Fall River, MA, Facility Owner Knew About Missing Sprinkler Test before Deadly Fire
Five days before a fatal blaze ripped through Gabriel House, a fire safety contractor alerted the building owner his sprinkler system had not undergone the state-mandated five-year inspection, according to sources familiar with the investigation.
The revelation is a critical piece of the state’s ongoing probe. On the night of July 13, in the second-floor unit where the fire started, the sprinkler didn’t go off, sources told MassLive.
Ten residents of the Fall River assisted living facility were killed, the highest death toll in a Massachusetts fire in more than 40 years.
The building’s sprinkler system had an annual inspection tag, meaning it had been visually inspected this year as required. However, there wasn’t a five-year inspection tag indicating an intensive physical inspection of internal components had been conducted, according to Shane Ray, president of the National Fire Sprinkler Association.
Ray has knowledge of the active investigation headed by the Bristol County District Attorney’s Office and the state Department of Fire Services. Officials are trying to determine if noncompliance with fire safety codes contributed to the severity of the fire that tested Fall River firefighters and police who converged on the building to rescue its 70 residents.
In a joint statement released last week, the National Fire Sprinkler Association and National Association of State Fire Marshals said neither entity is aware of a multiple-fatality fire “in a structure with a properly installed and maintained sprinkler system.”
The Department of Fire Services declined to comment on specific facts and evidence while the investigation is ongoing.
As civil lawsuits pile up, the allegations echo each other; when the fire ignited in a resident’s room, the sprinkler system didn’t work properly, ultimately fueling a five-alarm blaze that spread across the building. State fire officials have said the cause is undetermined, but narrowed it down to either an electrical or mechanical failure of an oxygen concentrator or the improper use or disposal of smoking materials.
Targeted by the lawsuits are Gabriel House owner Dennis Etzkorn and Fire Systems Inc., the private contractor that inspected the building’s sprinkler system over the last decade.
Some of the suits claim the sprinklers at Gabriel House had recalled components from decades prior, as first reported by WCVB, and that they weren’t replaced.
In prior statements, Etzkorn has said the sprinkler system, which was inspected quarterly, passed routine testing just five days prior to the fire, on July 8. But during the same visit, Fire Systems Inc. notified Etzkorn of his apparent ongoing failure to obtain a five-year inspection of the system’s critical internal components, sources told MassLive.
A spokesperson for Etzkorn said on Tuesday they’re refraining from commenting on specific questions at this time because of the pending investigation and litigation. Etzkorn has previously said he turned over all relevant building records to investigating authorities.
The spokesperson cited Etzkorn’s last public statement released on Aug. 6, which said he was working closely with investigators to find out “why a fire that should have been contained to one room spread beyond that point of origin, in light of all our inspections.”
Etzkorn had contracted with Dartmouth-based Fire Systems Inc. to inspect Gabriel House’s sprinklers and fire alarms since 2014. The contracted services, though, did not include five-year inspections, a source told MassLive.
In a statement this week, a Fire Systems Inc. spokesperson said the company conducted “periodic inspection and testing of the Gabriel House fire alarm and sprinkler system in accordance with its service agreement, applicable standards of the National Fire Protection Association (NFPA), and local requirements.”
Are fire safety inspections an honor system?
Also emerging after the fire are questions surrounding how sprinkler systems are inspected and tested in Massachusetts. Shortly after the July tragedy, Fall River Fire Chief Jeffrey Bacon said municipal fire inspectors rely on building owners to contract with licensed professionals to inspect and maintain their fire safety equipment, including sprinklers.
Those results, he said, are then relayed to local fire departments during their annual building inspection process.
During a press conference in July, Bacon said “no fire department in the country” is staffed to the level that they could verify and conduct all inspections themselves.
“We just don’t have the resources to do that,” Bacon said. “We need to rely on the licensed professionals to do those, to do their inspections. And we’re just following up to make sure those are done.”
The Fall River Fire Department inspected Gabriel House annually, and the assisted living facility passed its last six inspections, according to records.
On a check-off line for sprinkler systems, fire department inspectors often initialed “FSI” — short for Fire Systems Inc., and noted the date the inspection was conducted. Bacon told MassLive his inspectors take cues from inspection tags contractors attach to the system’s valves.
He couldn’t comment on the missing five-year inspection tag at Gabriel House.
“I’m not sure every inspector would pick up on those,” Bacon said of five-year inspections. “That’s definitely something between the building owner and the sprinkler contractor.”
- Read more: Roaches, missed care and no way out: What life was like at Gabriel House before fire killed 10
The impact of the devastating fire has spread far beyond Massachusetts. Ray recently spoke about it at an event in Florida, and said the fire safety industry across the U.S. is focused on finding out why 10 people died at Gabriel House when sprinklers save lives at other residential facilities every day.
“The whole fire protection community is interested in this, so we can make changes in the future,” Ray said. “There’s (building) owners out there who haven’t done what they’re supposed to do. We need the local and state jurisdictions to enhance the enforcement of this issue.”
Bacon anticipates the tragedy will prompt a critical examination of all relevant laws and requirements.
“From Coconut Grove (in Boston in 1942) to The Station nightclub (in West Warwick, Rhode Island in 2003), when there’s a tragedy of this magnitude, things change,” he said. “Unfortunately, that’s what it takes sometimes to move the needle on legislation and codes. But you’re going to see that that’s going to be a result of this.”
Gov. Maura Healey’s office would not comment when presented with the fire safety inspection allegations regarding Gabriel House’s sprinkler system, instead referring a reporter to other state agencies.
The current code requirements
A MassLive analysis of fire safety standards in Massachusetts revealed there are many types of sprinkler inspections and testing requirements, each with varying schedules. Some are mostly visual, while others test sprinkler functionality and physically examine internal parts.
NFPA 25 — the National Fire Protection Association’s minimum standard for water-based fire protection systems — governs sprinkler inspections and testing. The Massachusetts Comprehensive Fire Safety Code adopts NFPA 25, making it law. Cities and towns can take it further by adopting their own additional regulations.
According to the standard, property owners are responsible for ensuring proper inspection and maintenance of their sprinkler systems.
Sean Lawlor, president of the Fire Prevention Association of Massachusetts, likened the dynamic to an annual car inspection — the car’s owner is responsible for getting it inspected and ensuring any necessary repairs are made.
Building owners commonly hire licensed contractors to inspect and test their sprinkler systems.
Fire Systems Inc. has a current Massachusetts Systems Contractor Business License issued by the Board of State Examiners of Electricians, according to the Division of Occupational Licensure. The division licenses sprinkler apprentices, journeymen and contractors in the state.
State records also show there is one active sprinkler contractor license affiliated with Fire Systems Inc., issued by the Bureau of Pipefitters, Refrigeration Technicians and Sprinkler Fitters. Three apprentices are currently supervised by that individual.
“Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor,” NFPA 25 reads.
Sprinkler systems require both annual and five-year inspections, the latter of which includes an assessment of piping and an in-depth evaluation of internal parts. Individual components have a range of inspection and testing schedules — from monthly to every 10 years (see chart below). There is a distinction between visual — “from the floor” — and functional/internal inspections.
Visually, any sprinkler that shows signs of leakage, corrosion detrimental to performance or physical damage should be replaced, according to the standard.
If a sprinkler component is found to be under recall, the property owner should be notified in writing, the standard says, and then they are responsible to “correct, remedy, repair or replace components and equipment under recall or replacement program.”
The fire safety standard indicates that records should be maintained by building owners for all inspections, tests and maintenance of sprinkler systems, and they should be made available to local fire inspectors upon request.
Many communities are explicit about requiring records. In Reading, for example, the fire department has a webpage where building owners are required to upload evidence of inspections and testing. According to Stoneham’s town code, the fire department “will be annually requesting and reviewing records of completed testing and maintenance documentation of the fire suppression systems.”
In Fall River, Bacon said their policy is also to obtain documentation.
Fire departments should always ask for proof of inspections and their results, according to Ray, of the National Fire Sprinkler Association. That should be the gold standard across the board, he said.
State fire officials have said the ongoing death investigation at Gabriel House involves a “large number of relevant records, some of which are in the custody of third-party contractors requiring various processes to obtain.”
The investigation includes checking those records against appropriate regulations and investigators’ findings, they said. Investigators also took several sprinkler heads to assess.
Sprinklers were ‘inadequate or inoperable’ on night of fire
Attorney Steven Sabra, of Sabra Law, wants to learn more about what the fire safety inspections at Gabriel House entailed. He’s representing residents in Bristol County Superior Court and is also the lead attorney on a wrongful death suit filed by a deceased resident’s son.
“If the inspection company does their thing and then they tell the owner and the owner says to the fire department, ‘Yup, it’s all set,’” Sabra said, “then the issue becomes, is that all there is? Does the fire department just figure that these inspection companies are somehow certified, I guess, and therefore they take their word for it?”
In one of Sabra’s lawsuits, Gabriel House residents Michael Pimental and James Dixon claim the sprinkler system was “inadequate or inoperable, and failed to provide sufficient warning or provide life safety systems to alert residents and staff of the danger from the fire.”
Another lawsuit filed by the nation’s largest injury law firm Morgan & Morgan, on behalf of three residents, says the sprinklers “were improperly installed and maintained, and therefore were not operational at the time of the subject fire.”
Police body camera footage shows that at least some of the sprinklers were working on the night of July 13. Water can be seen on the floor of the Gabriel House dining room and in one resident’s apartment.
One of Sabra’s suits also claims that a prior recall of certain sprinkler components was skipped over — for decades.
The National Fire Sprinkler Association doesn’t yet know the specific manufacturer of the Gabriel House sprinklers, Ray said, but a major recall in the late 1990s and early 2000s was for Central Sprinkler Company “O-ring seals,” a component that could degrade and cause sprinkler heads not to activate in a fire.
WCVB previously reported that O-ring seals were the component needing replacement at Gabriel House. Before opening as an assisted living facility in 1999, the building had been a motel and was built in 1964.
It’s not clear at this time whether “the gross negligence and reckless conduct” alleged in Sabra’s lawsuits is attributable to Etzkorn or Fire Systems Inc., he said.
“Is it all on the inspection company or is it all on the owner, or a combination of both?” Sabra said. “If the fire started in a particular room and the sprinkler system in that room did not operate properly … if it had, it would have extinguished the fire and you wouldn’t have had all this death and destruction."
The National Fire Sprinkler Association and National Association of State Fire Marshals said jointly that if the sprinkler parts were in fact recalled and not replaced, “this could explain the tragic loss of life.”
Building owners, contractors and local fire inspectors should be following NFPA 25 as well as any additional oversight put in place at the state or municipal level, Ray said.
“That standard is law,” he said. “(Buildings) should be inspected in accordance with that standard.”
He emphasized the “onus” of fire sprinkler inspections is on building owners.
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