U.S. Fire Administration/Technical Report Series

Ten Elderly Victims From 

Intermediate Care 

Facility Fire

Colorado Springs, Colorado

USFA-TR-050/March 1991

U.S. Fire Administration Fire Investigations Program

T

he U.S. Fire Administration develops reports on selected major fires throughout the country. 

The fires usually involve multiple deaths or a large loss of property. But the primary criterion 

for deciding to do a report is whether it will result in significant “lessons learned.” In some 

cases these lessons bring to light new knowledge about fire--the effect of building construction or 

contents, human behavior in fire, etc. In other cases, the lessons are not new but are serious enough 

to highlight once again, with yet another fire tragedy report. In some cases, special reports are developed to discuss events, drills, or new technologies which are of interest to the fire service.

The reports are sent to fire magazines and are distributed at National and Regional fire meetings. The 

International Association of Fire Chiefs assists the USFA in disseminating the findings throughout the 

fire service. On a continuing basis the reports are available on request from the USFA; announcements of their availability are published widely in fire journals and newsletters.

This body of work provides detailed information on the nature of the fire problem for policymakers 

who must decide on allocations of resources between fire and other pressing problems, and within 

the fire service to improve codes and code enforcement, training, public fire education, building 

technology, and other related areas.

The Fire Administration, which has no regulatory authority, sends an experienced fire investigator 

into a community after a major incident only after having conferred with the local fire authorities 

to insure that the assistance and presence of the USFA would be supportive and would in no way 

interfere with any review of the incident they are themselves conducting. The intent is not to arrive 

during the event or even immediately after, but rather after the dust settles, so that a complete and 

objective review of all the important aspects of the incident can be made. Local authorities review 

the USFA’s report while it is in draft. The USFA investigator or team is available to local authorities 

should they wish to request technical assistance for their own investigation.

This report and its recommendations were developed by USFA staff and by TriData Corporation, 

Arlington, Virginia, its staff and consultants, who are under contract to assist the USFA in carrying 

out the Fire Reports Program.

The USFA greatly appreciates the cooperation received from the Colorado Springs Fire Department, 

with particular thanks to Fire Chief Louis A. Roman, Deputy Chief Terry Q. Gladdin, Captain Michael 

R. Gower, and Lieutenant Dave L. Stephenson. Mr. Paul Daraghy, Director of the State of Colorado 

Health Department also provided used information.

For additional copies of this report write to the U.S. Fire Administration, 16825 South Seton Avenue, 

Emmitsburg, Maryland 21727. The report is available on the USFA Web site at http://www.usfa.dhs.gov/

Ten Elderly Victims from

Intermediate Care Facility Fire

Colorado Springs, Colorado

Investigated by: Jack Yates

This is Report 050 of the Major Fires Investigation Project conducted

by TriData Corporation under contract EMW-90-C-3338 to the United

States Fire Administration, Federal Emergency Management Agency.

Department of Homeland Security

United States Fire Administration

National Fire Data Center

U.S. Fire Administration

Mission Statement

As an entity of the Department of Homeland 

Security, the mission of the USFA is to reduce life and economic losses due to fire 

and related emergencies, through leadership, advocacy, coordination, and support. 

We serve the Nation independently, in coordination with other Federal agencies, 

and in partnership with fire protection and 

emergency service communities. With a 

commitment to excellence, we provide public education, training, technology, and data 

initiatives.

TAblE oF ConTEnTS

OVERVIEW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SUMMARY OF KEY ISSUES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

STRUCTURE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

THE FIRE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

CODES AND INSPECTIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

FIRE AND SMOKE DETECTION EQUIPMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

FIRE DEPARTMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CONTRIBUTING FACTORS REGARDING THE FIRE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

LESSONS LEARNED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Appendix A: Floor Plan Showing the Point of Origin, Locations of Bodies, 

and the Extent of the Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Appendix B: Colorado Springs Fire Department Report on the Crystal Springs Estate Fire. . . 8

Appendix C: Alarm and Dispatch Log. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Appendix D: Uniform Fire Code, 1970 Edition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Appendix E: Uniform Fire Code, 1988 Edition, E&I Ratings. . . . . . . . . . . . . . . . . . . . . . . . . . 19

Appendix F: Fire Prevention Inspection Log Records for 1990 and 1991. . . . . . . . . . . . . . . . 23

Appendix G: Photographs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1

Ten Elderly Victims from Intermediate Care Facility Fire

Colorado Springs, Colorado

March 1991

Local Contacts: Louis A. Roman, Fire Chief

Terry Q. Gladdin, Deputy Chief

Colorado Springs Fire Department

31 South Weber Street

Colorado Springs, CO 80903

Michael R. Gower, Captain

Fire/Arson Investigations

Colorado Springs Fire Department

105 East Vermijo, Suite #300

Colorado Springs, CO 80903

David L. Stephenson, Lieutenant

Fire Prevention Bureau

Colorado Springs Fire Department

101 West Costilla Street

Colorado Springs, CO 80903

Paul Daraghy, Director

State of Colorado Department of Health

4210 East 11th Avenue

Denver, CO 80220

O

An accidental fire determined to have originated above ceiling level occurred in the early morning 

hours of March 4, 1991, to the Crystal Springs Estates personal care boarding home in Colorado 

Springs, Colorado. All indicators point to this fire as having been burning in the attic undetected 

for some period of time, perhaps as much as an hour or more before breaking through the ceiling 

drywall and having smoke detectors react.

Heat detectors were found in the attic but had not functioned. A pull station’s use and a 9-1-1 call 

alerted the fire department, but upon arrival they found a fire already ventilated through roof turbines. Nine elderly occupants perished, all as a result of carbon monoxide poisoning, in this fire. A 

tenth victim died months later of smoke aggravated lung problems.
2 U.S. Fire Administration/Technical Report Series

SUMMARY oF KEY ISSUES

Issues Comments

Cause of Fire Undetermined; first thought to be ceiling exhaust fan, but eliminated by investigation.

Fire Origin Ceiling space of east wing.

Delayed Detection Heat detectors in attic had not been connected or did not function. After considerable fire development, ceiling smoke alarm activated, nurse operated alarm pull station that closed fire doors 

and alerted central monitoring agency. Owner and nurse/director pounded on doors to wake 

residents. Owner called 9-1-1.

Building Structure Single-story, brick veneer; four connected wings. Attic of east wing had breech in draft stop. 

Between west and north wings, fire door on first floor was offset 36 inches from firewall in attic.

Residents Twenty-five at time of fire, aged 72 to 97; many required wheelchairs or walkers. Only two staff 

were present when fire occurred.

Casualties Nine fatalities during fire; one additional fatality months later from smoke aggravated lung 

problems; average age 85.

Fire Protection Features No sprinklers. Rate of rise heat detectors in halls and each room; smoke detectors in halls and 

dining area; hard-wired, no battery backup. Fire doors operated.

Inspections & Compliance State inspections incomplete due to limited staff but facility licensed to operate. Classed as 

“intermediate or personal care facility” rather than nursing home, which has more stringent fire 

protection requirements.

STRUCTURE

This facility was one constructed in three different phases. The first construction plans included the 

west and south wings which were begun in 1959. (See Appendix A for floor plan.) The east wing 

was added in 1960 and the north wing in 1962. The north and east wings do not connect and an 

opening large enough for vehicles to drive through was left at the northeast corner allowing access 

to a courtyard area in the center of the complex.

The exterior of this structure was of brick veneer. The interior finish consisted of drywall ceilings 

and walls. The floors were concrete slab with covering of carpet in some areas and tile in others.

All occupants’ rooms exited onto hallways that would lead to exterior exits and all rooms had windows approximately 48 inches above floor level. The facility appeared to comply with the National 

Fire Protection Association (NFPA) Life Safety Code requirements that apply to evacuation.

However, the actual structure did not have safety features that originally were thought to be there; 

in particular, properly rated and designed firewalls. A wall at the east end of the dining area was 

thought at first to be a firewall, however, closer inspection revealed that a tongue-in-groove ceiling 

extended over the top leaving exposed wood to the outside. A cinder block wall was constructed 

adjacent to it, but the integrity of the wall was breached when holes were punched in, in order to 

allow the ceiling joist for the east addition.

The second firewall was thought to be at the area of the addition of the north wing where it tied into 

the existing west wing. A closer inspection showed that the firewall in the attic was not designed to 

extend to floor level but in fact, the fire door for this wing was set approximately 36 inches north of 

the attic stop, again rendering this to be less than a fully rated firewall.
USFA-TR-050/March 1991 3

In this fire, this attic barricade along with the drywall ceiling did impede the communication of the 

fire in the west wing and prevent travel of the fire into the north wing area. However, had the fire 

begun closer to this wall, it most probably would not have stopped fire extension as it was thought 

to be designed for.

THE FIRE

At 0038 hours on March 4, 1991, the Colorado Springs Fire Department received an alarm notification of a structure fire at 825 South Hancock which is the address for Crystal Springs Estate. The 

first notification came from an alarm monitoring company out of Denver that monitored the Crystal 

Springs Estate system. The alarm was activated by a pull station in the facility. Within seconds of the 

alarm company’s call to the fire department, a second call, on 9-1-1, was received verifying actual fire 

at the scene. (See the Colorado Springs Fire Department’s Report on the Crystal Springs Estate Fire in 

Appendix B for further details on the early stages of the incident and the investigation findings.)

The initial alarm recommendation of one company was upgraded to two engine companies and one 

truck company. Upon arrival the first responding company reported visible fire and immediately 

requested more units to respond to assist in evacuation and suppression.

The fire department began immediate rescue operations and assumed an offensive fire attack. 

Occupants and victims were removed and the fire department attacked the fire for over an hour 

before they were forced to pull personnel from inside the building and then assume a defensive 

position.

Eventual damage was extensive causing total destruction to the roof over the east, south, and most 

of the west wing. The north wing still had roof area intact. Heavy interior damage occurred to the 

east, south, and west wings as a result of fall down and secondary burning.

A total of 25 residents were in the structure at the time of the fire along with two staff members. 

Nine fire fatality victims were removed during the suppression of the fire. The victims ranged in 

aged from 77 to 97. The El Paso County Coroner’s Office has determined that all the victims died 

from asphyxia due to carbon monoxide inhalation. All victims but one were found in their rooms; 

the one outside of her room was found in the dining area. One woman, Lois Mitchell, age 82, died 

in December 1991 of smoke aggravated lung problems.

In addition, eight residents of the home were treated for smoke inhalation and five firefighters 

were injured.

The people who died from this tragic fire were:

Name Age

Ruby Bowes 97

Ethyl Haythorn 90

Louise Evans 88

Velma McKahan 88

Muriel Hartman 84

Miriam Wilson 82

Lois Mitchell 82

Marion Staples 81

Catharine Martin 78

Alice Shuey 77
4 U.S. Fire Administration/Technical Report Series

CoDES AnD InSPECTIonS

At the time this property was constructed, there were no codes that would have prescribed installation of sprinkler systems. In Colorado, the intermediate care facilities such as this one are licensed 

and inspected by State Health Department Inspectors who work with NFPA Life Safety Code 101. 

Colorado Springs, however, subscribes to the Uniform Fire Code (UFC) as their regulatory guide.

Since this building was constructed it has been used for multiple purposes. The current owner applied 

for his license midyear of 1988. The three initial inspections are conducted by the fire department, 

zoning, and then building inspectors. The State Health Department then sends in their inspector. 

The first State Health Inspector was at the facility in August of 1989. The director of Colorado 

Department of Health indicated there were three additional inspections: November 27, 1989, May 

16, 1990, and November 14, 1990. As of the last inspection, he stated the installation of additional 

smoke alarms is all the facility needed in order to pass their requirements and be licensed.

The Colorado Springs Fire Department also continued to inspect these premises under the UFC. This 

is listed as an I inspection (Institutional facility), and inspections are conducted by engine company 

personnel after the initial inspection on a biannual basis.

FIRE AnD SMoKE DETECTIon EQUIPMEnT

This facility was equipped with rate of rise heat detectors in each room and in the halls. Smoke 

detectors were in-place in the halls and dining area. There were also heat detectors found within the 

attic space, however, in that the fire burned undetected within the attic before breaking through the 

ceiling, it is felt these detection devices were not connected or properly functioning.

It also appeared all systems were hard-wired and were not battery backed.

There was no sprinkler protection in the facility.

FIRE DEPARTMEnT

Colorado Springs is approximately 181 square miles in size with a population of 289,000. There 

are two fire districts, 15 stations, 20 fire companies, and approximately 375 personnel. Within that 

number is the fire prevention division, which includes Code Enforcement and Fire Investigations. In 

addition, a public education specialist is in a full-time capacity with the department.

The Colorado Springs Fire Department is an extremely professional organization with a well charted 

sense of direction. Their mission statement as outlined in their 1991 goals and objectives states 

their overall attitude: “To promote life safety and property conservation for the citizens of Colorado 

Springs through compassionate, professional service.”

ConTRIbUTInG FACToRS REGARDInG THE FIRE

This tragic fire, like many other similar fires in care facilities, illustrates common, preventable problems that continue to occur.

The first and foremost question deals with the inspection force and who is ultimately responsible 

for the well-being of the occupants in this type of facility. Colorado labeled this facility as an “intermediate or personal care facility” instead of calling it a “nursing home.” For this category there is 

supposed to be a lesser degree of care needed, i.e., less nursing staff. However, as shown in this 
USFA-TR-050/March 1991 5

scenario, this group of residents who averaged 85 years of age, many with limited mobility, were put 

at a serious disadvantage by this categorization when an emergency situation arose. Other States, like 

Colorado, need to review their criteria and practices in this important area.

Adequacy of inspections is another problem area spotlighted by this incident. Colorado currently 

has two inspectors for the entire State and 281 operational personal care homes. They range in 

size from three beds to several hundred, but most are twenty beds or smaller. The State Health 

Department Director is currently trying to arrange contracts with local county inspectors to maintain 

inspections on these facilities, but in the interim two inspectors are charged with the major portion 

of inspections in the State. The director indicates these are not trained building inspectors and have 

only a cursory amount of training in this area.

The State Health Department Director makes the point that the bulk of these facilities are not in-line 

for any Federal aid and if forced to go with more stringent safety features, they would be forced to 

close. By comparison, numerous States, such as Virginia and Alabama, have made sprinklering of this 

type of facility mandatory, and it does not appear that financial constraints have hampered them.

The Colorado Springs Fire Department is to be commended for their openness during USFA’s investigation of this fire and their willingness to learn from this loss. They indicated they will implement into 

their plan a program of more stringent code enforcement as a result of lessons learned from this fire.

The Colorado Springs Fire Department did a building inspection and outlined areas needing to 

be corrected, to which the owner complied. Their inspection was followed by the State Health 

Inspector and any additional fire safety and physical plant inequities found were to be corrected 

before a license to operate would be issued. The licensing process with the State began in August 

1989 and, as of the date of the loss, the final inspection had not been made. The last inspection on 

November 14, 1990, required that an additional 12 smoke detectors be installed in the dining area 

and halls. That was completed approximately one week prior to the fire, so, technically, the facility 

met with all licensing requirements.

Yet, according to the owner, no inspector reviewed evacuation procedures or checked emergency 

lighting or heat detection devices in the attic space. In this fire, the fact that fire burned in the attic 

undetected for an extended period means greater possibility for electric service to be severed. The 

value of battery back-up detection systems is clear from this incident. Also, as Colorado Springs Fire 

Department Deputy Fire Chief Terry Gladdin stated, sprinklers would have gone a long way toward 

controlling the fire.

L

1. Inspection for these types of care facilities must be conducted by full qualified building 

inspectors as well as by health inspectors, or joint inspections should be conducted.

There is little accomplished if buildings or institutions pass one area but fail in another. The 

inspection process must be a comprehensive operation and completed in full.

2. Properly working heat and smoke detection equipment is a must.

All detection equipment in-place must be kept in working condition. The system must be 

checked on a scheduled basis by trained personnel. Battery assistance to hard-wired heat/

smoke detectors offers the greatest safety. Although not a factor in this loss, the scenario of this 

incident illustrates the threat of loss of power.
6 U.S. Fire Administration/Technical Report Series

3. Adequate staff must be assigned for the number of occupants.

At the time of the fire only two staff were on the premises. Many of the “intermediate care” 

occupants present required wheelchairs, walkers, oxygen, and other aids. In a dire emergency 

such as this, that was entirely too few staff people to assist the occupants.

4. Care facilities should be sprinklered in patient rooms and halls.

Tragedies such as this fire demonstrates the increasing need for more individual facilities and 

communities to install sprinklers for the protection of life and property despite economic 

barriers.

5. Evacuation planning and regular drills are particularly important in facilities for the elderly.

Review of this fire once again reminds us of the difficulties involved in protecting the elderly 

from fire. In all facilities for the elderly, but particularly residences, evacuation planning and 

regular drills are an essential part of responsible facility management.
7

APPEnDIx A

Floor Plan Showing the Point of Origin, Locations of 

Bodies, and the Extent of the Fire

CRYSTAL SPRINGS ESTATES

Intermediate Care Facility 

Colorado Springs, Colorado 
8

APPEnDIx b

Colorado Springs Fire Department Report on the Crystal 

Springs Estate Fire

Crystal Springs Estate Fire 

825 S. Hancock Ave. 

Colorado Springs, Colorado 

3/04/91 
USFA-TR-050/March 1991 9

Appendix b (continued)

Crystal Springs Estate Fire

825 S. Hancock Ave., Colorado Springs, Colorado

3/04/91

This fire occurred in a "Personal Care Boarding Home" with 24

residents and 2 staff members in the building, 34 minutes after

midnight, on a Monday morning.

STRUCTURE:

The building is a single-story, brick veneer structure. It is

configured as 4 interconnected wings which enclose a center 

courtyard. The north and east wings do not connect at the

northeast corner of the property, allowing access to the center

courtyard. The sketch below illustrates the general layout of this

11,590 square foot building.

The east wing contains 8 resident rooms and a smoking room. There

is a draft stop separating the north one-third of the attic from

the larger south portion. This draft stop, however, is breached by

an opening measuring approximately 4' by 4' according to an

electrician performing work in the building the week before the

fire.

Rev. 3/21/91
10 U.S. Fire Administration/Technical Report Series

Appendix b (continued)

Crystal Springs Estate

3/04/91 Page 2

The east wing connects to the dining and kitchen area (south wing)

at its southern end. A single, automatic closing fire door

separates these two wings. Firefighters conducting a search of the

building found it in the closed position during the fire.

The west end of the dining room connects to the west wing, which

contains 10 resident rooms and the nurses station. No fire doors

or walls separate the south wing from the west wing.

The north wing contains 9 resident rooms and the business office.

The north and west wings were originally thought to be separated by

a brick fire wall and automatic closing door. A closer inspection

revealed that the rated doorway in the hall is positioned

approximately 4' north of the brick fire wall. This reduces the

protection provided to nothing more than a brick draft stop in the

attic.

Construction plans indicate the west and south wings were

constructed in 1959, the east in 1960, the north in 1962. The

entire facility is equipped with heat detectors in the resident

rooms, hallways, and attic spaces. Pull stations, a few smoke

detectors, and portable fire extinguishers are also located in the

hallways of the facility. A post-fire inspection of the remaining

systems and wiring indicated the pull stations, older smoke

detectors, and heat detectors were connected in series on a 2-wire

loop. The activation of a pull station or a detector was designed

to send an alarm signal to the central monitoring agency. Neither

the management of the facility nor the alarm monitor could verify

the condition of the alarm system prior to the fire.

An electrician who inspected this system stated that if a fire

burns through one of the wires in the loop, every portion of the

loop beyond that point would become deactivated. Also, a 2-wire

system is not able to send a "trouble" indication should this

scenario take place.

To satisfy the requirements of the State Health Department, an

electrician installed 12 additional smoke detectors in the dining

room and hallways approximately 1 week before the fire. These

ionization detectors were interconnected so the activation of any

detector would cause all 12 to sound an audible alarm. This 110

volt system received power through a separate circuit and was

designed to sound a "local alarm" only. After verification of an

emergency, a staff member must activate a pull station to send an

alarm to the alarm monitor.

Rev. 3/21/91
USFA-TR-050/March 1991 11

Appendix b (continued)

Crystal Springs Estate

3/04/91 Page 3

OCCUPANCY AT THE TIME OF THE FIRE:

As a "Personal Care Boarding Home," Crystal Springs Estate provided

meals, lodging, entertainment, and limited medical assistance to 25

residents ranging from age 72 to 97. Many required walkers and

wheelchairs to move about. One person who resided at Crystal

Springs was already at a hospital when the fire occurred. Everyone

except the occupant of room 28 was asleep in bed when a staff

person made her midnight rounds. This occupant was later found in

the dining area, fatally injured by the fire.

Two Staff members were in the building when the fire was

discovered. One, an owner of the facility, was asleep in the north

wing. The other, a registered nurse and the Director of the home,

was setting out silverware in the dining area in preparation for

breakfast.

ACTIVITIES AT THE TIME THE FIRE WAS DETECTED:

The Director of the facility reported that she was working in the

dining room when the "local" fire alarm system activated. This

employee also heard at least 1 person in the east wing screaming

"fire." The audible alarm most likely was activated by the smoke

detection system which was recently installed.

The Director stated she went into the east wing, looked north, and

observed a considerable amount of fire coming out of the smoking

room doorway. She then ran to the southwest corner of the dining

room, near the exit, and operated an alarm pull station. The fire

doors in the building immediately closed and an alarm was sent to

the central monitoring agency in Denver, Colorado at 12:34 a.m.

She continued to run through the building to the north wing, where

she awoke the other staff member. Together they pounded on the

doors of the north and west wings to wake the residents.

Upon arriving where the west wing meets the dining room, the staff

members found the dining room to be well involved in fire. The

owner then called the 911 emergency center from the nurses station

at that location. This was recorded as 12:37 a.m., which would be

approximately 3 minutes after the pull station was operated by the

Director.

At 12:42 a.m. the first-due engine company arrived and found fire

to be ventilating from the north windows of the dining room and the

roof above the south end of the east wing. Fire suppression and

rescue activities were begun immediately.

Rev. 3/21/91
12 U.S. Fire Administration/Technical Report Series

Appendix b (continued)

Crystal Springs Estate

3/04/91 Page 4

INVESTIGATION FINDINGS:

The fire destroyed the entire east wing, the kitchen and dining

facilities, and the south two-thirds of the west wing. The fire

did not travel north of the brick wall which separates the attics

of the west and north wings.

The smoking room is located on the west side of the east wing,

directly abreast of the dining room. Examination of the area above

the smoking room indicated the fire originated above the ceiling

and spread throughout the attic of the east wing.

A "consumer grade" 110 volt ceiling exhaust fan, similar to that

found in residential bathrooms, was recovered from the debris in

the smoking room. An employee informed investigators that the

ceiling fan was controlled by the overhead lighting and was very

noisy. She also said the fan was present when the building was

purchased by the current owners.

Closer inspection revealed that the bearing assembly to the fan

showed evidence of extreme wear, with the bearing/bushing being

worn into an oblong shape. An owner later stated that

approximately 1 month before the fire, the exhaust fan became very

noisy so someone removed the fan cover and sprayed WD-40 into the

motor housing. This reduced the amount of noise the fan made.

The double 2"x 4" top plate on the north wall of the smoking room

showed evidence of extreme heat and near total destruction above

the location where the ventilating fan was found. Distinct burn

patterns were also found on the wall beneath this area of the

room's north wall. A wall mounted cabinet was also burned at its

top, east edge immediately adjacent to the exhaust fan area.

An electrician inspected the circuit to the overhead lighting and

exhaust fan and found them to be powered by the only 15 amp circuit

breaker in the electrical panel. The breaker was tripped sometime

during the fire and showed evidence of extreme internal heat. The

electrician stated the breaker was no longer functional and

indicated that it may have been operating very near its capacity

for a long time. Adjacent breakers showed no signs of heat and

appeared to remain functional.

A second area of severe burning was located approximately 8' west

of the exhaust fan, at the enclosure to the furnace flue extending

from the basement. This flue is immediately next to the extreme

east end of the dining room. The top plate surrounding this flue

revealed extreme burning on the north side where a support strap

Rev. 3/21/91
USFA-TR-050/March 1991 13

Appendix b (continued)

Crystal Springs Estate

3/04/91 Page 5

connects to a ceiling joist. This was originally thought to be the

origin of the fire. It was during excavation of the smoking room

that the ceiling fan and its nearby structural members were

discovered.

A representative of the National Fire Protection Association, upon

viewing the two areas of burn, theorized that the fire burned

deeply near the flue because the enclosure was open and

unrestricted from the basement to the attic. This permitted a

sustained flow of fresh air into the attic at this point, which

allowed very hot, and efficient, burning to take place.

The fire originated near the ceiling exhaust fan in the smoking

room of the east wing and extended west into the dining room by way

of a void between the cinderblock and brick veneer of the dining

room's east wall. Openings were made in the brick veneer to

accommodate the mounting of roof members for the east wing.

The dining room burned at a very high temperature due to its heavy

timber roof/ceiling construction and possible cooking grease/oil

deposits which had adhered to it over time. Fire further extended

into the west wing, burning north until being stopped by the brick

wall subdividing the attic space.

It is unknown why the heat detectors found in the attic area of the

east wing did not warn of the fire in that area. Inspection of the

alarm panel revealed 2 fuses which were blown at some unknown time.

The condition of the system before the fire has not been

established.

Investigators feel that the fire burned in the attic above the

residents, undetected, for a considerable time. Only when the

ceiling in the smoking room collapsed, did fire products reach the

recently installed smoke detector system and activate a local

alarm.

Rev. 3/21/91
14 U.S. Fire Administration/Technical Report Series

Appendix b (continued)

Crystal Springs Estate

3/04/91 Page 6

FIRE COSTS:

Nine residents were found overcome within the structure and were

pronounced dead by the El Paso County Coroner's Office. Autopsies

revealed that all were killed by the effects of smoke inhalation.

Four of the victims were located in the east wing, four in the

west, and one was located in the dining room. Their ages were:

78 (2) 89

82 (2) 90

84 97

88

The Firefighters who removed the victims from the structure were

interviewed. They stated only 1 victim was found in bed. The body

positions of the others indicated they were attempting to escape

the building when they were overcome.

Also, 8 residents of the facility were treated for smoke inhalation

and transported to area hospitals. Their ages were:

72 88 (2)

77 91

80

83 (2)

Five Colorado Springs Firefighters suffered injuries and were

transported to Memorial Hospital for treatment. The injuries

included:

1 - Rib injury due to stepping into a window well and

falling against its side (Paramedic)

1 - Foot puncture from stepping on a nail during

overhaul (Firefighter)

The firefighter was wearing work boots at the

time.

1 - Smoke inhalation and exhaustion (Captain1

1 - Pulled back muscles due to moving heavy file

cabinets from the office area during property

conservation efforts (Driver-Engineer)

1 - Back injury due to falling while attempting to

pull himself up into an attic space (Firefighter)

Rev. 3/21/91
USFA-TR-050/March 1991 15

Appendix b (continued)

Crystal Springs Estate

3/04/91 Page 7

Twenty-one fire personnel were evaluated by rehab members and were

determined not to require further medical evaluation.

Captain 1

Lieutenants 6

Driver-Engineers 3

Firefighters 11

There were also 4 employees of private ambulance companies and 2

civilian rescuers/participants treated for smoke inhalation at

local hospitals.

The structure suffered $500,000 to $750,000 in direct fire loss.

Photos of the fire's progress and of the investigation are on file

at the Investigation Bureau.

Rev. 3/21/91
16

APPEnDIx C

Alarm and Dispatch Log
17

APPEnDIx D

Uniform Fire Code, 1970 Edition

Crystal Estates was then classified as a “D.” 

Shows when the building would have had to be first sprinklered.

TYPE lV AND V CONSTRUCTION: For Exterior wall and opening protection of Types IV and V buildings, see table below. Type V Construction is not 

TABLE NO. 5-A-WALL AND OPENING PROTECTION OF OCCUPANCIES BASED ON LOCATION OF PROPERTY 

permitted within Fire Zone No. I. Exceptions to limitations for Type IV and Type V Construction, as provided in Section 

2203 apply. For Types I, II, and Ill Constructlon see Sections 1803, 1903, and 2003. 

1109, 2103 and 5 -A 
18 U.S. Fire Administration/Technical Report Series

Appendix D (continued)
19

APPEnDIx E

Uniform Fire Code, 1988 Edition

E&I Ratings

1988 EDITION 9.116-9.117

2 . Material having a structural base of non combustible material as defined in 

Item No. 1 above. with a surfacing material not over 1/8-inch thick which 

has a flame-spread rating of 50 or less. 

“Noncombustible” does not apply to surface finish materials. Material required to be noncombustible for reduced clearances to flues. heating appliances or 

other sources of high temperature shall refer to material conforming to item 1. No 

material shall be classed as noncombustible which is subject to increase in 

combustibility or flame-spread rating beyond the limits herein estabiishcd. 

through the effects of age. moisture or other atmospheric condition. 

Flame-spread rating as used herein refers to rating obtained according to tests 

conducted as specified in U.B.C. Standard No. 42-1. 

NONFLAMMABLE MEDICAL GAS is a compressed gas which is nonflammable and used for therapeutic purposes and shall include, among others. 

oxygen and nitrous oxide. 

NORMAL TEMPERATURE PRESSURE (NTP) is a temperature of 70°F 

and a pressure of 1 atmosphere 14.7 psi). 

Sec. 9.117. OSHA is the Occupational Safety and Health Administration. 

OCCUPANCY is the purpose for which a building or part thereof is used or 

intended to be used. 

OCCUPANCY CLASSIFICATION. For the purpose of this code. certain 

occupancies arc defined as follows: 

Group A Occupancies: 

Division 1. Any assembly building or portion of a building with a stage and an 

occupant load of 1000 or more. 

Division 2. Any building or portion of a building having an assembly room 

with an occupant load of less than 1000 and a stage. 

Division 2.1 Any building or portion of a building having an assembly room 

with an occupant load of 300 or more without a stage. including such buildings 

used for educational purposes and not classed as a Group E or Group B. Division 2 

Occupancy.

Division 3. Any building or portion of a building having an assembly room 

with an occupant load of less than 300 without a stage, including such building 

used for educational purposes and not classed as a Group B or Group B. Division 2 

Occupancy.

Division 4. Stadiums. reviewing stands and amusement park structures not 

included within Group A Occupancies. 

Group B Occupancies: 

Division 1. Gasoline service stations garages where no repair work is done 

except exchange of parts and maintenance requiring no open flamc welding or 

the use Class I. II or III-A liquids. 

35
20 U.S. Fire Administration/Technical Report Series

Appendix E (continued)

9.117 UNIFORM FIRE CODE

Division 2. Drinking and dining establishments having an occupant load of 

less than 50, wholesale and retail stores, office buildings, printing plants, municipal police and fire stations, factories and workshops using materials not highIy 

flammable or combustible, storage and sales rooms for combustible goods, paint 

stores without bulk handling. 

Buildings or portions of buildings having rooms used for educational purposes 

beyond the 12th grade with less than 50 occupants in any room. 

Division 3. Aircraft hangars where no repair work is done except exchange of 

parts and maintenance requiring no open flames. welding or the use of Class I or II 

flammable liquids. 

Open parking garages. 

Helistops.

Division 4. ice plants. power plants, pumping plants. cold storage. creameries.

Factories and workshops using noncombustible and nonexplosive materials. 

Storage and sales rooms of noncombustible and nonexplosive materials. 

Group E Occupancies: 

Division 1. Any building used foreducational purposes through the 12th grade 

by 50 or more persons for more than 12 hours per week or four-hours in any one 

day.

Division 2. Any building used for educational purposes through the 12th grade

by less than 50 persons for more than I2 hours per week or four hours in any one 

day.

Division 3. Any building used for day-care purposes for more than six 

children.

Group H Occupancies: 

Division 1. Occupancies with quantity of material in the building in excess of 

those listed in Table No. 9-A which present a high explosion hazard. including but 

not limited to: 

1. Explosives. blasting agents. fireworks and black powder. 

EXCEPTION: Storage and the use of pyrotechnic special effect materials in 

motion picture television, theatrical and group entertainment production when 

under permit as required in the Fire Code, The time period for storage shall not 

exceed 90 days. 

2. Unclassified detonatable organic peroxides. 

3. Class 4 oxidizers. 

4. Class 4 or Class 3 detonatable unstable (reactive) materials. 

Division 2. Occupancies with quantity of material in the building in excess of 

those listed in Table No. 9-A which present a moderate explosion hazard or a 

hazard from accelerated burning. including but not limited to: 

1. Class organic peroxides. 

2. Class 3 nondetonatable unstable (reactive) materials. 

3 6
USFA-TR-050/March 1991 21

Appendix E (continued)

1988 EDITION 9.117

3. Pyrophoric gases. 

4. Flammable or oxidizing gases. 

5. Class I. II or III-A flammable or combustible liquids which are used in 

normally open containers or systems or in closed containers pressurized at 

more than 15-pounds-per-square-inch gage.

6. Combustible dusts in suspension or capable of being put into suspension in 

the atmosphere of the room or area. 

EXCEPTIONS: 1. Rooms or areas used for woodworking that do not exceed 

500 square feet in area may be classified as Group B. Division 2 Occupancies. 

provided dust-producing machines are equipped with approved dust collectors and 

there are not more than two such machines. 

2. Lumberyards and similar retail stores utilizing only power saws may be 

classified as Group B. Division 2 Occupancies. 

The building official may revoke the use of these exceptions for due cause. 

7. Class 3 oxidizers. 

Division 3. Occupancies with quantity of material in the building in excess of 

those listed in Table No. 9-A which present a high fire or physical hazard. 

including but not limited to: 

1. Class II, III or IV organic peroxides. 

2. Class 1 or 2 oxidizers. 

3. Class 1. II or III-A flammable liquids or combustible liquids which are 

utilized or stored in normally closed containers or systems and containers 

pressurized at 15-pounds-per-square-inch gage or less. 

4. Class III-B combustible liquids 

5. Pyrophoric liquids or solids. 

6. Water reactives. 

7. Flammable solids. including combustible fibers or dusts, except for dusts 

included in Division 2. 

8. Flammable or oxidizing cryogenic fluids (other than inert). 

9. Class 1 or 2 unstable (reactive) materials. 

Division 4. Repair garages not classified as a Group B. Division 1. 

Division 5. Aircraft repair hangars and heliports not classified as Group B, 

Division 3. 

Division 6. Semiconductor fabrication facilities and comparable research and 

development areas when the facilities in which hazardous production materials 

(HPM) arc used and the aggregate quantity of materials are in excess of those 

listed in Table So. 9-A or 9-B. Such facilities and areas shall be designed and 

constructed in accordance with Section 911. 

Division 7. Occupancies having quantities of materials in excess of those listed 

in Table No. 9-B that are health hazards. including but not limited to: 

1. Corrosives. 

2. Highly toxic materials 

37
22 U.S. Fire Administration/Technical Report Series

Appendix E (continued)

9.117 UNIFORM FIRE CODE 

3. Irritants. 

4. Sensitizers. 

5. Other health hazards. 

Group I Occupancies: 

Division 1. Nurseries for the full-time care of children under the age of six 

teach accommodating more than five persons). 

Hospitals. sanitariums. nursing homes with nonambulatory patients and similar buildings (each accommodating more than five persons). 

Division 2. Nursing homes for ambulatory patients. homes for children six 

years of age or over teach accommodating more than five persons). 

Division 3. Mental hospitals. mental sanitariums. jails. reformatories and 

buildings where personal liberties of inmates are similarly restrained. 

EXCEPTION: Group I Occupancies shall not include buildings used only for 

private residential purposes or for a family group. 

Group M Occupancies: 

Division 1. Private garages. sheds and agricultural buildings when not over 

1000 square feet in area. 

Division 2. Fences, tanks and towers. 

Group R Occupancies: 

Division 1. Hotels and apartments. Convents and monasteries (each accomo. 

dating more than 10 persons). 

Division 2. Not used. 

Division 3. Dwellings and lodging houses. 

OIL-BURNING EQUIPMENT is an oil burner of any type together with its

tank. piping, wiring, controls and related devices and shall include all oil burners. 

oil-fired units and heating and cooking appliances but exclude those exempted by 

Section 61.101. 

OIL-FIRED UNIT is a heating appliance equipped with one or more oil 

burners and all the necessary safety controls, electrical equipment and related 

equipment manufactured for assembly assembly complete unit. This definition does not 

include kerosene stoves or oil stoves. 

OPEN-AIR GRANDSTANDS and BLEACHERS are seating facilities

which are located so that the side toward which the audience faces is unroofed and 

without an enclosing wall. 

OPERATING LINE is a group of separated operating buildings of specities 

arrangement used in the assembly. modification. reconditioning, renovation. 

maintenance. inspection, surveillance, testing or manufacturing of explosives. 

ORGANIC COATING is a liquid mixture of binders such as alkyd, nitrocellulose. acrylic or oil and flammable and combustible solvents such as hydrocarbon. 

ester. ketone or alcohol. which when spread in a thin film converts to a durable 

protective and decorative finish. 

38
23

APPEnDIx F

Fire Prevention Inspection Log Records for 

1990 and 1991

. 2 LINE(S) FOUND OUT OF 1677 LINES .

* * * * * * * * * * * * * * * * * * * *****

* HANCOCK AV S 00825

:DATE 10:11:06 RID 9G 07 JAN 91 HUAN

.@921231 FIRE PREVENTION INSPECTION LOG G0004.

*RECS FROM l0/17 ARE HRE PREVIOUS RECS IN l0/88 ARE IN 46G 6G

*STREET NAME :D:ST-NUM :U-TYP:U-NUM:SC:ACT:HOURS:A-DATE:INIT:R-DA:

=============================.=.======.======.======.==.===.======.======.====.=====

HANCOCK AV S 000825 06 IA 2.50 880630 PJR

******* COMMENTS *** BY : PJR ON : 880630 RPT 88019

.OOl= 10.308 REMOVE PAINT FROM HEAT DETECTORS W/REQ.

.002= 10.402 ADJUST ALL EXTERIOR EXIT TO OPERATE PROPERLY-.

.003= 10.402 ADJUST INTERMEDIATE CORRIDOR TO OPERATE PROPERLY AND TO LATCH.

.003= 10.402 COMPLETE THE INSTALLATION OF THE MAGNETIC HOLD OPEN DEVICE AT

.005= THE KITCHEN DOOR.

.006= 10.314 INST A 40-B FR. EXT. IN KITCHEN ADJACENT TO THE COOKING AREA.

.007= 12.101 INST GUARDRAILING ADJACENT TO THE NORTH EXIT DOOR FROM DINING RM.

.008= 10.302 MOUNT EXISTING FR. EST. ON BRACKETS..009= 10.301A REPLACE 1-A FR. EXT. IN THE BASEMENT.

.OlO= 10.401 ACHIEVE COMPLETE 1 HR. FR. RESISTIVE CONST. IS THE BASEMEST MECH.

.Oll= 85.106 REPLACE TEMPORARY ELECTRICAL WIRING IN THE WEST CRAWLSPACE.

.012= 85.104 INST. METAL COVER PLATES OVER ELECT. JUNCTION BOX IN THE EAST CRAW

.013= 12.103 MAKE SOUTH EXIT DOOR FROM BASEMENT COMPLETELY OPERATIONAL.

.Old= SER. KITCHEN FR. EXT SYS. TAG SAME.

.015= 12.114 MAKE EXIT SIGNS IN THE WEST AND NORTH WING FULLY FUNCTIONAL..016= 11.2038 REMOVE ALL COMBUSTABLE WASTE AND DEBRIS.

.017= 25.107 MAINTAIN 48" CLEAR AISEL MAIN CORRIDOR..018= 25.107 MAINTAIN 36" CLEAR ASILE IN THE ROOMS OFF THE MAIN CORRIDOR..019= 12.103E MAINTAIN 24" CLEARANCE FROM CEILINGS TO COMBUSTABLE..===================================================================

HANCOCK AV S 000825 06 IA 0.50 880719 PJR

  COMMENTS ** * BY : PJR OS : 880719 RPT 880215

:001 = REINSP. APPD.

==========================================================

. . . . . . END REPORT . . . . .
24 U.S. Fire Administration/Technical Report Series

Appendix F (continued)

CITY OF COLORADO SPRINGS 

FIRE DEPARTMENT 
USFA-TR-050/March 1991 25

Appendix F (continued)

CITY of COLORADO SPRINGS 

FIRE DEPARTMENT 
26

APPEnDIx G

Photographs

Photo by Jack Yates 

Heat sensors from the attic, either not hooked up or not working as there was no early 

warning to any panel.
USFA-TR-050/March 1991 27

Appendix G (continued)

Photo by Jack Yates

Exterior of the structure as seen from the southeast and looking to the northwest. The east wing is to the 

right and the south wing is to the left.
28 U.S. Fire Administration/Technical Report Series

Appendix G (continued)

Photo by Jack Yates

Exterior as viewed from the south and looking north at the wall and roof area over the dining room.
USFA-TR-050/March 1991 29

Appendix G (continued)

Photo by Jack Yates

View of the east wing hall as seen from the south to the north. The smoking room where the fire began 

overhead is the first door on the left.
30 U.S. Fire Administration/Technical Report Series

Appendix G (continued)

Photo by Jack Yates

The smoking room. The corner to the right is the northwest corner where the vent stack to the heating unit below is 

located. This was thought originally to be the Area of Origin.
USFA-TR-050/March 1991 31

Appendix G (continued)

Photo by Jack Yates

View of the northeast corner of the smoking room. The light switch behind the door (just under the white spot in the 

center) controlled the fluorescent lights and the ventilation fan. The fan was located in the northeast corner. When the 

lights were on the fan was on. Since the switch location was difficult to get to, the lights and fan stayed on for hours 

and sometimes days at a time.
32 U.S. Fire Administration/Technical Report Series

Appendix G (continued)

Photo by Jack Yates

Nurses’ station just inside the front (southwest) door. The alarm panel is at this station. View is toward the northeast.
USFA-TR-050/March 1991 33

Appendix G (continued)

Photo by Jack Yates

Looking north from the entry area by the nurses’ station down the hall. Note all overhead framing was destroyed.
34 U.S. Fire Administration/Technical Report Series

Appendix G (continued)

Photo by Jack Yates

Front door through which initial interior attack was made, located at the southwest corner of the structure. View is from 

the interior toward the west.
USFA-TR-050/March 1991 35

Appendix G (continued)

Photo by Jack Yates

The east wall of the dining area. Note where holes have been punched in to put joists through. There was a cinder block 

wall behind this, but tongue-in-groove boards extended over the top exposing the boards to the brick area. Integrity of the 

firewall was breached from the holes and overlap of wood material.
36 U.S. Fire Administration/Technical Report Series

Appendix G (continued)

Photo by Jack Yates

Older existing smoke alarm in the structure, hard-wired, no battery backup.
USFA-TR-050/March 1991 37

Appendix G (continued)

Photo by Jack Yates

New smoke alarm installed approximately one week prior to the fire in order to be in compliance with State regulations.