U.S. Fire Administration/Technical Report Series

Ten Fatality Board and 

Care Facility Fire

Detroit, Michigan

USFA-TR-066/June 1992

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 and information received from officials of the Detroit 

Fire Department, most particularly Fire Marshal J. Richard Milliner, Fire Marshal Donald Robinson 

(Ret.), Fire Chief Harold Watkins, Battalion Chief Charles Evancho, Captain Donald B. Robinson 

(Ret.), Captain John Bozich, and Lieutenant Paul Green. We also wish to thank Captain William Peck 

and Sergeant Ron Connell of the Police and Fire Arson Unit and Creighton Lederer, Director, and 

Albert Thomas, Assistant Director, City of Detroit Building and Safety Engineering Department who 

also provided valuable information. Others who contributed information used in this report include 

Charles Kish, Chief Investigator; Dr. Bradford Helper, Chief Toxicologist; and Dr. Sawait Kanluen, 

Deputy Medical Examiner, Office of the Wayne County Medical Examiner; Inspector Robert Tarrant 

and Lieutenants John Madden and Eugene Schmitt of the Michigan State Police, Fire Marshal Division; 

and James Quigley, Director and Thomas Stuve, Supervisor, Adult Foster Care Licensing Division, 

Michigan Department of Social Services. 

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 Fatality Board and Care 

Facility Fire

Detroit, Michigan

Investigated by: Mark Chubb

This is Report 066 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.

Revised: March 2011

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

THE FIRE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

AFTER THE FIRE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

OCCUPANTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

EMERGENCY PLANNING AND PREPAREDNESS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

FIRE BUILDING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

REGULATORY ENVIRONMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ANALYSIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

OCCUPANT BEHAVIORS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

LESSONS LEARNED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

BIBLIOGRAPHY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Appendix A: Floor Plans and Area Map. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Appendix B: Detroit Fire Department Investigation Report. . . . . . . . . . . . . . . . . . . . . . . . . . 25

Appendix C: Revised Board and Care Facility Regulations, City of Detroit. . . . . . . . . . . . . . . 27

Appendix D: Fire Scene Photographs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

1

Ten Fatality Board and Care Facility Fire

Detroit, Michigan

June 1992

Local Contacts: Fire Commissioner Melvin D. Jefferson

Fire Marshal J. Richard Milliner

Chief of Fire Operations Harold Watkins

Battalion Chief Charles Evancho

Captain John Bozich

Detroit Fire Department

250 Larned Street

Detroit, Michigan 48226

(313) 596-2900

O

An early morning fire in an adult board and care facility housing mentally disabled adults left ten 

residents dead and two seriously injured. Detroit Fire Department investigators determined that 

smoking materials carelessly discarded in a kitchen trash receptacle started the blaze which led to the 

largest loss of life in a single residential fire in the city’s history.

The fire building was originally a two-family dwelling that was converted to a rooming house sometime in the 1960s. City building officials reported that their records indicated the dwelling was classified as a multi-family dwelling operating as a rooming house when they began regular inspections 

of it in 1969. In February 1975, the occupancy was licensed as an adult foster care facility by the 

Michigan Department of Social Services. An adult foster care facility would be classified as a board 

and care facility under National Fire Protection Association 101, Life Safety Code and a Use Group I-1 

structure by the Building and Code Administrators International, Inc. (BOCA) National Building Code, 

1990 edition.

Although AC-powered smoke detectors with interconnected sounding devices were installed throughout the dwelling, only one survivor – a third floor resident – reported hearing and responding to 

their warning. The night manager was alerted to the fire by sounds coming from the kitchen. Three 

other survivors reported that they first became aware of the fire when they heard the shouted warnings of the night manager and the occupant who had heard the smoke detectors. These warnings 

seemed to have alerted most, if not all, the building occupants, including the victims.
2 U.S. Fire Administration/Technical Report Series

Two of the survivors told investigators that they saw or heard some of their fellow occupants moving 

around, but were unable to explain why those occupants did not get out alive. Fire department and 

the medical examiner’s office investigators found all but one of the dead fully or partially clothed, suggesting that many of the victims attempted to dress before evacuating. According to the Wayne County 

Medical Examiner’s Office, all ten of the deaths were caused by inhalation of combustion products.

SUMMARY oF KeY ISSUeS

Issue Comments

Building Converted 2-1/2-story wood-frame duplex, with basement.

Casualties Ten dead; two injured; five escaped unharmed or with minor injuries.

Origin and Cause Detroit fire investigators believe the fire was ignited by smoking materials carelessly discarded 

in a trash receptacle next to the kitchen stove.

Smoke Detection Smoke detectors were installed throughout the building; however, only one survivor reported 

having heard and responded to their alarm.

Emergency Planning and 

Preparedness

An emergency plan had not been prepared or posted and fire exit drills were not performed.

Interior Finish Combustible interior finish materials added during remodeling contributed to rapid fire growth 

before the fire was detected.

Means of Egress Unenclosed front stairways provided avenues for smoke spread which probably cutoff the 

primary escape routes for many of the occupants.

Fire Department Notification Fire called in by neighbor, but several witnesses and at least one occupant reportedly 

attempted to notify the fire department via 9-1-1, but received busy signals.

The most important issues associated with this fire were the building features which fueled the fire 

and contributed to the spread of combustion products; the delayed detection and notification of 

building occupants; and the capabilities of the occupants themselves, most of whom were mentally 

or physically impaired and thereby unable to act appropriately. Questions have also arisen about the 

regulatory status of the premises, coordination of regulatory responsibilities between different agencies and levels of government, and compliance with the various codes, standards, ordinances, and 

statutes in effect at the time of the fire.

THe FIRe

The Detroit Fire Department received notification of a fire at 88-90 Pingree Street at 2:21 a.m., and 

dispatched a first alarm assignment consisting of four engine companies, two truck companies, one 

rescue company (for manpower), and one chief officer. When Engine 35 arrived they found a large 

amount of fire showing from the first floor front windows and door of 90 Pingree Street. After bringing the fire under control, firefighters made the grisly discovery that ten elderly or disabled residents 

had perished in the predawn fire. Of the seventeen people in the building at the time of the fire, only 

seven survived, and only five escaped unharmed. This fire has been described by Detroit fire officials as 

the deadliest fire in more than 40 years and the worst residential fire in the city’s history.
USFA-TR-066/June 1992 3

Detroit fire investigators believe the fire started when carelessly discarded smoking materials ignited 

trash in a kitchen waste receptacle. Investigation revealed that the fire started in the kitchen near 

the floor between the stove and kitchen counter on the east side of the room. (For floor plans, see 

Appendix A.) A distinctive V-shaped burn pattern was clearly evident on the outside wall adjacent 

to this area pointing to the likely point of origin. Combustible interior finish on this wall likely 

provided additional fuel as the fire grew and spread. Other combustibles, including containers of 

cooking fat on a shelf directly above the point of origin, probably became involved allowing the fire 

to grow rapidly. The quantity and configuration of fuel and the relative remoteness of the room of 

origin from the occupied portions of the building permitted the fire to grow significantly before it 

was detected.

Sometime between 11:30 p.m. and midnight, the residents retired for the evening after watching a 

baseball game on television. The night manager, Tyree “Ricky” Fluckes, remained downstairs in the 

living room watching television.

Sometime shortly after 2:00 a.m., Mr. Fluckes reportedly heard sounds in the kitchen and rose to 

investigate.1

 Approaching the rear of the dwelling, he observed a large fire in the kitchen through a 

pass-through opening to the dining room. When he arrived in the rear corridor at the open door to 

the kitchen, he reportedly attempted to enter to fight the fire, beating back the flames with his hands 

in an unsuccessful attempt to reach the fire extinguisher in the northeast corner of the room.

At some point during this sequence, smoke detectors installed in the house activated, alerting Glenn 

Gregory, a resident in the third floor southwest bedroom. He was watching a late-night movie 

and proceeded downstairs immediately to investigate. On the first floor he observed through the 

pass-through opening that the fire was extending up the back wall of the kitchen and witnessed Mr. 

Fluckes trying unsuccessfully to control the fire. Mr. Gregory attempted to dial 9-1-1 from the telephone in the dining room but reported that he received busy signals on two successive attempts.

Meanwhile, the neighbor in the dwelling just west of 90 Pingree Street reported she was awakened 

by unusual sounds outside, and she too got up to investigate. From her front porch, she reported 

seeing the window on the west side of the house break out.2

 She indicated she went back inside to 

call the fire department and then stretched a garden hose to protect her residence.

Michigan Bell said the busy signals received by some of the occupants and neighbors who dialed 

9-1-1 may have been due to high call volume reporting the incident.3 A police department official 

representing the 9-1-1 operators reported that an emergency call was received from 88-90 Pingree 

Street at 2:18 a.m., but that no one responded to the operator when the call was answered.4

 Another 

call (from a neighbor) was received shortly after 2:20 a.m., and was transferred to the fire department resulting in the dispatch of the first alarm.

1Mr. Fluckes could not be reached for an interview. Descriptions of his actions are based on statements he made to 

Detroit Fire Department investigators and one of the owners of the facility, Ophelia Simmons. These accounts are corroborated in part by the account given by Glenn Gregory, one of the residents, in a separate interview.

2

This is considered a good benchmark for occurrence of flashover – the point at which all combustible materials in the 

compartment reach their auto-ignition temperatures simultaneously.

3

WJR Radio news report, June 2, 1992.

4 Executive Deputy Police Chief James Bannon quoted in Detroit Free Press, June 4, 1992, p. 14A.
4 U.S. Fire Administration/Technical Report Series

About the time Mr. Gregory gave up his efforts to contact the fire department, Mr. Fluckes abandoned 

his efforts to control the fire and began attempting to wake and evacuate the residents. Two of the survivors interviewed, Mr. Darnell and Ms. Strempeck, said they first became aware of the fire when they 

awoke to Mr. Fluckes cries of “Fire! Fire! Everyone get out!” While Mr. Fluckes was warning residents 

on the upper floors of the west side of the building, Mr. Gregory returned to his room on the third floor 

to retrieve belongings, alerting occupants on the east side of the building along the way.

From his room directly above the room of fire origin, Willie Darnell was awakened by Mr. Fluckes’s 

warnings. Mr. Darnell’s first response to the warning upon waking was to get out of bed and dress. 

He confirmed that he could smell smoke when he got up but proceeded to put on trousers, shoes, 

and a shirt before evacuating. He also said he could hear residents of the room directly above his 

moving about. The sound was very much like someone shuffling about in their bare feet, and he 

was unaware of any commotion or shouting other than Mr. Fluckes’s warnings. The bodies of two 

victims, Richard Pascoe and Herman Holt, were found in this third floor room above Mr. Darnell’s 

after the fire.

Upon entering the second floor hallway to evacuate, Mr. Darnell encountered light smoke, which he 

passed through with little difficulty. Upon reaching the stairs, the smoke was heavier, and he had 

difficulty negotiating them. He proceeded only a short distance before falling down the remainder 

of the flight of stairs. When he landed at the bottom of the stairs he proceeded directly outside 

through the living room. The living room appeared relatively smoke-free at this time. Mr. Darnell 

also indicated he was not aware of any noise like a smoke detector sounding.

Like Mr. Darnell, Ms. Delores Strempeck said she was awakened by Mr. Fluckes’s warnings that the 

building was on fire. When she woke, she smelled smoke but heard no smoke detector sounding. 

Having survived a previous fire in 1989 by jumping from a second floor window, she took Mr. 

Fluckes’s warning seriously, wrapped herself in two blankets, and proceeded to evacuate her second 

floor northeast bedroom. When she entered the corridor, she encountered light smoke, covered 

her nose and mouth with the blankets, and proceeded to the front stairway. Like Mr. Darnell, she 

encountered heavier smoke there, and continued evacuating, but with greater difficulty. When she 

reached the first floor, she too proceeded through the living room and joined Mr. Darnell and other 

occupants outside.

Mr. Harris’s account is less cohesive, in part due to his poor mental condition, but he indicates he 

was awakened by a verbal warning and proceeded directly outside. When asked about the presence 

of indications of fire, he said that the corridor he passed through was filling with smoke and that he 

covered his nose and mouth when he began to experience difficulty breathing. When asked whether 

he had dressed or taken other actions prior to evacuating, it became clear that he had little recollection of these events but his account suggested that he took a little time to investigate and had dressed 

before evacuating.
USFA-TR-066/June 1992 5

AFTeR THe FIRe

The fire took more than 45 minutes to bring under control. Firefighters said that at no time during 

their firefighting efforts were they made aware that many of the building’s occupants might still be 

inside. Shortly after the fire was under control, they began a search of the building and discovered 

that 10 of the building’s 17 occupants had died.

The floor plan in Appendix A shows the locations of the victims. They were distributed throughout 

the building. The same number of victims was found on the east side as the west side and in the 

front part of the building as the rear. Eight of the victims were found on the second floor and two 

on the third floor.

Post mortem examinations of the victims were performed at the Office of the Wayne County Medical 

Examiner. Although autopsies were not conducted, blood toxicology tests were performed, and each 

victim was examined to confirm the most likely cause of death. Toxicology reports indicate that all 

10 victims died as a result of inhalation of smoke and toxic gases, and that none of the victims were 

intoxicated at the time of death.

O

Most occupants of this fatality became residents of one of the adult foster care facilities operated by 

Nu-Way Development Center after their release from State-run mental institutions prior to 1977. 

Newer occupants were often referred to the facility by operators of similar group homes or rooming 

houses.

All of the residents received some form of public assistance. Their public assistance checks were 

signed over to the proprietors in exchange for room and board services. Each of the residents was 

then allocated a small stipend from their checks for personal care and discretionary expenses.

Most of the occupants had some degree of physical or metal impairment. Of the survivors interviewed, all except the one who responded to the smoke detector activation showed moderate to 

severe signs of some mental disorder or physical disability. All of the residents present at the time 

of the fire were ambulatory. One non-ambulatory resident lived in the building but was hospitalized at the time of the fire. Despite their various impairments, the occupants of this facility would 

have been most appropriately classified as “slow” as defined by National Fire Protection Association 

(NFPA) 101 requirements for board and care facilities. This means that they were capable of selfevacuating but would be expected to experience some difficulty or delay in doing so.5

5 For a complete discussion of the criteria used to evaluate the evacuation capabilities of board and care residents, see 

NFPA 101, Life Safety Code, Section A-23-1.3 and NFPA 101M (92), Alternative Approaches to Life Safety, Chapter 5.
6 U.S. Fire Administration/Technical Report Series

Table 1. Disposition of Residents Present at Time of Fire

Name Age Sex Locationa Disposition

Steven Gregoroff 62 M To Be Determined Dead

Geraldine Hammond 67 F To Be Determined Dead

Herman Holt 54 M Third floor northwest 

bedroom

Dead

Theresa Hunterb 76 F Second floor northeast 

bedroom

Dead

Delroy Johnson 52 M To Be Determined Dead

Juanita Maxwell 57 F To Be Determined Dead

Viola Mull 61 F To Be Determined Dead

Richard Pascoe 89 M Third floor northwest 

bedroom

Dead

Joseph Shinske 56 M To Be Determined Dead

Michael Turner 45 M To Be Determined Dead

John Marshall 46 M To Be Determined Injured

Willie Sires 

(a.k.a. Willie Campbell)

59 M To Be Determined Injured

Willie Darnellb 64 M Second floor northwest 

bedroom

Uninjured

Tyree “Ricky” Flukesc 37 M First floor living room Uninjured

Glenn Gregoryb 47 M Third floor southwest 

bedroom

Uninjured

Walter Harrisb Unk M Second floor west center 

bedroom

Uninjured

Delores Strempeckb 

(a.k.a. Dolores Strembek)

60 F Second floor northeast 

bedroom

Uninjured

a Locations of survivors are where they were when they first became aware of the fire. Victims’ locations correspond to 

where their bodies were found after the fire.

b

These surviving residents were interviewed at the scene by the USFA investigator.

c

The descriptions of these residents’ actions during the fire are based on interviews with other survivors.

According to the owners and day manager of the facility, the capabilities of the survivors interviewed 

after the fire were representative of those in the building at the time of the fire. A preliminary investigation conducted by the State Department of Social Services appeared to confirm this assertion.
USFA-TR-066/June 1992 7

E

Survivors interviewed after the fire indicated that fire drills were not regularly conducted and that to 

their knowledge the facility had no emergency plan.

NFPA 101 and the BOCA National Fire Prevention Code/1990 both require the preparation of an emergency plan and the conduct of periodic fire drills in these occupancies. The requirements of these 

codes, which are outlined in the table on the following page, are quite similar in every respect except 

the frequency of fire exit drills. (NFPA 101 requires twice as many drills [after the first year of operation] as the BOCA National Fire Prevention Code.)

Although both codes specify that emergency plans must be written, neither provides specific guidance 

on how plans should be prepared. Important guidance on implementing these requirements, such as 

the descriptions of criteria used to evaluate the evacuation capabilities of occupants, are left to advisory 

sections and recommended practices. Many code officials and authorities having jurisdiction view such 

advisory provisions as unenforceable. However, codes often require such plans to be approved by the 

authority having jurisdiction so they are enforceable through discretionary judgment.

Lessons learned from this and other multiple-fatality fires suggest that emergency planning and preparedness can have significant impacts on the outcome of fires. However, the implicit assumptions 

underlying code requirements must be well understood for any emergency plan to be truly effective.

Table 2. Emergency Planning and Preparedness Requirements

Requirement BOCA National Fire Prevention Code/1990 NFPA 101, Life Safety Code (1991), Chapter 31

Emergency Plan Written plan required detailing evacuation or 

defend-in-place procedures

Written plan required detailing evacuation or 

defend-in-place procedures

Staff Training Periodic instruction on their duties under the plan 

and special procedures needed to ensure the 

safety of individual residents

Periodic instruction on emergency plan and 

special procedures needed to ensure the safety of 

individual residents

Resident Training All occupants capable of evacuating shall be 

trained; instruction shall include: how to assist one 

another and what to do if primary exit is blocked

All occupants capable of evacuating shall be 

trained; instruction shall include: how to assist one 

another and what to do if primary exit is blocked

Exit Drills Six drills per year; two drills on each shift (12 drills 

required during first year of operation); drills may 

be announced in advance

12 drills per year; four drills on each shift; drills 

may be announced in advance

Smoking No requirements Where permitted, noncombustible safety-type 

ashtrays are required

The development of an emergency plan for a facility requires a thorough analysis of the facility and 

evaluation of the particular circumstances that apply to its occupancy and use. The requirements of 

NFPA 101 for board and care facilities are based on the following assumptions:

•	 That the facility complies in all respects with the fire protection and means of egress requirements of the code;

•	 That the capabilities of the residents and the staff have been evaluated and are reflected in the

application of the code and the development of the emergency plan;
8 U.S. Fire Administration/Technical Report Series

•	 That an adequate number of trained staff are assigned to each shift to implement the emergency plan;

•	 That the emergency plan is reviewed regularly and revised as necessary; and,

•	 That the emergency plan is practiced regularly (not simulated) by residents and staff alike.

In spite of the lack of installed automatic fire protection systems, and without adequate trained staff 

to direct or assist in evacuation, it appears that a well designed evacuation plan and regular fire drills 

could likely have resulted in far fewer casualties. The favorable physical and mental capabilities of 

the occupants, as exhibited by those who did escape successfully and the physical arrangement of 

the facility suggest that the occupants could have likely been trained to react more appropriately to 

fire conditions.

FIRe BUIlDInG

When the State of Michigan assumed control of licensing and regulation of the adult foster care 

facility in 1976, local government enforcement efforts were restrained in accordance with the State’s 

reserved powers doctrine. At the end of 1977, State officials declined to renew the license to operate as an adult foster care facility and sought a court injunction to bar the operators – Nu-Way 

Development Center – from continuing to use the structure as an adult foster care facility. In an 

August 1979 Wayne County (Michigan) Circuit Court decision, Judge Thomas J. Brennan ordered 

the facility closed and permanently enjoined the owners of 88-90 Pingree Street from:

•	 Operating an adult foster care facility;

•	 Interfering with the relocation of residents to other licensed facilities;

•	 Interfering with the notification of residents that the home’s adult foster care license had

been revoked; and,

•	 Transferring any of the residents to unlicensed facilities they operated.6

All indications are that the owners violated this order and continued operating the home at 88-90 

Pingree Street as an unlicensed adult foster care facility. Records furnished by the State Department 

of Social Services confirm that eight of the ten victims who died in this fire had been residents of an 

adult foster care facility operated by the defendants in this court action at the time the permanent 

injunction and judgment were issued.

Table 3. Occupancy Classification

Code or Jurisdiction Classification

BOCA National Building Code, 1990 Edition Use Group 1-1, Board and Care Facility

NFPA 101 – Life Safety Code, 1991 Edition Large Board and Care Facility (Existing)

City of Detroit Fire Code (1977 Edition of the 

NFPA National Fire Codes)

Rooming, Boarding or Lodging House or Hotel, Motel or 

Dormitory

Department of Social Services State of Michigan Adult Foster Care Facility (unlicensed)

6 See State of Michigan v. Nelson, Case No. 78-819711-CZ, Circuit Court for the County of Wayne (MI).
USFA-TR-066/June 1992 9

The building was located at 88-90 Pingree Street in the center of Detroit in a residential neighborhood north of the New Center district. In recent years, this area had been referred to as a “human 

services ghetto” due to the large number of board and care facilities located in the six square blocks 

of Pingree and Blaine Streets between 2nd Avenue on the east and Woodward Avenue – the city’s 

main north-south surface street – on the west. The building was one of four such facilities in this 

area which had been owned or operated by Nu-Way Development Center at one time. Of these, 

only two remained in operation at the time of the fire: the others having suffered previous fires. In 

1989, one of these fires resulted in four deaths. (This facility was operating at the time of this fire.) 

Another fire in 1986, killed three occupants and destroyed that building. (The fourth building operated by Nu-Way Development had been closed for other reasons.)

Construction – The three story structure was of mixed ordinary and wood frame construction when 

originally constructed. Brick exterior load-bearing walls and a brick party wall separating the two 

halves of the structure supported the floors and roof. The party wall stopped at the underside of the 

wood roof deck. Openings, provided with doors, in the party wall on the first floor and third floor 

connected the two halves.

Table 4. Construction Requirements

Actual Building Conditions Required by BOCA National Building 

Code/1990 Use Group I-1

Required by NFPA 101 

Existing Board and Care

5B 5A Type III (211)a

3 Story (33 feet)b 2 Story (35 feet) Not required

1,800 square feet 4,200 square feet Not required

a

 Type III (200), Type IV (2HH), Type V (111), and Type V (000) construction are only permitted when combustible 

construction is sheathed in materials having fire-resistance characteristics equivalent to plaster and lath construction or 

are capable of providing a 15-minute thermal barrier, and the facility is protected throughout by an automatic sprinkler 

system.

b Estimated

The original structure was ordinary construction with brick bearing walls and wood floor and roof 

systems, which could be classified as BOCA Type 3-B (unprotected ordinary) construction. The third 

floor, a finished attic, more closely resembled BOCA Type 5-A (protected wood frame) construction. 

Later renovations had resulted in the removal of much of the original plaster and lath ceiling on the 

first floor, leaving the combustible floor joists unprotected. This lowered the construction classification of the building to Type 5-B (unprotected wood frame). Original interior partitions were of 

plaster on lath construction supported by wood framing. Newer partitions subdividing the original 

spaces were gypsum wallboard on wood framing. In recent years, a metal track suspended ceiling 

system had been installed below the original plaster lath ceilings throughout the first floor creating 

a 22-inch deep concealed space. Most partitions provided good horizontal separation and prevented 

the spread of fire and smoke into rooms with closed doors.

Openings in the party wall and voids in the floor and wall assemblies permitted the fire to spread 

vertically and horizontally after flashover occurred in the kitchen. Combustible structural elements, 

including floor joists and wall studs, exposed when the suspended ceiling in the kitchen and first 
10 U.S. Fire Administration/Technical Report Series

floor rear corridor failed, fueled the fire as it advanced throughout the dwelling. Before firefighters 

brought the fire under control, approximately half of the third floor at the rear of the building and 

the roof had collapsed.

Interior Finish – Combustible interior finish had been installed in the kitchen and rear hallways during earlier renovations, possibly at the time the building was converted to an adult foster care facility. In most cases, the wall finish materials consisted of 1/8-inch plywood paneling. Investigators 

also uncovered 1/2-inch particle board behind the stove in the kitchen. Paneling was also found 

elsewhere in the occupancy, usually where there was evidence of remodeling work to cover cosmetic defects in the original construction. These materials generally have flame spread index ratings 

between 100 and 150, and appeared to contribute to fire growth in the kitchen and fire spread 

elsewhere in the occupancy.

The use of interior finish materials having flame spread index ratings greater than 75 (Class C or 

III) would not be permitted anywhere in an existing board and care facility by the requirements of 

NFPA 101, Life Safety Code. The BOCA National Building Code, 1990 edition, would have permitted Class III 

interior finish materials in enclosed rooms or spaces, like the kitchen, but not in corridors or egress 

stairways. The BOCA National Building Code/1990 is adopted and enforced in Detroit by the Buildings 

and Safety Engineering Department. State requirements for adult foster care occupancies are based 

on the NFPA Life Safety Code.

Table 5. Interior Finish Requirements

Finish Type Actual Building 

Conditions

BOCA National 

Building Code 

Use Group I-1

NFPA 101 Existing 

Board and 

Care Facility

Wall Ceiling Floor Wall Ceiling Floor Wall Ceiling Floor

Exit stairways I I II A or B A or B NR

Corridors II II II A or B A or B NR

Enclosed rooms or spaces III III ND III III DOC FF-1 A or B A or B NR

ND = Not Determined; NR = No Requirement

Smoke Detection – Although unsprinklered, the facility was equipped with multiple-station 110-volt 

AC-powered smoke detectors. One detector was installed on each side of the party wall in the vicinity of the stairway and sleeping areas on the second and third floors. Likewise, a smoke detector was 

installed on the east side of the building on the first floor at the base of the front stairway. Detectors 

were also installed on each side of the party wall in the basement. No evidence of a detector could 

be found in the vicinity of the west side on the first floor at the base of the stairway. A smoke detector would have been required in this location by the BOCA National Building Code, 1990 Edition; BOCA 

National Fire Prevention Code, 1990 edition; and NFPA 74, Standard for Household Fire Warning Equipment.

According to Detroit building and fire officials, smoke detectors were not required in residential 

occupancies, which is how the facility was classified and regulated at the time of the fire. However, 

both the BOCA National Building Code, 1990 edition and the NFPA Life Safety Code, 1991 edition, would 

have required an automatic fire alarm system in this building, in addition to the multiple-station 
USFA-TR-066/June 1992 11

smoke detectors, based on its use as a board and care facility. As a result, additional detectors, as 

well as manual means of initiating a building-wide alarm, should have been provided. The BOCA 

code would also have required off-site monitoring of the fire alarm system to ensure fire department 

notification.

Fire Extinguishers – Portable fire extinguishers were provided throughout the building. Dry chemical 

fire extinguishers were found in the northeast corner of the kitchen, on the second and third floors 

on each side at the stair landing, and on the first floor in the east side corridor in the vicinity of the 

sleeping areas and office. Portable fire extinguishers are not required in this occupancy by current 

BOCA National Codes. However, NFPA 101, Life Safety Code does require portable fire extinguishers in 

the vicinity of hazardous areas. Hazardous areas are those rooms or spaces where the hazard exceeds 

that encountered in a common one- or two-family dwelling. None of the areas in this occupancy 

appeared to meet this definition.

Table 6. Required Fire Protection Features

Features Actual Building Conditions BOCA National Building 

Code Use Group I-1

NFPA 101 Existing Board 

and Care Facility

Automatic Sprinklers Not provided Required for I-1 greater than 

2-stories

Not required

Standpipe Hose System Not provided Required in I-1 of 3 or more 

stories

Not required

Fire Protective Signaling 

System

Not provided System with automatic and 

manual initiation required

System with automatic and 

manual initiation required

Single- or Multiple-station 

Smoke Detectors

In corridors in vicinity of 

each stairway

Required in sleeping rooms Not required

Portable Fire Extinguishers One in corridor in vicinity 

of stairway on 2nd and 3rd 

floor and in kitchen

Not required Not required

Central, Remote, or 

Proprietary Station 

Supervision

Not provided Required for automatic 

sprinkler, standpipe, and fire 

alarm systems

Not required

Mr. Fluckes’s delay in sounding the alarm while attempting to reach an extinguisher and fight the 

fire may have had a critical effect in determining the outcome of this incident, since nearly all of 

the occupants seem to have been motivated to act on his warnings. Without an emergency plan 

to give directions on what to do in the event of fire, the decision whether to attempt to fight the 

fire rested solely in Mr. Fluckes’ hands. Because the use of portable fire extinguishers can produce 

unintended results and may place an untrained user in a dangerous situation, the model codes and 

Federal Occupational Safety and Health Administration (OSHA) regulations contain requirements for 

employee training when fire extinguishers are relied on for incipient stage firefighting.

Means of Egress – Corridors led from all sleeping rooms to the stairways on each floor. The original 

corridor walls were of plaster on lath construction. In later renovations, gypsum wallboard construction was used. All corridor walls were continuous from the floor deck to the underside of the 

floor/ceiling assembly above. This type of construction provided at least minimal resistance to the 
12 U.S. Fire Administration/Technical Report Series

passage of smoke. Sleeping room doors were of wood panel construction without closers. Although 

they provided some smoke and fire-resistance, many were heavily damaged by the fire. Most of these 

doors were equipped with two latching or locking devices requiring separate operation. Although 

such arrangements are now prohibited by model codes, none of the doorways were found locked 

after the fire, and the locking arrangements did not explain the occupants’ delay in evacuating.

A single stairway was provided on each side of the party wall between the second and third floors. 

From the second floor down to the first, two stairways served by a common landing were provided 

on each side of the party wall. These stairways discharged at remote points on the first floor, but 

could not be considered independent or remote means of egress. Stairways adjacent to the rear stairways on each side provided access and egress from the basement. The stairways at the rear on each 

side were enclosed at the first floor, but open on all other floors. The front stairways were unenclosed 

on each floor. Both the front and rear stairways discharged inside at the first floor and were not connected to a fire-resistance rated or protected grade exit passageway. Therefore, neither stairway could 

be considered a continuous protected egress path.

Table 7. Means of Egress Requirements

Feature Actual Building Conditions BOCA National Building Code 

Use Group I-1

NFPA 101 Existing 

Board and Care Facility

Number of Exits Two unsegregated, unenclosed stairwaysTwo independent, remote exits 

from every floor

Two independent, remote exits 

from every floor

Means of Escape Openable window in each 

sleeping room

Openable window in each 

sleeping room

No requirement

Exit Access Corridors Smoke-tight partitions with 

non-rated doors

No requirement 20-minute fire-resistance rated 

separation designed to resist 

passage of smoke

Exit Stairways No enclosure 2-hour fire-resistance rated 

enclosure

1-hour fire-resistance rated 

enclosure

Exit Passageways No grade exit passageway 2-hour fire-resistance rated 

enclosure

1-hour fire-resistance rated 

separation

ReGUlAToRY enVIRonMenT

Four State and local agencies had jurisdiction over this facility at some time during its occupancy. In 

the aftermath of this fire, considerable attention has been focused on the role of each authority and 

the relationship between the overlapping jurisdictions. Although the issue of who was responsible 

for 88-90 Pingree Street remains unresolved, it is clear the facility had “fallen between the cracks” 

of the regulatory system.

Prior to 1975, the City of Detroit was primarily responsible for regulating fire safety at the facility. 

Two city agencies, the Buildings and Safety Engineering Department and the Fire Marshal Division 

of the Detroit Fire Department, were the agencies responsible for enforcing building and fire safety 

regulations in board and care facilities.

In 1974, the Buildings and Safety Engineering Department switched from a locally promulgated 

building code to adoption of the BOCA National Codes (then known as the Basic Codes.) These regulations have been updated periodically since then, and the 1990 edition of the BOCA National Building 
USFA-TR-066/June 1992 13

Code, BOCA National Mechanical Code, BOCA National Plumbing Code, and the BOCA National Property Maintenance 

Code are now in effect. All of these codes contain provisions related to fire safety. However, prior to 

1987, board and care occupancies were not treated separately by these codes and were governed by 

the requirements for multiple-family dwellings.

Unlike many other city building departments, Detroit’s Buildings and Safety Engineering Department 

conducts maintenance inspections to ensure compliance with building regulations. Periodic inspections of the Nu-Way Development Center were conducted by the Department’s Housing and Plumbing 

Division. These inspections were performed to determine compliance with the local housing code 

and to verify that the building was being occupied and maintained in accordance with its established 

legal use. The Buildings and Safety Department strived to inspect these occupancies annually, but 

normally had a considerable backlog due to staffing limitations.

The fire department has adopted and now inspects to the 1977 set of NFPA’s National Fire Codes, which 

include the 1975 edition of NFPA 101, Life Safety Code. The Life Safety Code did not recognize board and 

care facilities as a separate occupancy type until 1981. Until then the provisions for lodging and 

rooming houses or hotels, motels, and dormitories would have applied. Even under these classifications, the building failed to meet minimum fire and life safety standards.

Fire department inspectors reported that their inspections generally focused on “common-sense” 

fire safety practices and were intended to identify and encourage correction of hazardous conditions. 

As such, these inspections concentrated on maintenance of existing fire protection and life safety features and the fire safe occupation and operation of buildings and processes. Violations which would 

have required the installation of fire protection systems or modification of building elements, such 

as exit enclosure, provision of additional means of egress, or fire-resistance of building elements, 

were noted by fire department inspectors and referred to the Buildings and Safety Engineering 

Department for action.

Table 8. Applicable Code and Standards

Agency or Jurisdiction Code or Standard

Detroit Fire Department NFPA National Fire Codes, 1977 editions

City of Detroit Buildings and Safety Engineering 

Department

BOCA National Building Code/1990 

BOCA National Property Maintenance Code/1990

Michigan State Police

Fire Marshal Division

BOCA Basic Fire Prevention Code/1981 edition as amended

State of Michigan

Department of Social Services

Division of Adult Foster Care Licensing

Same as State Fire Marshal (see Act. No. 218, 1979, Section 10 (2) of the 

Michigan Compiled Laws)

At this time, it appears the two State agencies responsible for regulating this occupancy were the 

Department of Social Services and the Department of State Police, Fire Marshal Division.

In 1975, the State of Michigan became one of the first States in the Nation to enact specific regulations for board and care occupancies. Under the classification of adult foster care facilities, the State 

began issuing provisional licenses to exiting board and care facilities in early 1975. As this new 

regulatory program developed, periodic inspections were initiated to ensure compliance with fire 

safety, sanitation, and supervision mandates in the new laws. Fire safety specialists in the Department 
14 U.S. Fire Administration/Technical Report Series

of Social Services conducted many of these inspections. Under 1979 revisions to the laws, all adult 

foster care facilities are required to be inspected and certified in compliance with fire and life safety 

regulations by the Division of State Fire Marshal prior to licensure or renewal.

The State regulations explicitly superseded local authority. Although local jurisdictions could continue to inspect board and care facilities in their communities, they could not enforce their local 

fire and life safety regulations. Consequently, Detroit officials compiled the inspection records for 

all adult foster care facilities they had previously inspected and sent them to the State Department of 

Social Services for follow-up.

The following is a brief outline of the regulatory history of the facility beginning with its conversion 

from a two-family dwelling to a rooming house in 1969:

•	 1969 – City of Detroit issues certificate of use and occupancy for rooming house at 88-90

Pingree Street.

•	 February 1975 – State Department of Social Services (DSS) begins regulating adult foster care

facilities and issues a provisional license to Mid-City Living Quarters which later became 

Nu-Way Development Center; DSS performed regular health and safety inspections during 

this period.

•	 December 1976 – DSS declines to renew Mid-City’s license due to health, safety, and supervision deficiencies noted during inspections, some of which were precipitated by complaints.

•	 July 1978 – DSS receives a preliminary injunction supporting the summary suspension of

Nu-Way Development Center’s adult foster care license; DSS social workers visit the residents 

of 88-90 Pingree Street and offer relocation services; all residents refuse this assistance.

•	 August 1979 – A permanent injunction is issued in Wayne County Circuit Court restraining

Nu-Way Development Center from operating an adult foster care facility; DSS involvement 

with the facility ceases and regulatory authority reverts to the city.

•	 1988 – Last inspection performed by city’s Building and Safety Engineering Department

indicates that the third floor was being occupied in violation of the building’s established 

legal use; the case was referred for legal action, but was never prosecuted.

The Fire Marshal Division of the Detroit Fire Department conducted annual inspections of 88-90 

Pingree Street. In 1988, 1989, and 1990, city fire inspectors noted significant fire and life safety 

deficiencies and referred these violations to the building department with the notation that the facility was probably being operated as an unlicensed adult foster care facility. Like other such violations, 

these were referred to the State Department of Social Services for follow-up action.

Although many or most of the fire safety deficiencies noted in previous inspections had not been 

corrected, a city fire inspector noted no violations when the building was inspected in 1991, the last 

inspection prior to the fire. Although some actions were taken, the issues were not fully resolved.

Different levels of government and different agencies at each level had varying involvements in attempting to bring the building into compliance. Charges of involuntary manslaughter are pending against the 

owner/operator based upon her failure to comply with the 1979 permanent injunction and failure to 

comply with repeated notices of fire safety violations. It is generally considered to be the responsibility 

of the building owner and/or operator to provide and maintain safe conditions for building occupants, 

without regard to the efforts or failures of regulatory agencies to enforce code requirements.
USFA-TR-066/June 1992 15

New Regulatory Programs – In March 1991, in response to situations like Nu-Way Development Center, 

the Department of Social Services was given the authority to relocate occupants of adult foster care 

facilities whose licenses were revoked even if the residents refused these services. This authority did 

not extend to facilities whose licenses lapsed or were voluntarily surrendered.

Since the Pingree Street fire, the City of Detroit has enacted new regulations for adult board and 

care facilities. These amendments to the city building code would require all new and existing adult 

foster care facilities with two or more unrelated incidents to comply with BOCA National Building 

Code/1990 requirements for Use Group I-1 (board and care) occupancies with a few minor amendments. These changes to the local building code must be approved by the State of Michigan before 

they can take effect.

Meanwhile, the State of Michigan has been holding hearings on adult foster care licensing since 

shortly before the fire and is expected to adopt similar, although less stringent, requirements for 

application Statewide.

AnAlYSIS

Building features, such as combustible interior finish, voids in floor and wall assemblies, open stairways contributed to the spread of the fire. Although occupants were exposed to many cues that a significant fire was occurring, many appeared to have misinterpreted or underestimated the significance 

of these indicators. Without an emergency plan and regular fire drills, occupants were not prepared 

to evacuate promptly, which was complicated further by the lack of two independent, remote exits 

from each floor. Therefore, notwithstanding the other fire safety deficiencies found, the lack of an 

emergency plan and the failure to conduct regular fire drills appear to be the primary factors in the 

large loss of life in this fire. The most significant failure may be the failure of the occupants to react 

to the situation and quickly evacuate the building.

To understand how an emergency plan could have produced a more effective occupant response, it 

is important to understand the factors that may have influenced the behavior of the victims of this 

fire.

Individual Characteristics – It was clear that most of the occupants had definite mental and physical 

limitations, including advanced age, which predictably limited their abilities to escape in the event 

of fire. Social workers, who were familiar with the occupants and the occupancy, confirmed that 

most of the occupants had originally been referred by State agencies to this or other facilities owned 

by the same operator. They were referred to this type of facility because of their diminished mental 

capacities caused by mental retardation, manic-depressive illness, schizophrenia, and other dissociative disorders. Interviews with survivors indicated that, while they were capable of understanding 

their environment, they had sufficient difficulty performing basic life skills that they could be anticipated to have difficulty acting in the event of fire. Of the survivors, only one, Mr. Gregory, had no 

history of mental problems and had taken up residence at the Pingree Street board and care facility 

due to other medical problems. None of the victims showed signs of alcohol intoxication at the time 

of death. However, one fire department investigator who interviewed Mr. Fluckes at the fire scene, 

reported that he detected the odor of an alcoholic beverage on Mr. Fluckes’ person.

Group Characteristics – The residents were a relatively stable, permanent population, with no formal 

structure or organization. Although some had lived together longer than others, most had lived 

there long enough to be quite familiar with the other occupants and the building.
16 U.S. Fire Administration/Technical Report Series

One victim, Michael Turner, had moved into the house just four days before the fire. All of the other 

residents had lived there for periods ranging from 3 months to more than 20 years.

Each of the residents was encouraged to take responsibility for his or her own needs and occasionally 

performed tasks for the good of the group, such as setting the table for meals, doing basic household chores, and summoning other residents at mealtimes. No one was assigned permanent duties 

within the group. The caretaker was the only clearly defined leader in the group at any given time.

Caretakers were assigned to three shifts (day, evening, and night) and were responsible for cooking 

meals, assisting residents with basic life skills, seeing that residents took their prescribed medications, overseeing social activities, and maintaining a modicum of discipline and order within the 

group. The caretakers had no formal training or instruction in social services or allied health and 

their shift schedule and difficult working conditions contributed to a relatively high turnover rate. 

As a result, the caretakers may not have been intimately familiar with the histories, skills, and limitations of all of the residents.

Building Characteristics – The building characteristics were described in detail earlier. The features 

which contributed most to the outcome of this fire were the open stairways, combustible interior 

finish, and voids in walls and ceilings. The following building fire safety deficiencies were also noted 

during this investigation:

•	 Structural elements did not meet minimum standards for fire-resistance.

•	 Combustible interior wall finishes with high flame spread ratings were used throughout corridors and common areas.

•	 No automatic sprinkler system.

•	 No standpipe or hose system.

•	 No automatic or manual fire protective signaling system.

•	 No single- or multiple-station smoke detectors in sleeping rooms (smoke detectors were

only provided in corridors on each floor near the stairways).

•	 Inadequate number of exits.

•	 Inadequate exit access corridor width, and

•	 No exit enclosure or protected egress path.

Such a preponderance of building fire safety deficiencies would present serious life safety hazards 

even to well-trained occupants, let alone untrained occupants with mental disabilities.

Fire Characteristics – This early morning fire would have been relatively unspectacular if detected earlier 

and suppressed more effectively while it still involved only a small area in the kitchen. Although it 

probably involved a relatively small amount of fuel initially, it quickly spread to nearby combustibles 

and interior finish materials. None of these fuels is believed to have possessed unusually severe fire 

hazards or toxic potencies.

Given the relative abundance of fuel, the fire only required sufficient oxygen to continue its growth 

and spread. Once the window on the west side of the room of origin broke, fire growth was relatively unrestricted. Windows in many other rooms had been left open for ventilation. As building 

occupants fled, they left interior and exterior doors open. These conditions provided a fresh air sup-
USFA-TR-066/June 1992 17

ply and a route of spread for fire and smoke. All of the survivors interviewed reported encountering 

smoke during their evacuations.

The route of fire spread, after the kitchen reached flashover, primarily followed the paths provided 

by the open doors. However, voids in walls and ceilings also provided avenues for smoke and fire 

to spread.

O

The reported occupant responses are consistent with those observed and reported in similar fires.7

Some type of response is usually initiated when occupants receive cues or warning signals that a fire 

is occurring. When the early cues and warning signals about a fire are ambiguous or unrecognized, 

such as strange noises or odors, the occupant will usually investigate to find their source, like Mr. 

Fluckes and Mr. Gregory did. Once it is determined that a fire is actually occurring, based on less 

ambiguous signs, such as smoke or the fire itself, responses being to diverge. In multiple-family 

occupancies, hotels, and similar residential settings, occupants are likely to take time to dress either 

before or after investigating. Again, all of the victims of this fire except one was reported to have fully 

or partially dressed, as did a number of the survivors. This appears strongly related to the expectation 

that they would encounter other occupants in the process of their subsequent actions.8

 Generally, the 

decision to evacuate a building is arrived at only when an occupant has determined that it is unsafe 

to remain in the building. Apparently, the survivors interpreted the significance of the alerting cues 

differently and more urgently than the victims.

According to Wood (1990), the variables which are most likely to influence the decision to evacuate 

are (in descending order of importance):

•	 Smoke Spread – Occupants are more likely to respond when smoke spread is extensive.

•	 Occupancy – Occupants are more likely to evacuate in a home environment as opposed to a 

work environment.

•	 Previous fire involvement – People who have experienced previous fires are more likely to evacuate than others who have not.

•	 Gender – Women are more likely to evacuate than men.

•	 Age – Younger people are more likely to evacuate than older people.

•	 Training – Untrained people are likely to leave sooner than those who have received some 

firefighting training.

•	 Building familiarity – People completely familiar with a building are more likely to leave than 

those who are unfamiliar with it.

•	 Presence of Any Smoke – People are more likely to leave when smoke is present than in a situation where it is not.9

7 P. G. Wood, “A Survey of Behaviour in Fires,” and D. Canter, “An Overview of Human Behaviour in Fires,” in D. Canter, 

ed., Fires and Human Behavior, 2nd ed., London: David Fulton Publishers, 1990.

8D. Canter, J. Breaux, and J. Sime, “Domestic, Multiple Occupancy, and Hospital Fires,” in Fires and Human Behaviour, 2nd 

ed., 1990, p. 129.
18 U.S. Fire Administration/Technical Report Series

Although some of the victims did attempt to evacuate after having taken other actions first, many 

never made it out of their rooms. By the time many occupants began to clearly perceive the threat, 

apparently they found themselves unable to escape due to the worsening fire and smoke conditions 

in the stairways and corridors. Some of the occupants attempted to seek refuge with other victims or 

reach windows to signal for help, but they were unable to escape before being overcome by smoke.

Studies in the area of board and care fire safety that were conducted by the National Bureau of 

Standards (now known as the National Institute of Standards and Technology) in the 1980s suggest 

that emergency planning and regular fire drills can significantly improve the likelihood that occupants will successfully escape in the event of fire. The work of these investigators was instrumental 

in the development of criteria for evaluating the evacuation capabilities of residents and staff which 

now appear in NFPA 101, Life Safety Code and NFPA 101M, Alternative Approaches to Life Safety.

LE

1. Building and life safety regulations must be strictly followed to ensure adequate egress 

time.

Although smoke detectors were installed in the facility at the time of the fire and were reported 

by one of the tenants to have operated, other significant fire safety deficiencies contributed to 

the rapid growth and spread of a fire which claimed ten lives. Early detection represents only 

part of the equation. Once a fire is detected, means must be provided to evacuate occupants 

promptly via a protected travel path. The open stairways in this facility were quickly compromised by smoke. The lack of a second protected travel path precluded direct egress. Untenable 

conditions preventing their escape would have left occupants little alternative but to jump from 

windows or wait for rescue by the fire department.

Limiting the installation of combustible interior finish, protecting the means of egress, installing 

automatic sprinklers, or a combination of other available fire protection alternatives could likely 

have increased available safe egress time significantly.

2. All board and care facilities should have up-to-date emergency plans.

Emergency plans for board and care occupancies must clearly state the life safety objective to be 

accomplished and detail the appropriate responses to fires considering the following factors:

•	 Building characteristics

•	 Number and training of staff

•	 Number and capabilities of residents

Chapter 5 of NFPA 101M, Alternative Approaches to Life Safety is a good tool for evaluating 

these factors.

It cannot be assumed that all would have been well even if the building had complied in every 

respect with the provisions of current building and fire prevention codes requiring built-in protection. The occupants’ mental and physical capabilities, lack of adequate trained staff, and absence 

9 P. G. Wood, (1990), pp. 85-86.
USFA-TR-066/June 1992 19

of a planned emergency response would likely have presented serious life safety hazards to the 

occupants even if the fire were smaller or other contributing conditions were minimized.

Plans for evacuating board and care facilities are intended to complement the capabilities of residents, staff, and the built-in protection to ensure a balanced and comprehensive fire protection 

and life safety environment. Frequently and unfortunately, however, either none are practiced 

adequately or one aspect is emphasized over the others.

3. Resident and staff training must be conducted to help ensure that all occupants take appropriate actions to escape.

The nature of the physical and mental capabilities of residents is likely to change over time. So 

too are the number, training, and familiarity of staff members. Practice is intended to ensure 

not only that everyone is familiar with the plan but prepared to implement it. If deficiencies are 

noted in practices, such as too few staff members to evacuate the residents needing assistance, 

additional staff or additional built-in protection should be provided. In this case, only one 

staff member was present. By delaying to fight the fire, he substantially delayed the evacuation. 

Despite his best efforts to alert all of the facility’s occupants, he was only successful in encouraging five residents to leave promptly enough to save themselves.

4. Fire code officials should recognize and emphasize the value of emergency planning and 

preparedness measures.

Fire code officials traditionally focus a great deal of attention on the value of installed fire 

protection. Although building occupants are often assumed to exhibit uncontrolled or, at best, 

non-adaptive responses to fire, they frequently do respond appropriately. The fire record is 

replete with case studies of effective human response, indicating that adaptive, altruistic, and 

role motivated responses are the norm.

Fire safety training has been demonstrated to produce more effective responses. Occupants who 

are prepared for a fire, who know what to expect when one occurs, and what to do to protect 

themselves are apt to have a higher expectation of successfully evacuating, and therefore, would 

be more likely to try to evacuate. As described above, both staff training and protection systems 

are recommended, as is this fourth critical element – emergency planning and preparedness.

5. Fire safety inspections and violation notices are legal proceedings which must be pursued 

to their logical, legal conclusion.

The courts have ruled repeatedly that once a fire safety inspection is performed, the inspection 

authority incurs a special obligation to the occupants of that building to pursue every available 

legal remedy to compel compliance with safety standards.

Regardless which agency one holds responsible for the regulation and inspection of the Nu-Way 

Development Center, it is clear by the continued citation of violations by various authorities and 

the continued operation of the facility over a period of nearly 15 years despite those conditions, 

that the available procedural remedies were not diligently pursued. Besides failing to prevent 

this tragedy, their actions have exposed both city and State agencies to unnecessary complications in regard to pending civil litigation.
20 U.S. Fire Administration/Technical Report Series

BIBlIoGRAPHY

Bryan, J. L. “Human Behaviour in the Fire Situation,” Journal of Fire and Flammability, v., (Jan. 1975), 

pp. 17-27.

Building Officials and Code Administrators International, Inc. National Building Code, 11th ed. Country 

Club Hills, Ill.: BOCA International, 1990.

Building Officials and Code Administrators International, Inc. National Fire Prevention Code, 8th ed. 

Country Club Hills, Ill.: BOCA International, 1990.

Canter, D., J. Breaux, and J. Sime. “Domestic, Multiple Occupancy, and Hospital Fires,” in Fires and 

Human Behaviour, 2nd ed. London: David Fulton Publishers, pp. 117-136, 1990.

Canter, D. “An Overview of Human Behaviour in Fires,” in Fires and Human Behaviour, 2nd ed., pp. 205-

229, 1990.

Levin, B. M., N. E. Groner, and R. Paulsen. Affordable Fire Safety in Board and Care Homes: A Regulatory Challenge 

– Interim Report (NIST – GCR-92-611). Gaithersburg, MD: National Institute of Standards and 

Technology, 1992.

NFPA 101, Code for Safety to Life from Fires in Buildings and Structures. Quincy, Mass.: National Fire Protection 

Association, 1991.

NFPA 101M, Alternative Approaches to Life Safety. Quincy, Mass.: National Fire Protection Association, 1992.

Schwartz, J. A., “Human Behaviour in the Beverly Hills Fires,” Fire Journal, pp. 73-74, 108, May 1979.

Wood, P. G. “A Survey of Human Behaviour in Fires,” in Fires and Human Behaviour, 2nd ed., D. Canter, 

ed., pp. 83-95, 1990.
21

APPenDIx A

Floor Plans and Area MapNU-WAY DEVELOPMENT CENTER

88-90 PINGREE STREET, DETROIT, MICHIGAN

FIRST FLOOR

(Drawings are schematic in nature and not to scale.)
22 U.S. Fire Administration/Technical Report Series

Appendix A (continued)

NU-WAY DEVELOPMENT CENTER

88-90 PINGREE STREET, DETROIT, MICHIGAN

SECOND FLOOR

(Drawing is schematic in nature and not to scale.)
USFA-TR-066/June 1992 23

Appendix A (continued)

NU-WAY DEVELOPMENT CENTER

88-90 PINGREE STREET, DETROIT, MICHIGAN

THIRD FLOOR

(Drawing is schematic in nature and not to scale.)
24 U.S. Fire Administration/Technical Report Series

Appendix A (continued)

The above map shows locations of other adult board and care

facilities operated by the owners of Nu Way Developement

Center. Previous fires at two of these houses on Pingree

Street involved residents of 88-90 Pingree Street.
25

APPenDIx B

Detroit Fire Department Investigation Report
26 U.S. Fire Administration/Technical Report Series

Appendix B (continued)
USFA-TR-066/June 1992 27

APPenDIx C

Revised Board and Care Facility Regulations

City of Detroit

NO

ORDINANCE NO. 31-92 

CHAPTER 9 

Article 2 

To Change Requirements for 

Use Group I-1 Facilities

AN ORDINANCE to amend Chapter 8, Article 2 of the 1984 Detroit City Code (The Official Building 

Code of the City of Detroit) by adding Sections 307.2, 813.4.2, 1002.6, and 1021.2 requiring that 

they be for compensation, that they be for two (2) or more individuals unrelated by blood, adoption, marriage or without legal custodial arrangement, and that the include physical limitations and 

a reason for residency; to eliminate the definition of a Use Group I-1 to include such facilities with 

five (5) or less occupants; to provide that Use Group I-1 facilities shall be equipped with approved 

panic hardware; to provide that Use Group I-1 (fire areas with not more than two (2) stories above 

grade and having an occupant load of less than ten (10) shall be exempt from the requirement of an 

automatic fire suppression system with written approval from the Buildings and Safety Engineering 

Department and from the fire department pursuant to rules to be subsequently promulgated and 

adopted; and to provide that a portable fire extinguisher is to be installed on each occupied floor and 

in the basement of Group I-1 facilities.

IT IS HEREBY ORDAINED BY THE PEOPLE OF THE CITY OF DETROIT THAT:

Section 1. Chapter 9, Article 2 of the 1984 Detroit City Code (The Official Building Code of the 

City of Detroit) be amended by amending Sections 307.2, 813.4.2, 1002.6, and 1021.2 to read as 

follows:

Article 3 

Use Group Classification 

Section 307.0 Use Group 1, Institutional Uses

307.2 Use Group I-1: This use group shall include buildings and structures, or parts thereof, which 

house for compensation two (2) or more individuals unrelated by blood, adoption, marriage, or 

without a legal custodial arrangement, and who, because of age, mental disabilities, physical limitations, or other reasons, must live in a supervised environment but who are physically capable of 

responding to an emergency situation without personal assistance. Where accommodating persons 

of the above description, the following types of facilities shall be classified as I-1 facilities; board and 
28 U.S. Fire Administration/Technical Report Series

care facilities, half-way houses, group homes, social rehabilitation facilities, alcohol and drug centers 

and convalescent facilities.

Article 8 

Means of Egress 

Section 813.0 Means of Egress Doorways

813.4.2 Panic Hardware: All doors equipped with latching devices either in buildings of Use Groups 

A and E or portions of buildings used for assembly or educational purposes and serving rooms or 

space with an occupant load greater than one hundred (100), or in facilities of Use Group I-1 shall 

be equipped with approved panic hardware. Acceptable panic hardware shall be a door latching 

assembly incorporating a device which causes the door latch to release and the leaf to open when a 

force of fifteen (15) pounds (73 N) is applied in the direction of egress to a bar or panel, the activating portion of which extends not less than one-half of the width of the door leaf, and is applied at 

a height greater than thirty (30) inches (762 mm) but less than forty-four (44) inches (1118 mm) 

above the floor. The force shall be applied at the lock side of the door or thirty (30) inches (762 

mm) from the hinged side, whichever is farther from the hinge. Where fire door assemblies are 

required to have panic hardware, approved fire exit hardware shall be used. 

Article 10 

Fire Protection Systems 

Section 1002.0 Fire Suppression Systems

1002.6 Use Group I-1: An automatic fire suppression system shall be provided throughout all buildings with a Use Group I-1 fire area.

Exceptions:

1. Use Group I-2 hospitals of Type 1 construction not over five (5) stories and seventy-five (75) 

feet (22860 mm) in height, hospitals of Type 2A construction not over three (3) stories and 

forty-five (45) feet (13716 mm) in height, and hospitals of Type 2B construction not over 1 

story in height.

2. Use Group I-2 nursing homes of Type 1, 2A, or 2B construction not over 1 story in height.

3. In buildings where Use Group I-2 child care facilities are located in the first story above grade 

and which accommodate one hundred (100) children or less with each room having an exit 

directly to the outside.

4. Use Group I-1 fire areas not more than two (2) stories above grade and having an occupant 

load less than ten (10) with the written approval from the Buildings and Safety Engineering 

Department and from the fire department of an adequate alternative evacuation plan pursuant 

to rules to be subsequently promulgated and adopted by these departments.

Section 1021.0 Fire Extinguishers

1021.2 Where required: A portable fire extinguisher shall be installed in the following locations in 

accordance with NFPA 10 listed in Appendix A:

1. In all buildings of Use Group A-1, A-2, A-3, E, I-2, R-1, or H;
USFA-TR-066/June 1992 29

2. In all areas containing commercial kitchen exhaust hood systems;

3. In all areas where fuel is dispensed;

4. In all areas where a flammable or combustible liquid is used in the operation of spraying, coating, or dipping;

5. In all buildings of Use Group I-3 at staff locations; access to portable extinguisher shall be permitted to be locked;

6. On each completed floor of a building under construction, other than buildings of Use Group 

R-3;

7. In any laboratory, shop, or other room used for similar purposes; 

8. Where required by the fire prevention code listed in Appendix A; and,

9. On each occupied floor and in the basement of Use Group I-1 facilities.

Section 2. All ordinances or parts of ordinances in conflict herewith be and the same are herewith 

repealed.

Section 3. This ordinance is declared necessary for the preservation of the public peace, health, 

safety, and welfare of the People of the City of Detroit and shall be effective one hundred and twenty 

(120) days after the date of enactment.

(JCC P. October 7, 1992)

Passed: October 7, 1992

Approved: October 14, 1992

Published: October 25, 1992

Effective: February 11, 1993

JAMES H. BRADLEY

City Clerk
30

APPenDIx D

Fire Scene Photographs

Exterior of 88-90 Pingree Street (structure faces south). Firefighters found fire showing from the first floor 

west and front, with heavy smoke showing from the second and third floors.
USFA-TR-066/June 1992 31

Appendix D (continued)

Point of origin in kitchen showing evidence of low burn near the baseboard.
32 U.S. Fire Administration/Technical Report Series

Appendix D (continued)

Close-up of the point of origin. A small triangular section of the particle board installed over the plaster and lath remains 

in the lower center portion of the picture.
USFA-TR-066/June 1992 33

Appendix D (continued)

View from the kitchen looking south through the pass-through window into the dining room. 

The fire was observed through this window by Mr. Fluckes and Mr. Gregory.
34 U.S. Fire Administration/Technical Report Series

Appendix D (continued)

View looking south down the rear corridor adjacent to the kitchen showing heavy damage to 

the wall studs near the floor level. Also visible through the door opening at the south end of 

the corridor is heavy fire damage in the dining room.
USFA-TR-066/June 1992 35

Appendix D (continued)

Close-up of fire damage to the ceiling area in rear corridor next to kitchen. Pipe penetrations 

were one avenue of fire and smoke spread to the second floor.
36 U.S. Fire Administration/Technical Report Series

Appendix D (continued)

West stairway leading from the first floor living room to the second floor shows extensive 

charring to the stair risers, evidence of intense radiant heat exposure as the fire spread 

vertically cutting off the egress path.
USFA-TR-066/June 1992 37

Appendix D (continued)

Second floor west corridor looking south shows the heavy fire damage resulting 

from vertical fire spread via the front stairway.
38 U.S. Fire Administration/Technical Report Series

Appendix D (continued)

The remains of a melted aluminum fire extinguisher shell in a cabinet on the 

second floor west side.
USFA-TR-066/June 1992 39

Appendix D (continued)

West side rear stairway looking down from second floor. Extensive 

charring and plaster spalling provide evidence of the fire spread which 

cutoff access to both the front and rear stairways.
40 U.S. Fire Administration/Technical Report Series

Appendix D (continued)

View of west side stairway leading to the third floor. Once again, heavy fire damage to the 

door lintel and framing indicate that fire spread via this route was extensive.
USFA-TR-066/June 1992 41

Appendix D (continued)

View of east side front stairway looking down from second floor. Although heat damage is 

slightly less intense here, evidence of extensive heat and smoke spread is clear.