From 3.3.2, it is known that the nominal capacity of the nightclub is 769 persons. With this building capacity, the required width of exits can be derived according to Section 3.4.1. As seen in Table 3-2, the required width for the exit doors and accesses is 4.4 m.

Table 3-2: Exit doors and accesses required width

Population Capacity of the unit of Number of unit of Width (number of people) passage (people/min) passage (round up) (meters) 769 100 8 4.4

It is also important to mention that the capacity of the unit of passage decreases when there is not a full compliance of the requirements in the codes, such as population, emergency signaling and fully unobstructed escape routes [67].

With respect to the maximum travel distance allowed, this depends on the number of exit doors and with the type of construction as shown in Table 6 of NBR 9077. The original project assumed that the nightclub had 2 exit doors and a construction type Y, hence 30 meters are permitted. This situation changes if it is consider that the building only had 1 exit door, then the maximum travel distance is reduced to 20 meters.

Chapter 3. Fire Safety Requirements

Figure 3-7: NBR 9077 – Table 6 [64]

3.5 Extinguishing System

3.5.1 Requirements From DECREE N°37.380 [62]

Art 8. The installation of fire extinguishers in all the mentioned buildings in Art. 4 of these standards is mandatory, and the existence of other protection systems does not exempt this requirement.

Art. 9 - The buildings must be equipped with hydraulic fire-fighting installations when: I - have a height above 12 m; II - not being residential, have a total constructed area over 750 m2; III - are destined to service stations or garages with fuel supply, independent of the area; IV - intended for residence, with a floor area of over 750 m2; V - serve as liquefied petroleum gas deposits, in accordance with Decree No 27/96 of the DNC; VI - Deposits of flammable and combustible liquids.

Art 10. The installation of Automatic Fire Extinguishing System must meet, at least, requirements of NBRs 6,125, 6,135, 8,674, 10,897 and 12,232, all of which are from ABNT the following buildings:

I - buildings classified as high risk with a built area over 1,500 m² (one thousand five hundred square meters); II - buildings classified as medium risk area with a built area over 3,000 m² (three thousand square meters) or more than 20m (twenty meters) in height; III - buildings classified as small risk that have a built area over 5,000 m² (five thousand square meters), or 30m (thirty meters) in height, except the residential ones; IV - buildings classified as high or medium risk, when they are below the level of the entrance and with area superior to 500 m² (five hundred square meters).

Chapter 3. Fire Safety Requirements

From NBR 12693 [66]

Art 5.1.1 Selection of extinguishing agent

According to the nature of the fire, extinguishing agents should be selected from those in Table 3.

Art. 5.2.1.3 Protection requirements can be met with extinguishers of greater extinguishing capacity, but the distance should not exceed 20 m.

Art. 5.2.1.4 The area which may be protected by an extinguisher, class A, is presented in Table 5. The values are determined by multiplying the maximum area per unit of A, obtained from Table 4, by the various classes A until the value of 800 m2 is reached.

Art. 5.6 Maintenance. Fire extinguishers shall be subject to inspection and maintenance, in accordance with the codes.

3.5.2 Analysis As shown in Figure 2-11, the nightclub was classified as medium risk, having a built up area of 640m2, an automatic fire system is not required.

On the other hand, manual fire extinguishers are required. As seen in Section 2.2.3, the night of the fire there were only three of the five 4 kg ABC fire extinguishers in the nightclub [25]. The analysis to determine if five would protect the complete building is made based on this information.

Figure 3-8: Fire extinguisher with similar characteristics as the ones in Kiss Nightclub [68]

As seen in Figure 3-8, the rating of a 4 kg ABC fire extinguisher is 3A. The requirements established in NBR 12693 Table 4 and Table 5 indicate that the maximum travel distance to reach a device is 20 meters, with a maximum area to be protected per extinguisher of 405 m2.

One of the many possible configurations for the 5 fire extinguishers location in the nightclub is presented in Figure 3-9. Each of the devices was represented with a different color to clearly show the area that is being protected. It is possible to see that the whole building is covered.

Chapter 3. Fire Safety Requirements

Figure 3-9: Fire extinguisher location (the layout of the club from [8])

3.6 Detection and Alarm System

3.6.1 Requirements From DECREE Nº37.380 [62]

Art. 14. Fire detection and alarm apparatus shall be installed in the buildings provided for in NBRs 5,455, 9,077, 9,441 and 11,836, all of ABNT, according to the technique described therein, taking into account that the use of systems of alarm in the building, through automatic detectors, does not dispense with the obligation of the use of manual actuators, and in hospitals and other buildings with special occupations, the type of alarm system should have characteristics appropriate to the use of the building.

From LEI MUNICIPAL 3301/91 [63]

Article 9 - The installation of a fire alarm is mandatory in the types of buildings and establishments that follow: I-establishments of public meetings such as: cinemas, theater, nightclubs or similar

From NBR 9077 [64]

Art 4.12.1.2. Fire alarms shall be installed, of the type bi-tone, except for the special cases they recommend only luminous, such as in occupations H-2, H-3 and others, in the cases provided in Table 8 of the Annex.

3.6.2 Analysis In the regulation is not clearly stated the characteristics such as: occupation, size, height, capacity or location of the building where a detection system shall be required.

Chapter 3. Fire Safety Requirements

On the other hand, according to NBR 9077 Table 8 [64], the alarm system was not required due to the area and height of the nightclub. This contradicts the requirement stated in LEI MUNICIPAL 3301/91 – Article 9, where the fire alarm system is mandatory in nightclubs. In this case the most strict requirement will be considered.

Figure 3-10: NBR 9077 – Table 8 [64]

3.7 Signage and Emergency Lighting

3.7.1 Requirements From DECREE N°37.380 [62]

Art. 12. Emergency lighting shall be installed in the buildings provided for in NBR 9.077 and NBR 10,898, both of ABNT, and shall comply with the technical standards therein provided. Art. 13. Fire and panic safety signs shall be installed in buildings NBRs 9,077, 12,434, 13,435 and 13,437, all of ABNT, and should comply with techniques described there.

From NBR 9077 [64]

4.13 Emergency lighting and exit signaling

4.13.1 Illumination of exit routes The exit routes must have sufficient natural and / or artificial lighting according to NBR 5413. Even in the case of buildings intended for daytime use only, artificial night lighting is indispensable.

4.13.2 Emergency lighting

4.13.2.1 Emergency lighting is mandatory in accesses and discharges: (a) where there is a requirement for encased stairways (see Table 7 of the Annex); b) when the exit routes exceed 30 m, except occupancy buildings A (residential); c) in any non-residential building, class Y; d) in all class X buildings, except single-family houses (A-1).

4.13.2.3 Emergency lighting shall be performed in accordance with NBR 10898.

Chapter 3. Fire Safety Requirements

4.13.3 Exit Signage

4.13.3.1 Exit signage is mandatory: a) in the accesses and discharges of emergency stairs in general, in non-residential buildings (that is, excluding buildings in group A); b) access and discharges of public meeting places (group F), even when not provided with stairs; c) in buildings of occupations B, C, D, E and H, when classified in O (area greater than 750 m2).

3.7.2 Analysis The nightclub should have been provided with exit signage and emergency lighting in accesses and discharges, ensuring a minimum level of illumination on the floor and allowing the recognition of obstacles.

3.8 Summary According to the original project, the nightclub was classified as F-6, L, P, and Y. With this classification, the legal requirements for the Kiss nightclub were the following:

 A nominal capacity of 769 people.  A minimum of 2 exit doors, with an obstacle free exit route.  A minimum width for the exit doors, and the routes that leads to it of 4.4 meters (8 units of passage).  A maximum travel distance of 30 meters.  A minimum of 5 fire extinguishers.  A fire alarm system.  Emergency lighting in accesses and discharges. Allowing the recognition of obstacles that could impede the circulation.  Exit signage in access and discharges.  The use of easily ignitable materials and / or that emits toxic gases in case of fire, in partitions, coating and finishes is forbidden.

Chapter 4. Compliancy Issues

4 COMPLIANCY ISSUES

4.1 Materials As indicated in Section 2.1.3, several modifications were done to the original project that were not approved by engineers or architects [14].

At the beginning of 2011 the façade of the building was covered with wood, this situation affects the classification of the building, hence the fire safety requirements become much more strict.

At the end of 2011 the acoustic engineer notice that the east wall was covered with “sound insulation foam”. The law 3301/91 [63] clearly state that the use of easily ignitable materials and/or that emits toxic gases in case of fire, in nightclubs is forbidden, for this reason he requested to removed it and to build a masonry wall. The polyurethane foam remained in the nightclub, and in June of 2012 the owner gave instructions to placed it on stage ceiling and in the rear wall.

Considering that almost 90% of the victims died by asphyxiation [57] this situation becomes a main issue of concern.

4.2 Population As seen in 2.3.4, there is no agreement in the number of people that was on the nightclub the night of the fire. Nevertheless, it was not less than 864 [43] persons. Comparing this with the nominal capacity of 769 people determined in 3.3.2, it is possible to say that the club was overcrowded by at least 95 occupants. The situation becomes even more critical if it is considered that there could have been 1200 [41] or 2000 [17] persons in the nightclub that night.

4.3 Emergency Exit The club had a single exit for evacuation in the incident. This is not compliant to the building regulation requirements as analyzed in Section 3.3.2. For the given club, two exits are required, as mentioned in 3.4.2. However, it is not clear if it is accepted that the two exit doors are located next to each other, but for this analysis it will not. Therefore the nightclub was not in compliance with the number of exit doors.

There is a significant difference in the width of the exit doors that the nightclub had, 3.04 meters, with what was legally required, 4.4 meters. Furthermore the exit route had several metal bars that delayed the evacuation process, the presence of obstacles affects directly the capacity of the unit of passage.

The maximum travel distance was approximately 30 meters, when the maximum allowed, considering the existence of only one exit door in the nightclub, was 20 meters.

Given the layout of the nightclub (Figure 2-2), the only way to achieve a maximum travel distance of 20 meters is by implementing an exit door located opposite to the existent one. However, as it can be seen on Figure 6-1, it is not possible to implement an exit door on the back of the night club so this requirement could have never been fulfilled.

Chapter 4. Compliancy Issues

4.4 Fire Extinguishers As seen in Section 3.5.2, with the five 4kg ABC fire extinguishers that the nightclub should have had the complete building would have been protected. However, as mention in Section 2.2.3, only 3 devices were found in the building the night of the fire [25]. This means that it is likely that the travel distance to get to an extinguisher did not meet the legal requirements.

From the testimonies it is known that at least one of the extinguishers did not operate and that several devices were removed from the intended location [25][27]. It was also mentioned that during a previous party someone operated a fire extinguisher near the stage [25]. Which could be the reason for the device did not work during the fire.

Previne was the company that sold and maintained the fire extinguishers of the Kiss nightclub. The information of the dates on which they refilled the devices can be found in their management system. The first time was on July 2009, when three fire extinguishers sold by Previne to Kiss were purchased. The following year, the company postponed the recharge, being made only on October 2010. In 2011 the recharge occurred on November 11 and in 2012 it was anticipated to October [25].

Regardless the causes that led to the malfunction of the fire extinguisher, (lack of maintenance and/or the bad use of the equipment), the fact is that the night of the fire at least one device was not operative.

4.5 Fire Alarm System The nightclub did not have a fire alarm system which was required in the Article 9 of the code LEI MUNICIPAL 3301/91.

4.6 Signage and Emergency Lighting It is not possible to determine if the number and location of the emergency lights and the exit signs was in compliance with the codes requirements, but according with the expert report Nº12268/2013 [32], there were insufficient exit signs and no illumination to recognize obstacles. However, the emergency lighting present in the nightclub met the requirements from Santa Maria, and even overpassed them, because it had autonomous systems with accumulators However, they activated after the power outage, which happened when the fire was already developed and smoke had spread in the building [69].

4.7 License to Operate Figure 2-11 shows that the Nightclub fire prevention and protection license had expired on August 10 of 2012, which means that the nightclub should have not been in operation the night of the fire [19].

4.8 Trained Staff As mentioned in Section 2.2.3, firefighters inspectors requested that the staff have a Prevention and Fire Fighting Training taught by a qualified professional. However, a member of the personnel stated that they did not receive the training [29].

4.9 Use of Pyrotechnics The pyrotechnics use during the band show had instructions that were not followed. It was intended for outdoor use only and that should not be used near people, houses, fuels or flammable products.

Chapter 4. Compliancy Issues

4.10 Summary There were many breaks of the regulations in the Kiss nightclub . One of the most important issues is that the Fire prevention and protection license had expired 5 months before the fire, which means that it should not be in operation that night. Moreover the nightclub should not have been open to the public since August 2011, as it was not complying with the fire safety regulations required when the operation license was granted.

Several articles of the NBR 9077 regulation [64] were not being fulfilled, especially with respect to the exit routes there was only one exit door, which was not wide enough, there were obstacles (metal barriers) in the exit route and the travel distance was 30 meters instead of 20 meters. Additionally, the nightclub was overcrowded.

Regarding the fire extinguishers there were supposed to be five 4kg ABC devices, however, only 3 devices were found in the building the night of the fire. In addition, at least one of the extinguishers did not operate and that several devices were removed from the establish location.

In concern with the emergency lighting and signage, there was an insufficient amount of devices to comply with the regulations.

The staff have not received proper Prevention and Fire Fighting Training.

The pyrotechnics used during the band show should not be used near people, houses, fuels or flammable products.

Chapter 5. Investigation Method

5 INVESTIGATION METHOD

5.1 BuildingEXODUS The buildingEXODUS evacuation model is an egress model designed to simulate the evacuation of large numbers of individuals from large multi-floor buildings [3]. The model tracks the trajectory of each individual as they make their way out of the building, or are overcome by fire hazards such as heat and toxic gases. The buildingEXODUS model comprises five core interacting submodels, these are the Occupant, Movement, Behaviour, Toxicity and Hazard submodels (see Figure 5-1). The software describing these submodels is expert system based; the progressive motion and behaviour of each individual being determined by a set of heuristics or rules [3].

Figure 5-1: Sub-models in buildingEXODUS

5.2 Coupled Fire and Evacuation Analysis Technique The Hazard sub-model can read data generated by the SMARTFIRE CFD fire model. To transfer CFD fire hazard data the user must define a consistent set of zones within both the SMARTFIRE and EXODUS geometry. The hazard data within SMARTFIRE is averaged over these zones to produce two values, a hazard value at an arbitrary nominal head height, 1.7 m and a value at an arbitrary nominal knee height, 0.5m. It is these zone averages which are then mapped to the appropriate zone within EXODUS. When occupants are considered to be standing, they are exposed to the hazards at head height (irrespective of their actual height) and when the occupants elect to crawl, they are exposed to the hazards at knee height. Occupants crawl when the temperature or smoke concentration at head height exceeds a critical value [4][5]. In addition, when occupants are forced to move through smoke, their walk speed is reduced according to the data produced by Jin [4][5][70].

In this study the following terms are used to describe the results produced by buildingEXODUS:

 TET: Total Evacuation Time.  PET: Personal Evacuation Time. It is a measure of the time spent by the occupant in the evacuation  CWT: Cumulative Waiting Time, It is a measure of the total time that an occupant remains stationary after having started to evacuate.  CWT to PET Ratio: an indicator of the proportion of the evacuation time that agents spent waiting in congestion.  FIH: Measures an individual’s cumulative exposure to radiative and convective heat.  FIN: Measures an individual’s cumulative exposure to narcotic gases.

Chapter 5. Investigation Method

The coupled fire and evacuation techniques has been used in many fire and evacuation analysis. This technique has been used to explain the outcome of the Rhode Island Nightclub fire involving 100 fatalities [6]; to reconstruct the 1985 fatal Manchester B737 fire that claimed the lives of 55 people [71]; to investigate an indoor shooting range fire with 15 fatalities [72]; to assess the fire safety as part of a design evaluation of a Blended Wing Body aircraft concept involving 1000 passengers and crew [73]; and to assess the fire safety of open wide gangway underground trains in tunnels [74].

5.3 Incident Reconstruction With the joint fire/evacuation techniques, the Kiss Nightclub disaster has been numerically reconstructed under some assumptions made by the Fire Safety Engineering Group [2]. The main result are briefly described here and in Appendix A, while the details of the reconstruction can be found in [2].

Due to the many unknowns of the event and uncertainties in the data required for models, the reconstruction of the accident is a repetition of a two-step process. First the fire is simulated and then the coupled fire and evacuation is simulated. The results from the fire simulation are part of the inputs to the evacuation simulation to predict the impact of the fire on the evacuating occupants. The occupants are exposed to the fire hazards determined from the fire simulations which include temperature, radiative flux, concentrations of toxic gases, low oxygen and smoke obscuration. The reconstruction of the fire development and evacuation process for the Kiss Nightclub fire is considered to be completed when appropriate values for the unknown parameters are identified. Thus the simulation produces a reasonable agreement with the known outcomes.

The reconstruction is performed with the model parameters being as close to the real values as possible. The key model parameters which are specially addressed in this study include:

 The number of exits (1);  The number of occupants (1200);  Metal barriers around the exit (Yes);  Appropriate evacuation signage (No); The geometry setup of the fire simulation in the reconstruction is shown in Figure 5-2.

Figure 5-2: SMARTFIRE set up of the Kiss Nightclub in the fire simulation [2].

Chapter 5. Investigation Method

As shown in Figure 5-3 a total of 52 identical hazards zones are defined in both the fire and evacuation simulations. The light extinction coefficients in Zone 44 increase to 4.0/m at 240 seconds, which implies a visibility of 2 m only for light-emitting sign. Under this situation, occupants standing along the bar walls are allowed to go to the toilets if there is congestion there due to the bad visibility.

Figure 5-3: Fire hazard zones prescribed within both the fire and evacuation models identified by dashed lines and walls (several key zones are indicated by their zone number)[2].

The evacuation geometry setup is presented in Figure 5-4. The evacuation routine around the exit was complex with metal bars (See Figure 5-5). This reconstruction of the Kiss Nightclub fire is the base of this study.

Figure 5-4: Evacuation simulation setup in the reconstruction [2].

Chapter 5. Investigation Method

Figure 5-5: Evacuation routes near the exit (dashed line representing the path for entering the nightclub hall in the reconstruction [2].

5.4 Investigation Method In this study, the evacuation of the Kiss Nightclub fire is further analyzed based on the reconstruction in [2]. The investigation method is the same as the reconstruction performed by Fire Safety Engineering Group. However, in the joint fire/evacuation analysis process, the fire hazards are fixed to those from the fire simulation in [2], while the values of the evacuation parameters varies from the reconstruction to those compliant to the building requirements as analyzed in Chapter 4. Therefore, the following assumption is made in this study.

Assumption: the change of the number of exits, the number of occupants, the use of appropriate signage will not essentially change the fire behaviors as in the incident, or the reconstruction.

With this assumption, the fire hazards derived from the fire simulation in [2] can be used to continue the evacuation analysis in Chapter 6.

Chapter 6. Evacuation Analysis

6 EVACUATION ANALYSIS

6.1 Evacuation Scenarios From the review of the Brazilian fire safety several breaks of the building regulations have been identified for the Kiss Nightclub in Chapter 4. To assess the extent to which these factors impact the evacuation performance, 14 evacuation scenarios were analyzed, Table 6-1 summarizes them and presents its mains features.

In contrast to the real incident or the reconstruction with some people being “attracted” to the toilets, in some scenarios, an appropriate signaling and/or emergency lighting system are assumed. Rather than implementing a signage system in the evacuation, people are simply assigned exit targets to prevent people to move to the toilets. The scenarios in Table 6-1 with ‘No’ in the last column are with this configuration. The use of a signage system is further discussed in the last chapter of this thesis.

Table 6-1: Summary of the evaluated Scenarios

Number of Number of Width of exit Metal Response Toilets mistaken Scenario occupants exits door (m) bars Time (s) for exits N°11 1200 1 3.2 Yes 25 - 60 Yes N°1.2 1200 1 3.2 Yes 25 - 60 No N°2.1 1200 1 4.4 Yes 25 - 60 Yes N°2.2 1200 1 4.4 Yes 25 - 60 No N°3.1 769 1 3.2 Yes 25 - 60 Yes N°3.2 769 1 3.2 Yes 25 - 60 No N°4.1 1200 1 3.2 Yes 25 - 40 Yes N°4.2 1200 1 3.2 Yes 25 - 40 No N°5.1 1200 2 (front) 3.2/1.2 Yes 25 - 60 Yes N°5.2 1200 2 (front) 3.2/1.2 Yes 25 - 60 No N°5.3 1200 2 (opposite) 3.2/1.2 Yes 25 - 60 Yes N°5.4 1200 2 (opposite) 3.2/1.2 Yes 25 - 60 No N°6.1 1200 1 3.2 No 25 - 60 Yes N°6.2 1200 1 3.2 No 25 - 60 No N°7 769 2 3.2/1.2 No 25 - 40 No

In Table 6-1, Scenario N°1.2, N°2.2, N°3.2, N°4.2, N°5.2, N°5.4, N°6.2 and N°7 assume an efficient signage system that direct people to the exits rather than moving towards the toilets. Scenario N°1.2, N°2.1, N°3.1, N°4.1, N°5.1, N°5.3 and N°6.1 investigate the impact the individual factors on the evacuation, while Scenario N°7 is the case with all the identified issues complying the regulations.

The factors that influence the fire development such as the effectiveness of fire extinguishers or the presence of polyurethane foam in the nightclub were not analyzed in this study.

A detailed description of the different scenarios is presented below.

1 Reconstruction to the incident 39

Chapter 6. Evacuation Analysis

6.1.1 Scenario N°1: Reconstruction Scenario It is the reconstruction of what happened the night of the fire at Kiss nightclub. This scenario was investigated by FSEG, University of Greenwich [2]. This is considered the base scenario. The simulation takes into account the following:

Exit Routes. There is only one door of 3.2 meters, and there are several metal barriers which interfere with the evacuation, some of them were even pushed down during the fire. Also the toilets located in the front of the building were mistaken for an exit.

Overcrowding. As it was mentioned in 2.3.3 the club was overcrowded, the number of people is unknown, but it should be between 864 and 2000, for the simulations a number of 1200 occupants will be used.

Response Times. The response time of the occupants depended on their location on the nightclub. According to the gathered information people who were in the dance floor 1, near the stage, were the first to evacuate, for this reason a response time of 25 to 30 seconds was assigned. People located in the main hall will have a response time of 30 to 35 seconds, while for the occupants that were in the dance floor have a response time of 35 to 41 seconds. The last occupants to react were the ones situated in the VIP area and in rooms (toilets, offices, storage room) with a response time between 41 and 60 seconds.

Untrained Staff. Doors were closed because the staff of the nightclub thought that people were leaving before paying the bill. Also they did not warned that a fire was taking place in the nightclub.

No signage system. There was not a signage system that guide the occupants to the exit door.

6.1.2 Scenario N°1.2: Signage System Scenario N°1.2 studies the influence of having an efficient signage system directing people to the exits rather than moving towards the toilets.

6.1.3 Scenario N°2: Wider Exit Door This scenario set assesses the effect of the width of the exit door, which is increased from 3.2 to 4.4 meters, corresponding to the legally required for a nominal capacity of 769 people (see Section 3.4.2).

6.1.4 Scenario N°3: Nominal Capacity This scenario set studies the influence of the amount of occupants present in the nightclub in the evacuation results. The population of the nightclub was decreased from 1200 persons to 769 people, which correspond to the nominal capacity, as calculated on Section 3.3.2.

6.1.5 Scenario N°4: Trained Staff This scenario set evaluates the impact of having a trained staff in the nightclub, this considers that there will be a notification of the fire in an early stage and that doors will be blocked during 25 seconds instead of 45. In this scenario, people who were in the dance floor 1, near the stage, are set to have a response time of 25 to 30 seconds, while for the rest of the occupants the response time is set to 30 to 40 seconds.

Chapter 6. Evacuation Analysis

6.1.6 Scenario N°5: Two Exit Doors This scenario set assesses the effect of having two exit doors and its location. For the actual implementation of this scenario probably a new architectural project would be required the modification of the layout of the nightclub. These modifications are not part of this analysis. In addition, there are limitations due to the location, being impossible to have an exit door in the back of the nightclub.

Nevertheless two set up were analyzed, the first with both of the exit doors placed in the front and the second where they are remotely located from each other. Figure 6-1 shows the location of the exit doors, in yellow is the main entrance that is set to have 3.2 meters wide, in green is the new exit door with a width of 1.2 meters.

For the two proposed locations two cases were studied. The first assumes that the occupants are more familiar with the main entrance than with the new exit door. The second considers that the nightclub had a signage system that prevents people from entering to the toilets and also contributes to an efficient door usage.

Figure 6-1: Left two exit doors in the front. Right exit door in the front and in the back

6.1.7 Scenario N°6: Clearance of the Evacuation Route This scenario set studies the influence of the obstacles present in the exit routes. The presence of the metal bars have a direct impact on the flow rate of people.

6.1.8 Scenario N°7: Compliance with All Regulations This scenario combines the different scenarios to evaluate the situation that comply with all of the requirements establish in the Brazilian´s codes. This means that there are two exit doors with a total width of 4.4 meters, without the presence of metal bars, the club is at its nominal capacity and the staff is trained and with an efficient signage system.

6.2 Evacuation Simulations

The evacuation simulations of the scenarios previously described were performed using buildingEXODUS [3]. In scenarios, (N°1.2, N°2.2, N°3.2, N°4.2, N°5.2, N°5.4, N°6.2 and N°7), with assumptions that an efficiency signage system is applied, the signage system is not implemented in the model in this study. Instead of such a system, occupants are assigned appropriate exit targets to guarantee their reasonable evacuation routines. The simulations were performed are using a PC with 4 GHz processor and 64 GB memory. Due to the involvement of random factors in the simulation, the simulation for each scenario has been repeated 500 times.

Chapter 6. Evacuation Analysis

6.2.1 Scenario N°1: Reconstruction Scenario This is the reconstruction of the fire and evacuation simulation performed by the Fire Safety Engineering Group of the University of Greenwich [2].This scenario provides features such as: geometry of the building; type and location of nodes; flow rates, potentials and status of internal and external doors; age, gender, travel speed and response times of the population; and behavior options, that are used as a base for the others scenarios.

The layout of the nightclub is shown in Figure 6-2, it was constructed based on the information shown in Section 6.1.1. Each node represents a vertical and horizontal distance of 0.4 meters, which gives a length of 25.2meters and a width of 22.4 meters, the thickness of the internal walls was not considered.

8 internal doors and 3 exit doors are considered, (Door 1, Door 4 and Door 5), but only Door 1 is actually used as an exit, the other 2 are used to attract people to the front toilets. Their configuration is shown in Table 6-2.

Figure 6-2: Geometry of the Nightclub in buildingEXODUS for Scenario N°1

Chapter 6. Evacuation Analysis

Table 6-2: Scenario N°1 Parameters

Scenario N°1 Door Flow Rate Status Potential Times Comments [occ/m/s] InDoor_1 1.16 Open 100 InDoor_2 1.16 Open 100 InDoor_3 1.16 Open 100 InDoor_4 0.66 Closed 100 45 Internal doors that were closed at the InDoor_5 0.66 Closed 300 45 beginning, they open at 45s. InDoor_6 0.2 Open 130 Represents the metal barrier that is InDoor_7 0.16 Closed 91 240 pushed down at 240s. This internal doorway is used to stop InDoor_8 1.33 Open 75 570 people in the toilets to go back to the Door_1 1.33 Open 90 Alwaysmain exitopen These two doors are only used to attract Door_4 1.33 Closed 62 240-241-1800 the people to the toilet during the evacuation. They are closed immediately Door_5 1.33 Closed 61 240-241-1800 after they are opened at 240 seconds

6.2.2 Scenario N°1.2: Signage System

Considers the same configuration, but Internal Door 8, Door 4 and Door 5 were removed, which implies that no people will be attracted to the toilets. Figure 6-3 presents the configuration of Scenario N°1.2. The parameters are the same than for Scenario N°1.

Figure 6-3: Scenario N°1.2

6.2.3 Scenario N°2: Wider Exit Door Compared with the reconstruction scenario, the number of nodes associated to the external Door 1 increases from 8 to 11, to obtain a width of 4.4 meters for Scenario N°2. The width of the doors that leads to Door 1 were also increased. Three different configurations were studied.

Figure 6-4 shows Scenario N°2.1, in which the only difference with respect to the reconstruction scenario is the widened doors.

Chapter 6. Evacuation Analysis

Figure 6-4: Scenario N°2.1

Scenario N°2.2 maintains the same configuration of Scenario N°2.1, but in this case Internal Door 8, Door 4 and Door 5 were removed, which implies that no people will be attracted to the toilets.

Figure 6-5: Scenario N°2.2

Table 6-3 shows the parameters for each configuration.

Table 6-3: Parameters for Scenario N°2.1 and N°2.2

Scenario N°2.1 Scenario N°2.2 Door Flow Rate Flow Rate Status Potential Status Potential [occ/m/s] [occ/m/s] InDoor_1 1.16 Open 100 1.16 Open 100 InDoor_2 1.16 Open 100 1.16 Open 100 InDoor_3 1.16 Open 100 1.16 Open 100 InDoor_4 0.66 Closed 100 0.66 Closed 100 InDoor_5 0.66 Closed 300 0.66 Closed 300 InDoor_6 0.2 Open 130 0.2 Open 130 InDoor_7 0.16 Closed 91 0.16 Closed 91 InDoor_8 1.33 Open 75 Door_1 1.33 Open 90 1.33 Open 90 Door_4 1.33 Closed 62 Door_5 1.33 Closed 61

Chapter 6. Evacuation Analysis

6.2.4 Scenario N°3: Nominal Capacity The population decreases from 1200 to 769 persons. Figure 6-6 shows the two scenarios that are analyzed, the first considers that people mistake the toilets for exit doors, while in the second people go directly to the main exit door. The features of the population remains the same as for the Reconstruction Scenario.

Figure 6-6: Scenario N°3. (Left) Scenario N°3.1; (right) Scenario N°3.2

The geometry parameters are the same shown in Table 6-3, for Scenario N°2.1 and N°2.2.

6.2.5 Scenario N°4: Trained Staff The decrease of the response times is shown in Figure 6-7, the red squares represent people with a response time of 25 to 30 seconds, while the cyan squares represent people with a response time of 30 to 40 seconds.

Figure 6-7: Response times of occupants for Scenario N°4

Chapter 6. Evacuation Analysis

In this scenario the internal doors 4 and 5 change from being closed during the first 45 seconds to being open after 25 seconds.

Table 6-4: Parameters for Scenario N°4

Scenario N°4.1 Scenario N°4.2 Door Flow Rate Flow Rate Status Potential Times Status Potential Times [occ/m/s] [occ/m/s] InDoor_1 1.16 Open 60 1.16 Open 60 InDoor_2 1.16 Open 60 1.16 Open 60 InDoor_3 1.16 Open 100 1.16 Open 100 InDoor_4 0.66 Closed 60 25 0.66 Closed 60 25 InDoor_5 0.66 Closed 300 25 0.66 Closed 300 25 InDoor_6 0.2 Open 130 0.2 Open 130 InDoor_7 0.16 Closed 91 240 0.16 Closed 91 240 InDoor_8 1.33 Open 75 570 Door_1 1.33 Open 90 1.33 Open 90 Door_4 1.33 Closed 62 240-241-1800 Door_5 1.33 Closed 61 240-241-1800

6.2.6 Scenario N°5: Two Exit Doors The first two set-up have 2 exit doors in the front, the configuration for Scenario N°5.1 can be seen in Figure 6-8. The width of the hallway that leads to new door was increased by 0.4 meters.

Scenario N°5.2 has the same configuration that Scenario N°5.1 but without Internal Door 8, Door 4 and Door 5. This modification was done to represent that the nightclub has a signage system that will guide people to the exit doors.

Int. D3 Int. D1 Int. D8

Int. D6 Int. D2 Int. D7

Int. D5 Int. D9

Int. D4

Figure 6-8: Scenario N°5.1 Two exit doors (Door 1 and Door 2) in the front

Chapter 6. Evacuation Analysis

The parameters used for these scenarios are shown in Table 6-5.

Table 6-5: Parameters for Scenario N°5.1 and N°5.2

Scenario N°5.1 Scenario N°5.2 Door Flow Rate Flow Rate Status Potential Times Status Potential Times [occ/m/s] [occ/m/s] InDoor_1 1.16 Open 60 1.16 Open 100 InDoor_2 1.16 Open 100 1.16 Open 100 InDoor_3 1.16 Open 100 1.16 Open 100 InDoor_4 0.66 Closed 100 45 0.66 Closed 100 45 InDoor_5 0.66 Closed 300 45 0.66 Closed 97 45 InDoor_6 0.2 Open 130 0.2 Open 100 InDoor_7 0.16 Closed 91 240 0.16 Closed 100 240 InDoor_8 1.33 Open 75 570 InDoor_9 1.16 Open 80 1.16 Open 100 Door_1 1.33 Open 90 1.33 Open 90 Door_2 1.33 Open 80 1.33 Open 90 Door_4 1.33 Closed 62 240-241-1800 Door_5 1.33 Closed 61 240-241-1800

The last two set-up have one exit door in the front and the other one in the back. The configuration for Scenario N°5.3 can be seen in Figure 6-9.

Figure 6-9: Scenario N°5.3 One exit (Door 1) door in the front and one (Door 2) in the back

Chapter 6. Evacuation Analysis

The parameters used for these scenarios are shown in Table 6-6.

Table 6-6: Parameters for Scenario N°5.3 and N°5.4

Scenario N°5.3 Scenario N°5.4 Door Flow Rate Flow Rate Status Potential Times Status Potential Times [occ/m/s] [occ/m/s] InDoor_1 1.16 Open 100 1.16 Open 75 InDoor_2 1.16 Open 100 1.16 Open 100 InDoor_3 1.16 Open 100 1.16 Open 100 InDoor_4 0.66 Closed 100 45 0.66 Closed 100 45 InDoor_5 0.66 Closed 300 45 0.66 Closed 87 45 InDoor_6 0.2 Open 130 0.2 Open 90 InDoor_7 0.16 Closed 91 240 0.16 Open 91 InDoor_8 1.33 Open 75 570 InDoor_9 0.66 Open 85 0.66 Open 90 Door_1 1.33 Open 90 1.33 Open 80 Door_2 1.33 Open 100 1.33 Open 100 Door_4 1.33 Closed 62 240-241-1800 Door_5 1.33 Closed 61 240-241-1800

6.2.7 Scenario N°6: Clearance of the Evacuation Route Figure 6-10 shows the configuration of Scenario N°6.1, it is possible to see that the metal barriers were removed. Internal door 6 and internal door 7 were relocated and their flow rates were increased from 0.2 and 0.16 in the reconstruction, to 0.66 occ/m/s.

Int. D3 Int. D1 Int. D8

Int. D2 Int. D6

Int. D5 Int. D7

Int. D4

Figure 6-10: Scenario 6.1

Scenario N°6.2 has the same configuration than Scenario N°6.1, but without the Internal Door 8, Door 4 and Door 5, as shown in Figure 6-11.

Chapter 6. Evacuation Analysis

Int. D3 Int. D1

Int. D2 Int. D5 Int. D6

Int. D7

Int. D4

Figure 6-11: Scenario N°6.2

The parameters used for these scenarios are shown in Table 6-7.

Table 6-7: Parameters for Scenario N°6.1 and N°6.2

Scenario N°6.1 Scenario N°6.2 Door Flow Rate Flow Rate Status Potential Status Potential [occ/m/s] [occ/m/s] InDoor_1 1.16 Open 100 1.16 Open 100 InDoor_2 1.16 Open 100 1.16 Open 100 InDoor_3 1.16 Open 100 1.16 Open 100 InDoor_4 0.66 Closed 100 0.66 Closed 100 InDoor_5 0.66 Closed 300 0.66 Closed 300 InDoor_6 0.2 Open 130 0.66 Open 130 InDoor_7 0.16 Closed 91 0.66 Open 91 InDoor_8 1.33 Open 75 Door_1 1.33 Open 90 1.33 Open 90 Door_4 1.33 Closed 62 Door_5 1.33 Closed 61

6.2.8 Scenario N°7: Compliance with All Regulations Scenario N°7 includes all the measures taken in the previous scenarios to make the club comply with the regulations: from Scenario N°2 the width of the exit door; from Scenario N°3 the nominal capacity of 769 occupants; from Scenario N°4 the reduction in the response times of the occupants and the scenario the internal doors 4 and 5 open sooner; from Scenario N°5.6 the two opposite exits; and from Scenario N°6 the obstacles free exit route.

Chapter 6. Evacuation Analysis

Figure 6-12: Number of occupants and their response times

Int. D7 Door 1 Int. D6

Int. D5 Door 2 Int. D9

Int. D3 Int. D4

Int. D2

Int. D1

Figure 6-13: Scenario N°7

Chapter 6. Evacuation Analysis

The parameters used for this scenario is shown in Table 6-8.

Table 6-8: Parameters for Scenario N°7

Scenario N°7 Door Flow Rate Status Potential Times [occ/m/s] InDoor_1 1.16 Open 65 InDoor_2 1.16 Open 100 InDoor_3 1.16 Open 100 InDoor_4 0.66 Closed 100 25 InDoor_5 0.66 Closed 100 25 InDoor_6 0.66 Open 90 InDoor_7 0.66 Open 90 InDoor_9 0.66 Open 90 Door_1 1.33 Open 90 Door_2 1.33 Closed 62 6.3 Evacuation Results

6.3.1 Statistics Results Due to the involvement of random factors in the simulation, the simulation for each scenario has been repeated 500 times. The statistical results from the 500 simulations are reported here.

Table 6-9 shows the average total evacuation time (TET), the average of fatalities and the cause of deaths. The average personal evacuation time (PET) and waiting time (CWT) are given in Table 6-10 and Table 6-11 for the survivors and the fatalities respectively. The degree of injuries for the survivors (Table 6-10) and the locations of the fatalities (Table 6-11) are analyzed too. Screenshots of the simulation of each scenario can be found in Appendix C.

Generally, the evacuation requires a long TET for all scenarios (between 530 and 836 seconds), with the exception of Scenario N°7 (295.6 seconds). Due to the congestion, people have to wait in the queue to the exit. The average of waiting time to evacuation time ratio are in the range of 62.9% (for Scenario N°7) to 78.6% (in Scenario N°1.2 and N°2.2). These high levels demonstrate that the evacuation in the Kiss Nightclub is not efficient, even in those scenarios with almost no fatalities.

The fatalities in all scenarios are caused by the inhalation of toxic gases. The fatalities are main located in the entrance of the club if no occupants go to the toilets. As in the reconstruction and in the real incident, the fatalities are mainly in the area from the entrance to the toilets.

In addition to the fatalities, there are a number of occupants with different level of injuries, Table 6-10. The analysis of each scenario in the rest of this chapter is mainly based on the number of fatalities.

Chapter 6. Evacuation Analysis

Table 6-9: Average evacuation time and fatalities from 500 simulations repetitions

Number of Scenario TET (s) Cause of deaths fatalities N°1 791.8 241.1 Inhalation of toxic gases N°1.2 835.0 74.7 Inhalation of toxic gases N°2.1 812.9 229.1 Inhalation of toxic gases N°2.2 807.5 29.6 Inhalation of toxic gases N°3.1 530.6 118.6 Inhalation of toxic gases N°3.2 597.3 1.3 Inhalation of toxic gases N°4.1 689.6 176.2 Inhalation of toxic gases N°4.2 836.3 126.2 Inhalation of toxic gases N°5.1 729.7 181.5 Inhalation of toxic gases N°5.2 750.1 23.4 Inhalation of toxic gases N°5.3 606.8 150.1 Inhalation of toxic gases N°5.4 562.5 0.5 Inhalation of toxic gases N°6.1 552.3 49.9 Inhalation of toxic gases N°6.2 676.5 10.0 Inhalation of toxic gases N°7 295.6 0.02 Inhalation of toxic gases

Table 6-10: Average results for survivors from 500 simulation repetitions

Number of injuries PET CWT Life threatening Severe Moderate Scenario (s) (s) (FIN/FIH>=0.7) (0.7>FIN/FIH>=0.3) (0.3>FIN/FIH>=0.1) FIN FIH FIN FIH FIN FIH N°12 319.9 245.5 39.8 180.5 238 N°1.2 363.6 285.7 91.7 0.7 291.9 62.3 230.3 67.0 N°2.1 313.5 240.2 42.3 0 150.5 4.5 241.5 47.8 N°2.2 360.2 283.0 97.3 0 277.6 58.7 257.2 58.6 N°3.1 268.8 198.3 0.4 0 30.7 0 147.8 0 N°3.2 286.2 212.4 4.8 0 117.2 0 173.6 0 N°4.1 323.1 246.6 18.8 0 201.7 19.5 239.0 111.5 N°4.2 339.9 261.7 60.5 0 210.4 28.2 237.4 107.2 N°5.1 284.7 213.7 30.5 0 175.9 2.6 236.3 35 N°5.2 311.0 237.2 41.2 0 298.6 35.5 264.2 104.0 N°5.3 274.7 205.5 7.5 0 160.3 33.2 229.5 78 N°5.4 251.0 179.3 2.2 0 90.1 1 241.9 17 N°6.1 275.6 205.5 16.1 0.3 122.9 23.6 279.3 77.3 N°6.2 290.5 217.2 22.3 0.1 177.2 21 252.8 74.6 N°7 153.1 96.3 0 0 0.4 0 9.2 1.4

2 The number of injuries in the reconstruction (Scenario N°1) is the total number by heat exposure and smoke inhalation [68].

Chapter 6. Evacuation Analysis

Table 6-11: Average results for fatalities from 500 simulation repetitions

Scenario PET (s) CWT (s) Death locations N°1 820.4 712.6 Toilets in the front and entrance N°1.2 755.1 664.6 Entrance N°2.1 827.9 723.9 Toilets in the front and entrance N°2.2 697.2 608.0 Entrance N°3.1 927.2 836.1 Toilets N°3.2 723.8 658.7 Entrance N°4.1 816.9 713.0 Toilets in the front and entrance N°4.2 786.6 693.9 Entrance N°5.1 822.0 714.0 Toilets in the front and entrance N°5.2 647.3 560.0 Entrance N°5.3 861.0 756.9 Toilets N°5.4 460.8 381.0 Entrance N°6.1 835.5 736.9 Toilets and proscenium N°6.2 502.9 436.7 Entrance Toilets and proscenium N°7 453.4 107.7 Entrance

6.3.2 Scenario N°1.2: Signage System Only one configuration was analyzed, Scenario N°1.2 assumes having an appropriate signaling and/or emergency lighting system that allows to the occupants to recognize the exit routes, with this measure the number of fatalities were reduced by 69.02%.

6.3.3 Scenario N°2: Wider Exit Door All the two cases analyzed for Scenario set N°2 consider a widening of the exit door (37,5% wider than in the reconstruction scenario). Scenario N°2.1, where only this improvement is considered the number of fatalities decreases by 5%, from 241.1 persons in the reconstruction to 229.1. A considerable amount of the casualties occurred in the toilets.

Scenario N°2.2 presents a big improvement, just by having an appropriate signaling and/or emergency lighting system that allows to the occupants to recognize the exit routes the number of fatalities was reduced in 87.7%. On the other hand the evacuation time was 807.5 seconds, 15.7 seconds more that the reconstruction scenario , which is reflected in the large number of injuries.

6.3.4 Scenario N°3: Nominal Capacity Scenario set N°3, that considers the nominal capacity legally required for the nightclub, confirms that the number of people in the nightclub is strongly related with the number of fatalities.

In Scenario N°3.1 an average of 118.6 people die, almost 50% less that in the base scenario, all the fatalities where located in the toilets.

In Scenario N°3.2, when people is not attracted to the toilets, an average of 1.3 fatalities is achieved, a 99.46% less than in the reconstruction scenario.

The evacuation times for Scenario N°3 present a reduction of more than 20% with respect to the reconstruction, this allowed a decrease in the number of injuries as well.

Chapter 6. Evacuation Analysis

6.3.5 Scenario N°4: Trained Staff Scenario set N°4 is the same as the reconstruction scenario but with a faster reaction from the staff, which allows a reduction in the occupant’s response time, going from 25 to 40 seconds and that the doors open at 25 seconds instead of 45.

Scenario N°4.1 presents a reduction of 27% in the fatalities with respect to the base scenario, going from 241.1 persons to 176.2. However, just like in the previous cases, an important amount of casualties occurred in the toilets.

For Scenario N°4.2, that considers the used of signage, the number of fatalities was 126.2, which represents a decrease in a 48% with respect with the reconstruction. This result does not follow the performance of the other scenarios, where for the cases where exit signs where used the number of casualties was strongly reduced.

Two factors can explained this situation. Firstly, since the response times of the people that is near the stage are between 25 and 30 seconds, the fact that the doors open at 25 seconds does not necessarily mean that people will leave the nightclub sooner. Figure 6-14shows that at t=25 seconds no one has reached to the doors, (Internal Door 4 or Internal Door 5). At t=31.5s the first occupants arrive to the Internal Door 5, for Internal Door 4 this situation happened at t=40s .

Secondly, the reduction of the response time of the occupants that are not near the stage is not useful if it is no possible to exit the nightclub. This mostly produces an increment of the waiting times of the occupants, in fact, Scenario N°4 presents two of the highest CWT, average of waiting time to evacuation time ratio, while the higher TET of all 12 simulations was obtained for Scenario N°4.2.

Figure 6-14: Screenshots from the simulation of Scenario N°4.2. From left to right the images are at 25s; 31.5s; and 40s of this video

6.3.6 Scenario N°5: Two Exit Doors Scenario set N°5, considers two exits doors which comply with the regulation requirement for the Kiss Nightclub. This scenario group provide evidence the importance of: the location of the exit doors and being familiar with the exit doors available or having a signage system that guide people to them.

In Scenario N°5.1, where the doors were located in the front of the nightclub, an average of 181.5 people die, almost 25% less that in the base scenario, several fatalities where located in the toilets.

For Scenario N°5.2, when people is not attracted to the toilets, an average fatalities of 23.4 was achieved, a 90.29% less than in the reconstruction scenario.

Chapter 6. Evacuation Analysis

Scenario N°5.3, where one door is located in the front and the other in the back of the nightclub, presents a reduction of 37.74% in the fatalities with respect to the base scenario, going from 241.1 persons to 150.1. In this case all the casualties were found in the toilets.

For Scenario N°5.4, that considers the used of signage, the number of fatalities was 0.5, which represents a decrease in a 99.79% with respect with the reconstruction.

From the previous analysis it is clear that the use of signage improves significantly the evacuation results. By comparing Scenario N°5.1 with Scenario N°5.3 and Scenario N°5.2 with N°5.4, it is possible to see that the location of the doors affects the outcome, obtaining approximately a 10% less of fatalities in the scenarios where the doors are remotely located. Furthermore the evacuation times are much lower when the doors are in opposite locations, which allowed that the number of injuries is decreased as well.

The reduction of the evacuation time in Scenario N°5.4 with respect to Scenario N°5.3 was due to the efficient usage of the exit doors, 375,9 people used the new exit, in contrast with the 150.5 that used it in Scenario N°5.3, which represents an increase of 150%.

Regarding the use of the new door, in Scenario N°5.1 208.1 persons evacuate through it, while for Scenario N°5.2 385.7 occupants used it. This means that the door usage was increased by 85% which is significantly lower than when the doors are located in opposite positions. This finding reassures the importance of having the exit door remotely located.

The configuration of Scenario N°5.4 allows that people top left and right corners are able to use the new door, also people who is queuing in the main exit can go to the back of the nightclub and evacuate. In contrast, Scenario N°5.2 just gives the possibility to people located in the left part of the nightclub to use the new door, people who are waiting to use the main door will not try to evacuate by Door 2, because that would mean to come near the fire.

6.3.7 Scenario N°6: Clearance of the Evacuation Route Scenario set N°6 considers an exit route without obstacles. It had the highest reduction of fatalities (79.3%) for the cases that considers that people could mistake the toilets for exit doors (Scenario N°6.1). The increase in the flow rate produces an evacuation much more efficient, allowing that a significant number of people leave the nightclub before the visibility conditions affected their orientation. Further reduction (95.85%) is seen without allowing people to move to the toilets.

6.3.8 Scenario N°7: Compliance with All Regulations Scenario N°7 considers: 2 opposite located exit doors, with a total exit width of 4.4 meters and an obstacle free exit route; the nominal capacity of 769 people; a reduction of the response time between 25-40 seconds for occupants and the doors open at 25 seconds.

An average of 0.02 people die, which means that the number of fatalities was reduced in 99.99%. In addition the reduction of the evacuation time from 791.8 seconds to 295.6 seconds, a decreased of almost 75%.

From Appendix C, it is possible to see that this is the only scenario where people has pass the critical point, (the path that leads to the front toilets, Zone 44 from Figure 5-3), before 240 seconds, when the visibility conditions are low (see Section 5.3), this means that it is unlikely, for the people that are still in the nightclub, to follow a wrong direction.

Chapter 6. Evacuation Analysis

This scenario reveals that if the nightclub would have been complying all the fire safety regulations related with evacuation, the disaster could have been avoided.

However, it should be noted that there are still 9.6 moderate to life threating injuries and a large CWT to PET ratio of 62.9% for this scenario with all the evacuation related issues complying with the regulations.

6.4 Main Findings Figure 6-15 presents the number of fatalities in each scenario ordered from the highest to the lowest. The yellow bar symbolize the reconstruction scenario, while the blue bars represent to those scenarios where only one modification to the reconstruction scenario was done. The orange bars symbolize the scenarios in which two or more modifications were implemented.

In order to derived the critical factors for the large numbers of the fatalities, Table 6-12 presents the reduction in the number of fatalities of the different scenarios that were analyzed, indicating the issues that were modified, with respect to the reconstruction scenario, to comply the building regulations. In order to determine which is the impact of the individual measures, only those scenarios that consider one change to Scenario N°1 will be taking into consideration. In Table 6-12 is possible to see the detail of the different configurations. The reduction of fatalities from the highest to the lowest are:

 Removal of metal bars (Scenario N°6.1) with 79.30% fatality reduction;  The signage system, if it was possible to direct all the people to the exits rather than moving towards the toilets (Scenario N°1.2) with 69.02% fatality reduction;  The use of the nominal capacity of the nightclub (Scenario N°3.1) with 50.81% fatality reduction;  Two exit door remotely located (Scenario N°5.3) with 37.74% fatality reduction;  The training of the staff (Scenario N°4.1) with 26.92% fatality reduction;  The wider door (Scenario N°2.1) with 4.98% fatality reduction.

The previous analysis shows that an efficient signage system is one of the most critical fact to improve the survivability of the Kiss Nightclub fire, if it was possible to prevent people to take an incorrect path, many lives could be saved. Therefore, it is interesting to see how the combinations of this fact with other investigated factors to improve the reduction of the fatalities. The improvements with respect of the survivability are: the implementation of two exit doors in opposite locations (Scenario N°5.4 with 99.79% fatality reduction), the use of the nominal capacity of the nightclub (Scenario N°3.2 with 99.46% fatality reduction), and the obstacle free exit route (Scenario N° 6.2 with 95.85% fatality reduction). In these scenarios, where also a signage system was consider, the average of fatalities decreased to no more than 10.

Clearly, the best results were obtained for Scenario N°7, in which the identified issues are modified to comply with the regulations, with 99.99% fatality reduction almost all the fatalities could have been avoided.

Chapter 6. Evacuation Analysis

Number of fatalities

N°1 N°2.1 N°5.1 N°4.1 N°5.3 N°4.2 N°3.1 N°1.2 N°6.1 N°2.2 N°5.2 N°6.2 N°3.2 N°5.4 N°7

0 50 100 150 200 250 Figure 6-15: Number of Fatalities

Table 6-12: Improvement of the survivability with respect to the Reconstruction (Scenario N°1), based on the improvements proposed to comply the regulations

Compliance with regulations Reduction in Number fatalities with Exit Signage Scenario Width of the Number of respect to Population Trained Route (avoiding main exit of exits (max 769) Staff obstacle to move to fatalities Reconstruction (min 4.4 m) (min 2) free toilets) Scenario (%) N°1 NO NO NO NO NO NO 241.1 N°1.2 NO NO NO NO NO YES 74.7 69.02 N°2.1 YES NO NO NO NO NO 229.1 4.98 N°2.2 YES NO NO NO NO YES 29.6 87.72 N°3.1 NO YES NO NO NO NO 118.6 50.81 N°3.2 NO YES NO NO NO YES 1.3 99.46 N°4.1 NO NO YES NO NO NO 176.2 26.92 N°4.2 NO NO YES NO NO YES 126.2 47.66 N°5.1 NO NO NO YES NO NO 181.5 24.72 N°5.2 NO NO NO YES NO YES 23.4 90.29 N°5.3 NO NO NO YES NO NO 150.1 37.74 N°5.4 NO NO NO YES NO YES 0.5 99.79 N°6.1 NO NO NO NO YES NO 49.9 79.30 N°6.2 NO NO NO NO YES YES 10 95.85 N°7 YES YES YES YES YES YES 0.02 99.99

Chapter 6. Evacuation Analysis

Table 6-13: Improvement of the survivability with respect to the use of signage for each scenario

Reduction of Number of Scenario TET (s) fatalities due to the fatalities use of signage (%) N°1 791.8 241.1 69.0% N°1.2 835.0 74.7 N°2.1 812.9 229.1 87.1% N°2.2 807.5 29.6 N°3.1 530.6 118.6 98.9% N°3.2 597.3 1.3 N°4.1 689.6 176.2 28.4% N°4.2 836.3 126.2 N°5.1 729.7 181.5 87.1% N°5.2 750.1 23.4 N°5.3 606.8 150.1 99.7% N°5.4 562.5 0.5 N°6.1 552.3 49.9 80.0% N°6.2 676.5 10

In Table 6-13, it is presented the improvement of the survivability for each Scenario set due to the use of an efficient signage system. For scenario N°2, N°3, N°5 and N°6 the fatality reduction is higher than 80%, which is a significant difference. Clearly, the impact is higher in those scenarios where the evacuation capability of the scenario was not being fully used.

Table 6-14: PET, CWT and CWT Ratio of survivors

Scenario PET (s) CWT (s) CWT Ratio N°1 319.9 245.5 0.767 N°1.2 363.6 285.7 0.786 N°2.1 313.5 240.2 0.766 N°2.2 360.2 283 0.786 N°3.1 268.8 198.3 0.738 N°3.2 286.2 212.4 0.742 N°4.1 323.1 246.6 0.763 N°4.2 339.9 261.7 0.770 N°5.1 284.7 213.7 0.751 N°5.2 311.0 237.2 0.763 N°5.3 274.7 205.5 0.748 N°5.4 251.0 179.3 0.714 N°6.1 275.6 205.5 0.746 N°6.2 290.5 217.2 0.748 N°7 153.1 96.3 0.629

Chapter 6. Evacuation Analysis

From Table 6-14, it is possible to see that the for Scenario N°7, people waste in average a 62.9% of their evacuation time waiting in congestion, this means that even when complying with all the requirements the evacuation is still not optimal. In addition, Table 6-10 shows that for Scenario N°7 an average of 10 people will get injured. This is an issue of major concern, because it could reveal that the legal requirements are not sufficient to ensure an efficient evacuation.

6.5 Recommendations For the fire safety of the Kiss Nightclub, through the findings in Section N°6.4, it is suggested to:

 Strictly limit the occupants under the certificated capacity;  Have at least two emergence exits which are located on the opposite sides;  Install efficiency signage and emergency lighting;  Keep the area around the exit clear (removing all metal barriers);  Have appropriate staff training in evacuation.

6.6 Limitations The evacuation results of the different scenarios have been presented. However there are limitations that could have an influence on them.

Firstly, the fire hazard used in the current analysis was derived under some assumptions [2]. Due to the many unknowns of the event and uncertainties in the data required for models, the reconstruction of the accident is a repetition of a two-step process [2]. First the fire is simulated and then the coupled fire and evacuation is simulated. The results from the fire simulation are part of the inputs to the evacuation simulation to predict the impact of the fire on the evacuating occupants. The reconstruction of the fire development and evacuation process for the Kiss Nightclub fire is considered to be completed when appropriate values for the unknown parameters were identified. Therefore, the fire hazards from the reconstruction would have some uncertainties.

Secondly, the different scenarios were simulated with the same fire hazard, without taking into consideration that some of the modifications made could affect the fire development. For example, changes in the layout due to the implementation of new exit doors (Scenario N°5) or doors that are opened at a different time (Scenario N°4) could have an impact.

Thirdly, for those scenarios considering that the signage system would prevent that people mistook the toilets for exit doors, an efficiency of 100% was assumed. This means that all the occupants would see and follow the signs.

6.7 Summary From the review of the Brazilian fire safety several gaps were identified in Chapter 4. To assess the extent to which this factors impact the evacuation performance, 14 evacuation scenarios were analyzed. The evacuation scenarios with all or some of the following features:

 Widen exit;  Additional exit;  Efficiency signage system;  Certificated capacity;  Removal of the bars around the exit;  Well trained staff.

Chapter 6. Evacuation Analysis

From the analysis of them it the following are the most important issues (See Section 6.4 for details):

If the Kiss Nightclub had been in compliance with the fire safety regulations the large number of fatalities and injuries could have been avoided with a reduction of 99.99%. At 240 seconds people has pass the critical point, this means that it is unlikely, for the people that are still in the nightclub, to follow a wrong direction. However, even with this configuration people spend large amount of time waiting in congestion (62.9%) and approximate 10 moderate to life threating injuries are produced, which means that the evacuation is still not sub-optimal.

This study suggested to take the following measures to avoid fatalities for the given Kiss Nightclub fire under the limits listed in Section 6.6:

 Strictly limit the occupants under the certificated capacity;  Have at least two emergence exits which are located on the opposite sides;  Install efficient signage and emergency lighting;  Keep the area around the exit clear (removing all metal bars);  Have appropriate staff training in evacuation.

Chapter 7. Conclusions

7 CONCLUSIONS

On 27 January of 2013 a fire broke out in the Kiss nightclub in Santa Maria, Rio Grande do Sul, Brazil. The fire was one of the most deadly nightclub fires in recent times, claiming the lives of 242 young people. It is of common knowledge that the Kiss nightclub was breaking several regulations the night of the fire.

The purpose of this thesis was to determine if the number of fatalities would have been reduced if the Kiss Nightclub had been compliant with the fire safety regulations.

Reviews to the fire disaster of the Kiss nightclub are made in Chapter 2 including the building layout, materials, capacity, the fire protection measures, the cause of the fire, the evacuation and the consequence etc. This Chapter has explored the question ‘What were the conditions of the nightclub the night of the fire?‘ raised in Chapter 1.

Reviews and analysis to the building regulation requirements related to the Kiss Nightclub are made in Chapter 3 including the nominal capacity, the minimum exit number, the maximum travel distance, extinguishing system, detection and alarm system, signage and emergency light etc. This Chapter has explored the question ‘What were the fire safety requirements for the nightclub?’ raised in Chapter 1.

Some of the inconsistences with the building regulations in the Kiss nightclub have been identified in Chapter 4. The question ‘Which fire safety regulations were not satisfied by the nightclub on the night of the fire?’ raised in Chapter has been answered in this Chapter. According to the original project, the nightclub was classified as F-6, L, P, and Y. With this classification, it can be establish that:

 It should have minimum of 2 exit doors, at least 4.4 meters wide, with an obstacle free exit route. This would have allowed a maximum travel distance of 30 meters. The nightclub had only one exit door, with a total width of 3.05m, there were metal bars in the exit route that delayed the evacuation.  The nominal capacity of Kiss Nightclub was 769 people. There were not less than 864 people in the nightclub.  Firefighters inspectors requested that the staff have a Prevention and Fire Fighting Training taught by a qualified professional. However, a member of the personnel stated that they did not receive the training.  The nightclub should have had a minimum of five 4kg ABC fire extinguishers, but only 3 were found in the scene, and one of them did not work.  Kiss Nightclub required emergency lighting and signage in accesses and discharges. The illumination system should aided the recognition of obstacles that could impede the circulation. The emergency lightning system did not operate. There were insufficient exit signs in the scene after the fire.  The use of easily ignitable materials and/or that emits toxic gases in case of fire, in partitions, coating and finishes is forbidden. However, the façade of the building was covered with wood and the window were sealed and polyurethane foam was used for acoustic insulation purposes.  The pyrotechnics instructions were not followed. The pyrotechnics used were intended for outdoor use however, the band used them inside the nightclub.  Furthermore, the night of the fire the Kiss nightclub should not been in operation because the fire prevention and protection license had expired on August 10 of 2012.

Chapter 7. Conclusions

To analyze the impact of the breaches related with evacuation, the research method is introduced in Chapter 5. A total of 14 scenarios with various modifications to the reconstruction of fire and evacuation performed by FSEG of the University of Greenwich have been investigated in Chapter 6, for this the buildingEXODUS evacuation software was used. The question ‘What is the impact of the non-compliant features on the number of casualties and injuries? ‘ raised in Chapter 1 has been answered in this Chapter. From the analysis of the non-compliant features the following key conclusions can be made:

 Removal of metal bars (Scenario N°6.1) with 79.30% fatality reduction;  The signage system, if it was possible to direct all the people to the exits rather than moving towards the toilets, (Scenario N°1.2) with 69.02% fatality reduction;  The use of the nominal capacity of the nightclub (Scenario N°3.1) with 50.81% fatality reduction;  Two exit door remotely located (Scenario N°5.3) with 37.74% fatality reduction;  The training of the staff (Scenario N°4.1) with 26.92% fatality reduction;  The wider door (Scenario N°2.1) with 4.98% fatality reduction.

The study has addressed the main question raised in Chapter 1 as the aim and motivation of this thesis.

Would the number of fatalities in the nightclub be reduced if it had been compliant with the fire safety regulations?

If the Kiss Nightclub had been in compliance with the fire safety regulations the large number of fatalities and injuries could have been avoided with a reduction of 99.99%.

The wider obstacle free exits, low population, trained staff and signage system allowed that people pass the critical point before the visibility conditions are low (240 s). Therefore, it is unlikely that them will take a wrong direction.

However, even with this configuration people waste a large amount of time waiting in congestion (62.9%) resulting in approximately 10 people suffering ‘moderate to life threating’ injuries which means that the evacuation is still sub-optimal.

This study suggested to take the following measures to avoid fatalities for the given Kiss Nightclub fire under the limits listed in Section 6.6.

Chapter 7. Conclusions

It is important to keep in mind that the conclusions of this study are subject to the following limitations:

 The uncertainty in the simulated fire environment derived from the fire reconstruction in [2];  The simulated fire environment was not subjected to the suggested modifications to the scenarios such as the introduction of an additional exit;  The assumption that the signage system would be 100% efficient.

Chapter 8. Further Work

8 FURTHER WORK

An analysis of the impact that the different breaches has been developed in this thesis. In this chapter suggestions for further analysis regarding the evacuation of the Kiss Nightclub are presented.

8.1 Full Analysis The analysis of the evacuation outcomes was mainly based in the fatalities results. However the number of injuries, especially those life threatening, are also of concern. This could be done by using weight factors in order to obtain a value that represent the consequences of each scenario for a full understanding the evacuation results.

8.2 Signage For scenarios involving signage, it is assumed that the signage system would prevent building occupants from taking incorrect exit paths (for example, leading to the toilet rather than the exit doors). An efficiency of 100% was assumed. This means that all the occupants would see and follow the signs, which is not a realistic assumption. For this reason, the actual implementation of the signage system is recommended in future study. These scenarios must consider the interaction of the signage system with the potentials maps.

In this study, scenarios with the implementation of signage system were initially investigated. Due to the involvement of different events in this complicated evacuation case (signage, internal doors, impassing zones etc.), some strange evacuation phenomenon was noted. For example, some of the occupants suddenly go back to the rear of the club when they almost reach the exit. To solve this problem, requires a better understanding of these powerful features within the software.

8.3 Fire Spread The study in this thesis is with the fire hazards from the burning of polyurethane foam [2]. As it was indicated in Section 3.2, there were regulations regarding the use of combustible materials and the quantity of fire extinguishers and its maintenance. This issues had a direct impact on: fire development, the combustions products and in the fire development. It would be interesting to analyze how addressing these issues would have impacted the evacuation results.

8.4 Extend the Solution Domain As shown in Figure 2-3, the Kiss Nightclub also had metal bars outside, and from witnesses testimonies it is known that other factors such as a car in front of the entrance, (see Section 2.3.4), delayed the evacuation. These issues suggest that it is important to extend the solution domain to the outside of the nightclub.

8.5 Comparison with Regulations from other Countries Were the local legal requirements for the Kiss Nightclub sufficient to provide a safety environment for the occupants? This question can be answered by comparing the Brazilian regulations with NFPA or European codes.

References

REFERENCES

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Appendix A: Fires in Nightclubs

Fires in Nightclubs

Table A-1 presents information about fires in nightclub that have occurred since 2000.

Table A-1: Fires in Nightclubs

Name Location Year Deaths Injuries Origin Notes Romania - Smoking Should not be in Bamboo 2017 0 44 Bucharest pyrotechnics operation Ghost Ship

USA - Oakland, 2016 36 2 Electrical failure collective Colectiv Romania - Acoustic foam 2015 64 160 Pyrotechnics nightclub Bucharest (polyurethane) Brazil - Santa Kiss nightclub 2013 242 168 Pyrotechnics Acoustic foam

Maria

Tiger Disco Thailand - Patong 2012 4 11 Electrical failure Acoustic foam

Jack Daniels Taiwan - 2011 9 13 Torch

nightclub Taichung

Lame Horse Russia - Perm 2009 156 ≤160 Pyrotechnics Decorations

Thailand - Paper, waterproof Santika Club 2009 66 222 Pyrotechnics Bangkok plastic China - Wuwang Club 2008 43 88 Pyrotechnics Guangdong

Factory nightclub Ecuador - Quito 2008 15 35 Pyrotechnics

Styrofoam and República Argentina - 2004 194 1432 Pyrotechnics wood decorations,

Cromañón Buenos Aires acoustic panels The Station USA - Rhode 2003 100 230 Pyrotechnics Acoustic foam

nightclub Island Venezuela - La Gaujira 2002 47 Caracas Wood, acoustic Utopia Disco Peru - Lima 2002 30 Torch foam Canecão Mineiro Brazil - Belo 2001 7 197 Pyrotechnics

nightclub Horizonte Volendam New Netherlands - Pyrotechnics Christmas 2001 14 241

Year's fire Volendam (sparkler) decorations Lobohombo Mexico - Mexico 2000 22 24 Unknown

explosion City Luoyang China - Luoyang 2000 309 50 Welding Christmas

Appendix B: Numerical Reconstruction

Numerical Reconstruction

A numerical reconstruction of the Kiss Nightclub fire has been reconstructed by the FSEG, the University of Greenwich using the coupled fire and evacuation technique. While the details of the reconstruction can be found in [2], it is briefly described in this appendix.

About the reconstruction

Due to too many unknowns in the event and uncertainties in the data required for models, the reconstruction of the accident is a repetition of a two-step process. First the fire is simulated and then the coupled fire and evacuation is simulated. The results from the fire simulation are part of the inputs to the evacuation simulation to predict the impact of the fire on the evacuating occupants. The occupants are exposed to the fire hazards determined from the fire simulations which include temperature, radiative flux, concentrations of toxic gases, low oxygen and smoke obscuration The reconstruction of the fire development and evacuation process for the Kiss Nightclub fire is considered to be completed when appropriate values for the unknown parameters are identified, with which the simulation produces a reasonable agreement with the known outcomes.

Geometry

The geometry set up with SMARTFIRE is shown in Figure B-1.

Figure B-1: Geometry of the Kiss Nightclub.

Appendix B: Numerical Reconstruction

Timeline of the Kiss Nightclub from reconstruction

Figure B-2 is the timeline of the reconstructed Kiss Nightclub fire and evacuation (event in bold are from publications).

Figure B-2: Timeline of the Kiss Nightclub fire

Evacuation set up

Hazard zones

In order to represent the predicted fire hazards within the club, a set of 52 hazard zones are defined in the building in both the fire and evacuation model. As seen in Figure B-3, Zone 2 is located on the stage and just under the fire origin. Zone 10 in the dancing hall is located adjacent to the internal doorway D2. Zone 30 is the corner of the VIP area. Zone 38 is the bar in the main hall. Zone 40 is the changing room. Zones 43 and 44 are between the exit and the bar. Zones 47 and 48 represent the toilets. Zone 52 is just inside the exit. Within each zone, fire hazard values (i.e. temperature, smoke concentration (optical density), radiative flux, and concentrations of CO, CO2, HCN and O2) predicted in the fire simulations in a layer from 1.5 m to 2.0 m are averaged and taken to represent the hazards at head height while hazard values from 0.3 m to 0.8 m are averaged and taken to represent the hazards at knee height (for crawling agents).

Appendix B: Numerical Reconstruction

Figure B-3: Fire hazard zones prescribed within both the fire and evacuation models identified by dashed lines and walls (several key zones are indicated by their zone number)

Populations

The exact number of occupants involved the incident is unknown. It is estimated between 1200 and 1300. 1200 people are located in the club with 550 in the dancing hall and 650 in the main hall and rooms (Figure B-4). Since the occupants in the club were mainly young students, the population panel aged between 17 and 29 in buildingEXODUS is selected to locate the 1200 people. All other agent attributes such as walking speeds assume the default buildingEXODUS values. The response times for people in various regions of the nightclub are of 25-30 seconds, 30-35 seconds and 35-41 seconds are assigned to occupants at the dance floor (red people), the main hall (green people) and the area between the main hall and VIP area (blue people) (according to response times of the Station Nightclub fire). For people in rooms and the VIP area (yellow people), response times 41-60 seconds are assigned.

Figure B-4: Initial location of the 1200 occupants

Evacuation route

As seen in Figure B-5, people enter the club by passing the ticket window and following the path indicated with broken lines. People leave the club via the internal doorway D7 after their fees being paid at the payment desk. The metal barriers used to keep people in line on their way into the hall, ended up at point ‘A’ blocking people from getting out in emergence. In the evacuation, people in the hall went to the exit via the internal doorways D5 and D6 while some of the people in the dance

Appendix B: Numerical Reconstruction area exited through the corridor linking the internal doorway D7. The end point ‘A’ of the metal barriers in the hall allows only one person to pass at a time.

D5 and D7 are assumed closed initially as they are usually used as exits; Door 6 was used as entrance and assumed to be open initially. However, the evacuation initially was limited by the bottle neck A formed with metal bars. The time to open D5 and D7 are derived through the reconstruction.

Figure B-5: Evacuation routes near the exit (broken line representing the path for entering the nightclub hall

Time to move to the toilets

The time for some people start to move to the toilet is determined the visibility in Zone 44 (See Figure B-3 for Zone 44 location). This is achieved by setting doors link to the toilets but setting times just for attracting occupants.

Im-passing hazard zones

As seen in Figure B-6, addition to the 52 hazard zone defined in fire simulation, six extra zone are defined in evacuation modelling. They are actually separated from some of the fire simulation zones. For example, im-passing zone ‘barrier-1’ has the same hazard as Zone 3.

The purpose of the im-passing zone is to change the original moving direction of occupants.

Figure B-6: Hazard zone list

Appendix B: Numerical Reconstruction

Non-crawling behaviour

For the over-loaded population, it is assumed that the evacuating occupants always keep ‘standing’.

Statistical Evacuation Results

Accident Reconstruction Number of fatalities 242 241.1 Cause of deaths Inhalation of toxic gases Inhalation of toxic gases About 180 in the toilets and Distribution of fatalities See Figure B-7 Fatalities others around the bar and toilets The survival time in the changing >32 minutes based on the lower room was as long as 50 minutes Maximum survival time layer hazard (0.3-0.8); ( at rest (one person sent out message 50 state) minutes after the start of fire ); A total of 602.8 injuries (FIH or There were 761 injuries with 138 FIN >0.03); of them being hospitalized and Number of injuries 623 of them receiving 39.8 of them with FIH or FIN >0.7; treatments in the first week 180.5 with the maximum of FIH following the incident and FIN between 0.3-0.7 Injuries Among 68 investigated injuries, The data is 42.6% in the Cause of injury 50% of them are solely injured reconstruction by inhalation of toxic smoke NA; Evacuation time Rescue ended 2 hours after the 791.8 s without assistant start of the fire

Figure B-7: Predicted death locations from a single evacuation simulation

Appendix C: Simulation Results

Simulation Results

In this section, the evacuation screenshots of the different scenarios are presented. In the top left corner, the time of simulation is indicated in seconds. The last image on each scenario displays the locations of the fatalities.

Scenario N°1.2

Appendix C: Simulation Results

Scenario N°2.1

Appendix C: Simulation Results

Scenario N°2.2

Appendix C: Simulation Results

Scenario N°3.1

Scenario N°3.2

Appendix C: Simulation Results

Scenario N°4.1

Appendix C: Simulation Results

Scenario N°4.2

Scenario N°5.1

Appendix C: Simulation Results

Scenario N°5.2

Appendix C: Simulation Results

Scenario N°5.3

Scenario N°5.4

Appendix C: Simulation Results

Scenario N°6.1

Appendix C: Simulation Results

Scenario N°6.2

Scenario N°7