U.S. Fire Administration/Technical Report Series

Indianapolis Athletic 

Club Fire

Indianapolis, Indiana

USFA-TR-063/February 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 Fire Administration 

in carrying out the Fire Reports Program.

The U.S. Fire Administration greatly appreciates the cooperation and information received from officials of the Indianapolis Fire Department, most particularly Fire Chief Keith Smith, Deputy Chiefs 

David Grider and Curtis Gregory, Fire Marshal Timothy Whitaker, District Chief Clyde Pfisterer, and 

Captain Mark Rihm as well as Peter Beering, General Counsel, Department of Public Safety. Others 

who contributed valuable information include David Bills, Indiana Fire Prevention and Building 

Safety Commission; Adam Holman, Indianapolis Department of Metropolitan Development; and 

Mark Clinton, Regional Account Manager, Koorson Protection, Inc.

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 Administration’s Web site at http://

www.usfa.dhs.gov/

National Guard Plane Crash at Hotel Site

Evansville, Indiana

Investigated by: Mark Chubb

 

This is Report 064 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 Federal Emergency 

Management Agency (FEMA), the mission 

of the U.S. Fire Administration (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 BUILDING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Fire Prevention Regulations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Building Location. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Use and Occupancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Mechanical Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Elevators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

FIRE PROTECTION FEATURES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Standpipes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Fire Alarm and Detection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Fire Separation and Compartmentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Interior Finishes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

MEANS OF EGRESS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Confusing and Nonconforming Means of Egress. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

No Stairway Separation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

THE FIRE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Detection of the Fire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Occupant Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Fire Department Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Initial Operations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Initial Attack. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Problems Develop. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Search and Rescue Operations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Rescue of Civilians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

ANALYSIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Origin and Cause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Fire Development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Communications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

AFTER THE FIRE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Review Panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

continued on next page
CRITICAL INCIDENT STRESS DEBRIEFING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

FUNERALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

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

Appendix A: Timeline of Events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Appendix B: Floor Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Appendix C: Additional Information About Fire Protection

Deficiencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Appendix D: Fire Origin and Cause Determination Section fromthe

Athletic Club Fire Review Board Report, Indianapolis Fire

Department. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Appendix E: Lessons Learned or Reinforced Section fromthe Athletic

Club Fire Review Panel Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Appendix F: Photographs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Table of Contents (continued)
1

Indianapolis Athletic Club Fire

Indianapolis, Indiana

February 5, 1992

Local Contacts: Chief Keith Smith

Deputy Chief David Grider

Deputy Chief Curtis Gregory

Fire Marshal Timothy Whitaker

Indianapolis Fire Department

555 North New Jersey Street

Indianapolis, Indiana 46204

(317) 633-6041

Peter Beering, General Counsel

Department of Public Safety

City of Indianapolis

50 North Alabama Street

Indianapolis, Indiana 46204

(317) 327-5090

O

Two Indianapolis firefighters and an elderly male guest died in an early morning fire in the 

Indianapolis Athletic Club. This fire received widespread media coverage since it occurred while the 

building housed the jury hearing testimony in heavyweight boxer Michael G. Tyson’s rape trial. The 

true significance of this incident is not the involvement of the Tyson jury--their presence was merely 

coincidental--but why it turned so tragic.

The fire originated in the third-floor bar due to an electrical malfunction in or near a refrigerator. A 

detailed chronology of the incident and the plan of the floor of origin are presented in Appendices 

A and B. Indianapolis fire communications received a 9-1-1 call at 12:06 a.m., February 5, 1992, 

reporting an odor of smoke in the lobby of the Indianapolis Athletic Club, a nine-story mixed-use 

building. Within two minutes a first alarm assignment of four engine companies, two truck companies, and two chief officers was dispatched to the incident. A little more than a minute and a half 

later, the first company arrived on the scene and reported “nothing showing.” What looked routine 

upon arrival would become tragic less than 20 minutes later when fire erupted from a concealed 

space on the third floor, resulting in a flash fire which claimed the lives of Corporal Ellwood Gelenius 

and Private John Lorenzano, seriously injured two other Indianapolis firefighters, and caused minor 

injuries to two more. The civilian guest was killed when fire and smoke spreading up a stairway 

caught him trying to flee the building. Of the 45-50 people in the building at the time of the fire, a 

number of people had to be rescued from upper floors by firefighters using aerial ladders.
2 U.S. Fire Administration/Technical Report Series

SUMMARY oF KEY ISSUES

Issue Comments

Casualties Two firefighters and one civilian died; four firefighters were seriously injured.

Fire Origin Electrical malfunction in or near a refrigerator in bar on third floor.

Structure Nine-story mixed-use 70-year-old building, no sprinklers.

Interior Finishes Highly combustible interior finish fueled the rapid spread of the fire.

Standpipes Incompatible threads and lack of hose outlets for fire department use on the occupant use 

standpipe hose system hampered fire department attack.

Concealed Spaces Overhead noncombustible concealed spaces allowed products of combustion to accumulate 

above the ceiling. The fire spread rapidly when these gases ignited.

Unenclosed Stairways Unenclosed and unprotected stairways provided an ideal avenue of vertical fire and smoke 

spread, permitting the fire to involve a significant portion of the floor above the fire.

Confusing Exit Confusing exit arrangement and extensive upward smoke 

Arrangement migration via the stairways may have contributed to the loss of one civilian life.

Mechanical System Control Smoke detection was not provided to shut down air handling systems; this contributed to smoke 

transport throughout the building.

Fire Detection and Only partial smoke detection was provided in the building.

Suppression Systems The nearest smoke detector to the room of origin, in the elevator lobby, was not connected to 

the building fire alarm system. Automatic sprinklers were not provided.

Firefighter Access Revolving doors appeared to impede firefighter access and the deployment of a backup 

hoseline.

Fire Department Tactics The lack of Standard Operating Procedures (SOP’s) for buildings with standpipes and/or a 

prefire plan for the specific building may have compromised efforts to control the fire.

Communications One firefighter was seriously burned attempting to activate the 

Equipment emergency notification button on his portable radio.

Communications Systems Problems in communication between the incident commander and the communications center 

may be related to the activation of a new radio system shortly before the incident. Additional 

training should have been conducted.

Personal Alert Safety PASS devices were not issued to firefighters operating at structural

System (PASS) Devices fires and could have helped rescuers locate downed firefighters more efficiently.

The firefighter fatalities were the first line-of-duty deaths in the Indianapolis Fire Department in 23 

years. Following this incident, the department activated its Critical Incident Stress Debriefing (CISD) 

program and convened a formal review panel to investigate every aspect of the incident. Both of 

these actions have had significant impacts on the department as it recovers from this incident. The 

review panel has given the department a constructive outlet for implementing operational changes. 

The CISD program has offered firefighters an opportunity to seek confidential help in coping with 

the loss of their colleagues.
USFA-TR-063/February 1992 3

The analysis of this fire reinforces the lesson that no fire or suspected fire, especially one in a complex 

mixed-use building, can be treated as routine. Firefighters must be trained, equipped, and prepared 

for the worst when working in these types of buildings. This is never truer than when the building 

involved is old, unsprinklered, and occupied by people unfamiliar with the structure.

It also demonstrates the risk factors which can be significantly reduced through the installation of 

automatic sprinklers in existing, non-code-compliant buildings.

THE bUIlDING

The Indianapolis Athletic Club was completed and occupied in 1922. City and State officials indicate that neither jurisdiction had adopted nor enforced a building code at the time of original 

construction.1 

Notwithstanding the lack of a building code, the design and construction of the Athletic Club building appears to have been consistent with generally recognized practices of the 1920s.

Typical building features included fire-resistive construction with open stairways, non-continuous 

egress paths, large air handling shafts without fire or smoke dampers, an unsupervised manual fire 

alarm system, occupant use standpipes without fire department hose outlets, and no automatic 

sprinklers.

The building construction most closely resembles Uniform Building Code Type 1 construction or 

National Fire Protection Association (NFPA) 220 Type 1 (4, 3, 3). Consequently, the fire caused little 

structural damage despite its extensive spread. A concrete protected steel frame supports concrete 

floor decks and nonbearing masonry exterior walls. Interior partitions consist of plaster and lath on 

wood studs. Vertical shaft enclosures, including the elevator, stair, air handling, and plumbing shafts 

and chases are generally of concrete masonry or brick masonry construction.

Fire Prevention Regulations

Fire and building codes adopted subsequent to the building’s original occupancy applied to its 

operation and maintenance. At the time of the fire, the Indiana Building Code and Indiana Fire 

Code were in effect.2 These codes are promulgated by the Indiana Department of Fire Prevention and 

Building Safety and are based on the 1988 editions of the Uniform Building Code and the Uniform Fire Code

published by the International Conference of Building Officials. Both city and State building and fire 

officials had jurisdiction over code enforcement.

Building Location

The building location permitted unobstructed exterior access for firefighting and rescue from three 

sides. The building faces Meridian Street, the principal north-south thoroughfare in downtown 

1 State building regulations were adopted beginning in 1923. City regulations were adopted much later, in the mid to 

late 1960s.

2 In 1984, the State of Indiana consolidated building and fire regulatory authority at the State level and enacted statewide 

minimum building and fire regulations in 1985. Local authorities must enforce the State regulations and may not adopt 

or enforce requirements which conflict with the State requirements. More stringent local requirements may not be 

adopted without the review and approval of the Indiana Fire Prevention and Building Safety Commission.
4 U.S. Fire Administration/Technical Report Series

Indianapolis. The parcel to the south is occupied by a surface parking lot. To the west, across a 

15-foot-wide alley, is an open parking structure attached to the Athletic Club building by a pedestrian walkway at the third floor. Vermont Street borders the building on the north side.

The dimensions of the nine-story building are approximately 100 feet by 200 feet, with the long axis 

running parallel to Vermont Street on the north side of the building.

Grade-level entrances were located on the north (Vermont Street) and east sides (Meridian Street) 

through revolving doors. A shipping and receiving entrance was provided at grade level on the west 

side of the building, accessible from the alley. 

Use and Occupancy

The first through fourth floors of the Athletic Club were occupied by a variety of uses, including the 

hotel and club lobby, offices, meeting rooms, a pool, exercise equipment rooms, locker rooms, a 

barber shop, newsstand, restaurants, dining rooms, and the bar and lounge where the fire occurred. 

Three below-grade floors housed mechanical rooms, workshops, storage, and a laundry. Floors five 

through eight were occupied by guest rooms and suites which were rented through the club. Part 

of the fifth floor also housed small meeting rooms. The ninth floor was occupied by a lounge and 

meeting rooms which provided panoramic views of downtown Indianapolis and environs. The 

elevator machine equipment and controls and building maintenance supplies were located in a 

mechanical penthouse above the ninth floor.

Mechanical Systems

Three separate air-handling systems circulated and conditioned air in the building. None of the 

systems were equipped with smoke detectors or controls to shut the fans down in order to prevent 

recirculation of smoke. The first sign of a fire in the building was the presence of smoke in the lobby 

that had been circulated by the air handling system.

Two air handling systems, located in the basement, were dedicated to the three floors below grade 

and the first through fifth stories, respectively. Each of these systems heated, cooled, and mixed air, 

moving fresh supply air to the floors through a large air shaft near the center of the building. A 

separate shaft was provided for returning air from these floors to the air handling units in the basement. Supply air was ducted to registers throughout these areas, while return air was transported 

to the shaft through a common return air plenum above the original plaster ceiling. The dangerous 

accumulation of fire gases on the third floor is believed to have occurred in this return air plenum as 

well as a secondary void space between the original ceiling and a “dropped” ceiling.

Floors five through nine received air from a shared mechanical unit located between the eighth and 

ninth floors. Individual units were used for heating and cooling in the guest suites. Return air circulated through the corridors.3 The provision of a separate air handling system for the upper floors 

prevented smoke from the fire on the third floor from being recirculated to the guest rooms by the 

air handling system.

3

The use of corridors for return air purposes is now expressly prohibited by several model codes. See Section 803.1 of 

the BOCA National Building Code, 1990 edition, and NFPA 90A-(89), Section 2-3.11.1.
USFA-TR-063/February 1992 5

Elevators

Although the elevator shafts did not contribute significantly to smoke spread, some occupants used 

the elevators rather than stairways to evacuate the building. A single bank of two elevators served all 

floors except the mechanical penthouse. At least one hotel guest reported that he left the building 

via an elevator after becoming aware of the fire.

FIRE PRoTECTIoN FEATURES

Standpipes

The building was not equipped with automatic sprinklers. A standpipe for occupant use (Class II 

according to NFPA 14, Standpipe and Hose Systems) was provided. A single 6-inch riser supplied one 

hose station on each floor from the basement through the fifth floor. Above the fifth floor the water 

supply split into two 4-inch risers to supply hose outlets on each floor. The mechanical penthouse 

had a single hose station supplied from one of the 4-inch standpipe risers.

Each hose station was equipped with 100 feet of 1-1/2-inch single-jacketed linen fire hose and a 

plastic variable stream fog nozzle. Hose outlets consisted of national pipe standard threaded connections, not national standard fire hose thread as specified by NFPA 1963, Screw Threads and Gaskets for Fire 

Hose Connections. As a result, firefighters were unable to connect their hoses directly to the standpipe 

outlets. During their initial attack, firefighters extended the occupant use hoseline with 50 feet of 

their own hose, but the line disconnected when it was charged and they were forced to rely solely 

on the occupant use hose for the initial attack on the fire.

The primary water supply for the standpipe was provided through a 6-inch domestic service line. 

Pressure for the upper floors was boosted by two electric pumps, which were not listed or approved 

for fire protection service. A single fire department connection located at the northeast corner of 

the building provided two 2-1/2-inch hose inlets to supplement the water supply for the standpipe 

risers. The standpipe system appeared to be well maintained and in good condition at the time of 

the fire.

Fire Alarm and Detection

The building had a manual fire alarm system and two separate smoke detection systems covering 

different areas. The only smoke detector on the third floor, where the fire originated, was in the 

elevator lobby and was not connected to the fire alarm system. The elevator lobby smoke detectors 

were single-station devices that were installed solely to activate the elevator recall feature and did not 

start the alarm.4

Fire Separation and Compartmentation

Although the building construction closely resembled Type 1 fire-resistive construction, floor-tofloor and area separation was generally nonexistent. Vertical and horizontal communication between 

areas, including areas with different uses, was common throughout the building. As noted below, 

4

 NFPA 72-(90), Section 3-7.3.3 requires that smoke detectors used to initiate elevator recall also activate the building 

fire alarm signals.
6 U.S. Fire Administration/Technical Report Series

some stairways and vertical shafts were open on one or more floor levels. These conditions contributed to smoke and fire spread beyond the area of origin, especially during fire control efforts.

Interior Finishes

Combustible interior finish materials were installed extensively throughout the third and fourth 

floor areas that were damaged by the fire. Combustible ceiling tiles and plywood paneling installed 

on furring strips contributed to the severe flash fire which occurred during firefighting operations.

At the time of construction, most of the areas involved in the fire had smooth or decorative plaster 

ceilings. Decorative wood and leaded glass fixtures were installed in ceilings in the special function 

areas, including the large dining room. In succeeding years, 1-foot by 1-foot composite ceiling 

tiles were glued to the underside of the plaster ceiling in many areas to hide defects. Sometime 

later, a new suspended track ceiling was installed below the plaster ceiling to hide other defects and 

accommodate new lighting fixtures. The ceiling tile materials used in both of these systems were 

combustible; however, the flame spread ratings could not readily be determined.

Like the ceilings, wall coverings had been successively replaced and modified. In the bar and McHale 

Rooms, 1/8-inch plywood paneling was installed on 1-inch by 3-inch furring strips. In corridors 

and the monumental stair leading from the lobby to the third floor, foil-backed vinyl wall coverings 

had been installed. The plywood paneling was labeled to indicate it had been tested in accordance 

with ASTM E84, Test of Surface Burning Characteristics of Building Materials and had a flame spread index rating of 150. The Uniform Building Code requires that interior finish material covering fire-resistive or 

noncombustible assemblies be attached directly to the assembly.5

 Installing the paneling on furring 

strips instead of directly attaching it to the wall surface could be expected to significantly increase 

the material’s flame spread index rating.

Most floor surfaces were covered with carpeting. Tile or other resilient floor coverings were used in 

service spaces and some high traffic areas including stairs, some corridors, bar backs, and restrooms. 

Floor coverings did not appear to contribute significantly to the fire.

MEANS oF EGRESS

There were 45-50 people in the building at the time of the fire. The toll from this fire could have 

been significantly higher had there been more people in the building or if those occupants who were 

closest to the area of fire origin had not reacted promptly to use the available means of escape to 

leave the building. The body of one male hotel guest who was killed was found in the west service 

stairway between the sixth and seventh floors after the fire was extinguished.

Confusing and Nonconforming Means of Egress

Only one stairway, a service stairway, provided direct, unobstructed access to all floors, including 

the three levels below grade. However, this stairway was not of adequate width to function as an 

approved means of egress and the stair shaft also accommodated mechanical and plumbing services, 

including a laundry or trash chute. Moreover, it did not provide a continuous protected path down 

and out of the building.

5 See Uniform Building Code (1991), Section 4203. Whittier, CA: International Conference of Building Officials.
USFA-TR-063/February 1992 7

Five stairways served the residential floors above the sixth floor. With the exception of the service 

stair, all other stairways serving the guest room floors required occupants to leave the stairways on 

the sixth and third floors to cross over to another stairway, in order to continue downward.

Three stairways served the lower floors. The east stairway carried occupants from the sixth down to 

the third floor. The occupants had to cross over to the center monumental stairway to continue down 

to the lobby (grade) level. The west stairway continued down to the first basement level. No means 

was provided for identifying which stairways provided access to which floors.

No Stairway Separation

All of the stairways below the sixth floor, except the service stair, were unprotected on one or more 

floors. The center monumental stair was open to floors one through three. The east stairway, which 

connected the third through ninth floors, was open on the third and fourth floors. This stairway, the 

operating air handling system, and open mechanical shafts provided the primary means of smoke 

transport to the upper floors of the building. Smoke damage varied from light to extensive on all 

floors above the fire.

Smoke entering the west service stairway was a fatal problem for the civilian victim of this fire. If 

there had been more people in the building, the confusing stairways and lack of proper stairway 

enclosures would probably have caused a major problem.

THE FIRE

Detection of the Fire

Between 11:45 p.m. and 12:00 a.m., building employees became aware of an odor of smoke in the 

lobby. As indicated above, neither smoke detectors nor sprinklers were installed in the area of fire 

origin and therefore, occupants had difficulty identifying the source of the smoke odor. None of the 

smoke detector systems gave the critical alarm.

Occupant Response

Employees began to investigate the smoke odor, but their attempts to locate the fire were unsuccessful, and while they investigated conditions grew worse. Eventually, it became apparent that the 

smoke was coming from the air handling registers. After nearly fifteen minutes of searching, at 

12:06 a.m., the desk clerk notified the fire department via 9-1-1. Meanwhile, the security guard 

notified the security detail sequestering the Tyson jury that the building might be on fire. Bailiffs 

guarding the jury hastily woke the twelve principal and three alternate jurors and escorted them 

from the building, carefully maintaining security during the evacuation. After the fire department 

arrived, it was discovered that one juror had not made it out with the rest. Firefighters successfully 

located and rescued this individual before the flash fire occurred.

Other occupants became aware of the fire by various means. Some reported having heard the fire 

alarm sounding. Others reportedly became aware of the incident upon hearing the commotion 

associated with the fire department’s arrival. Although some of these occupants reportedly fled the 

building, firefighters were forced to rescue several from upper floors using aerial ladders.

Several occupants who successfully evacuated were videotaped by news crews after their escape and 

reported taking inappropriate actions prior to their escape. One occupant said he took the elevator 
8 U.S. Fire Administration/Technical Report Series

from his floor to the lobby, but upon arriving there realized he had forgotten something of value and 

took the elevator back upstairs to return to his room.6 In his subsequent attempt to leave, recalling 

the advice that stairs, not elevators, should be using during a fire, he returned safely to the lobby via 

a stairway.

Most occupants appeared to have dressed and collected some valuables before evacuating. Several 

occupants were rescued by firefighters using aerial ladders. To reach some seventh and eighth floor 

occupants, firefighters were forced to extend the reach of their aerial ladders with ground ladders. 

It should be noted that all reported occupant responses were consistent with those observed and 

reported at other similar incidents.7

Fire Department Response

The Indianapolis Fire Communications Center received a 9-1-1 call reporting the odor of smoke at 

350 North Meridian Street at 12:06 a.m. and dispatched a first alarm assignment consisting of four 

engine companies, two truck companies, a district chief, and the division chief. At 12:10 a.m., Truck 

7 arrived on the scene and took up a position on the Vermont Street (north) side of the building, 

reporting, “on the scene, nothing showing, will investigate.”8

Initial Operations

Arriving with the first companies, Division Chief Charles Williams entered the building with the 

firefighters from Engine and Truck 7 to investigate. Upon entering the lobby, firefighters confirmed 

the presence of a heavy smoke haze. The building fire alarm was reportedly sounding and the fire 

alarm control unit indicated smoke detector activation in the basement laundry room. It is believed 

that smoke from the fire on the third floor activated a smoke detector in the basement, near the air 

handling equipment. Engine 7 and Truck 7 firefighters proceeded downstairs to the second basement level to investigate. 

(No permanent record of the device activation was maintained and the location of the activated initialing device(s) could not be determined during the investigation. Due to the absence of controls 

to shutdown the air handling system, recirculation of smoke could have activated a basement smoke 

detector.)

See Table 1 on the following page for the first alarm company assignments.

The smoke condition suggested that there must be a significant fire somewhere in the occupied 

high-rise building. District Chief Clyde Pfisterer (DC3) established a command post on the Vermont 

Street side of the building and assumed the role of incident commander. Division Chief Williams 

(Car 2) went inside to supervise interior operations. Rescue 13 established a medical sector on the 

Vermont Street side. And Captain Michael Spalding from Truck 7--working inside with his crew, 

attempting to locate the seat of the fire--was designated the Ventilation Sector Officer.

6 It was not determined during the investigation whether or not elevator recall activated. The fire department did not use 

Phase II Firefighters’ Service (elevator control) during their operations.

7 See D. Canter, J. Breaux, and J. Sime. (1990), “Domestic, multiple occupancy, and hospital fires,” in Fires and Human 

Behavior, 2nd ed., D. Canter, ed. London: David Fulton Publishers.

8Athletic Club Review Panel Report, “Synopsis of the Indianapolis Athletic Club Fire,” p. 8.
USFA-TR-063/February 1992 9

Firefighters spent several minutes unsuccessfully searching for a fire in the basement, sub-basement, 

and first floor areas. Additional crews from Engine 13 and Truck 13 joined the crews of Engine 7 

and Truck 7 attempting to locate the source of the smoke. Engine 13 was reportedly equipped with 

a high-rise pack consisting of rolled 1-1/4-inch hose, “hotel adaptor,” spanner wrench, and nozzle. 

The crews from Station 13 went to the second floor to investigate while the Station 7 companies 

continued to search the lower floors.

In a room in the north central portion of the second floor, directly beneath the third floor bar, Truck 

13 firefighters found water dripping from the ceiling. They thought the water might be coming 

from an operating sprinkler on the floor above them and preceded to the third floor to investigate.9 

As they entered the third floor from the monumental stair, a smoke haze hung in the elevator lobby 

and public corridor.

Initial Attack

At approximately 12:17 a.m., more than 30 minutes after building occupants first smelled smoke, 

the fire was located on the third floor. Truck 13 reported “we have a working fire in the dumbwaiter 

on the third floor.” Firefighters from Engine 7, Truck 7, Engine 13, Truck 13, and Division Chief 

Williams were all on the fire floor at this time. Smoke was visible; however, conditions did not 

require firefighters to don the facepieces of their self-contained breathing apparatus (SCBA).

Table 1: First Alarm Company Assignments

Company ID Assignment

Engine 7 

(1st Due Engine)

Investigated, attempting to locate source of smoke. Once fire is located, stretched 

attack line from third floor standpipe and attack fire.

Truck 7 

(1st Due Truck)

Attempted to locate source of smoke. Located fire. During initial attack, ventilated, 

monitored fire progress, checked for extension, and supported attack crew.

Engine 13 

(2nd Engine)

Assisted Engine 7’s crew with attack line.

Truck 13

 (2nd Truck)

Forced entry to bar and assisted Engine 7’s crew with interior attack.

Engine 5 

(3rd Engine)

Connected and stretched backup line from second floor standpipe. Located and 

removed injured Firefighters Comparet and Gates.

Engine 1 (4th Engine) Performed search and rescued missing juror on sixth floor.

Rescue 13 Established medical sector on north side of building. Treated injured firefighters and 

civilians.

DC 3 

(1st Due Chief)

Incident commander. Established command post on north (Vermont Street) side of 

the building.

Car 2

(2nd Due Chief — Shift Commander)

Division chief supervised interior operations until fire was located, then took up an 

exterior position on Meridian Street (east side).

9

They were aware that the building was not fully sprinklered, but surmised that sprinklers could be present in limited areas.
10 U.S. Fire Administration/Technical Report Series

Firefighters mistakenly identified an opening between louvers in the top half of a dutch door as a 

dumbwaiter. A strong upward draft drawing fire past the opening on the opposite side of the door 

resembled a chimney, which suggested to the firefighters that the space was a vertical shaft. In fact, 

the concealed space above the ceiling on the other side of the door was a return air plenum connected to a mechanical shaft, explaining the fire behavior they witnessed.

Fire had become visible on the exterior of the Vermont Street side through the windows of the bar. 

Upon receiving Truck 13’s report of a “fire in the dumbwaiter,” DC3 reported that he attempted to 

summon extra companies. However, Chief Pfisterer recounted that his request was never acknowledged by the fire department communications center. An alarm for another incident was being 

dispatched at the same time and may have interrupted the fireground talk group (channel) while he 

was trying to contact the dispatcher.

Fire department records indicate that a 2nd alarm was requested approximately 21 minutes into the 

incident. One of the 2nd alarm companies (Truck 1) was dispatched to this incident on a special 

alarm three minutes later and the full 2nd alarm assignment was dispatched seven minutes after the 

request, according to the recorded times. However, two of the engines on the 2nd alarm (Engines 4 

and 19) arrived just over a minute after the request was made, which was six minutes before the 2nd 

alarm was actually transmitted. The companies may have been monitoring radio traffic in quarters 

or on-the-air and responded in anticipation of the 2nd alarm.

Meanwhile, interior crews prepared to attack the fire in the bar area behind the location identified as 

a dumbwaiter. Engine 7’s crew attempted to disconnect the occupant use hose from the standpipe 

at the west end of the corridor but were unsuccessful. They decided to stretch the occupant use line 

and an additional 50 feet of 1-3/4-inch hose from their high-rise pack to ensure they had sufficient 

hose to reach the fire.

As the line was extended, Engine 7’s and Truck 13’s crews donned their SCBA facepieces and entered 

the McHale Room. When they reached the door to the bar area, Truck 13 reported that the fire was 

actually in a room (the bar) between the corridor and dining room. Standing-by at the entrance 

from the McHale Room (lounge) west of the bar area, Truck 13’s crew received instructions from 

Chief Williams to wait until Engine 7 had a hoseline in place before opening the door to the room 

of fire origin.

At this time, Chief Williams reportedly left the building to direct exterior operations on the Meridian 

Street side of the building. After this point, DC3’s aide, Lieutenant David Smearage provided communication between the interior crews and the incident commander.

Indianapolis Fire Department operating procedures call for use of the Indianapolis Fire Incident 

Command (IFIC) system at major incidents. Normally, the incident commander would maintain 

contact with interior crews through his aide. When the IFIC is activated, an interior sector and/or 

operations division are usually established, but neither was formally used at this time.

With the fire now located and interior crews preparing to engage the fire, DC3 assigned companies 

to extend a backup line to the fire area. Engine 5 was assigned to stretch a second 1- 3/4-inch line 

from the second floor standpipe to backup Engine 7 on the fire floor. At this time, in addition to 

Engine 7’s and Truck 13’s crews attacking the fire, the firefighters in the area included Truck 7’s captain (assigned to oversee ventilation) and his crew monitoring fire conditions in the elevator lobby 

at the entrance to the McHale Room and at the doors from the bar area to the corridor. Engine 13’s 

crew was backing up Engine 7 on the attack line.
USFA-TR-063/February 1992 11

Problems Develop

When Engine 7 arrived in the McHale Room with a charged hoseline at approximately 12:23 a.m., 

Truck 13’s firefighters forced open the door to the bar area. At approximately the same time, firefighters from Truck 7 forced open the dutch doors on the east corridor side of the bar adjacent the 

large dining room. As the firefighters advanced the attack line on the seat of the fire, the couplings 

connecting the fire department hose to the standpipe hose separated, leaving the crews at the nozzle 

without water. To control the fire while Engine 7 worked to identify the problem and restore water 

supply to their handline, Truck 13’s crew attempted to close the door between the McHale Room and 

the bar area. At this point in the fire, the status of the dutch door on the corridor side could not be 

positively determined, but physical evidence suggested that this door remained open.

When their water supply was interrupted, the crew from Engine 7 quickly retraced the attack line 

out of the McHale Room and discovered that their 1-3/4-inch line had disconnected from the occupant use hose. They decided to abandon their line, reattached the occupant use nozzle, and stretched 

the occupant use line back to the entrance to the bar. At this point, Truck 13 reopened the doors and 

the crews advanced together on the fire with Private Gates at the nozzle.

With the crews inside again advancing on the fire, Lieutenant Smearage broke out a window in the 

large dining room to the east of the bar area. It remains unclear whether the window was broken 

to provide ventilation or to provide access for a backup line. Approximately 2-1/2 minutes later, the 

lieutenant and another firefighter were forced to evacuate the building via this window.

Engine 7 and Truck 13 firefighters quickly gained control of the fire in the bar area using the occupant use hoseline and nozzle. As the fire was nearly extinguished in the bar, two of the Engine 7 

firefighters, Privates Comparet and Gates, were forced to leave when their SCBA low air supply alarms 

began to ring. Private Gates handed over the attack line to the Truck 13 firefighters who continued 

the attack. Within seconds of their departure, the Engine 7 firefighters became aware that a rapid 

and intense flame front was advancing over their heads. Gates later reported that he felt as if he 

himself was about to burst into flames. In the process of evacuating through the McHale Room, 

Comparet and Gates became separated. Gates reported trying to follow the hoseline, but lost track 

of it somewhere beyond the elevator lobby. Disoriented by the deteriorating conditions around him 

and a depleted air supply, Gates located the monumental stair. Attempting to descend it, he stumbled 

and rolled to the second floor landing near the elevator lobby. Comparet successfully retraced the 

hoseline back to the cabinet in the service corridor before collapsing.

While Engine 7’s and Truck 13’s crews fought to control the fire in the bar, Private John Lorenzano 

and Captain Michael Spalding of Truck 7, who were operating behind the attack line crews in the 

McHale Room, became aware that Corporal Ellwood Gelenius of Truck 13 had run low or out of 

air in the third floor elevator lobby and needed assistance leaving the area. They responded to aid 

him. Within seconds of arriving in the elevator lobby, the three men were driven to the floor by a 

blast of flames coming through the doors from the McHale Room. Somewhere in the confusion, 

Captain Spalding and Private Lorenzano became separated. Spalding stayed with Gelenius, who was 

unconscious, and struggled to drag him to safety. Disoriented in the rush of heat and smoke that 

had descended so suddenly, Spalding reportedly attempted to follow the attack line down the monumental stair. When he realized it led past the stair, he turned and headed east down the long corridor 

past the monumental stair without Gelenius, who he was forced to leave at the doors separating the 

service corridor from the lobby. By the time Spalding arrived at the east stairway leading up, he had 

run low on air himself. Realizing that this would lead him nowhere, he turned and continued back 
12 U.S. Fire Administration/Technical Report Series

to the east into the large dining room. Here he turned right, into the Grill Room, and collapsed as 

a section of ceiling dropped on him from above.

During his desperate attempt to rescue Gelenius and find safety himself, Captain Spalding activated 

the emergency button on his portable radio and made several unsuccessful attempts to verbally 

request assistance. To operate his radio controls, he had been forced to remove his glove, severely 

burning his hand in the process.

After becoming separated from Spalding in the elevator lobby, Private Lorenzano apparently followed 

Engine 7’s attack line west down the service corridor. Since the standpipe was located in the corridor 

on the wall opposite the entrance to the stairway, it did not provide a direct path into the exit. Three 

doors on the opposite wall opened off of the corridor in the immediate vicinity of the standpipe 

cabinet. Two of these doors led to stairways. The center door of the three opened into a short service 

corridor which led back into the McHale Room. Investigators believe Private Lorenzano reentered 

the McHale Room through this corridor and headed north towards the windows on the Vermont 

Street side. Before he could reach the outside wall, however, Lorenzano became entangled in furniture, ran out of air, collapsed, and died.

Meanwhile, in the bar area, Truck 13’s crew reportedly became aware that, in their words, “something terrible” was happening behind them and in the corridor while they were knocking down the 

fire in the southeast corner of the room. Outside, Truck 7’s chauffeur, Private Toffolo, positioned his 

aerial ladder at the window broken earlier by Lieutenant Smearage and quickly extricated the lieutenant and another firefighter. With heavy smoke and flame now venting from the eastern most windows of the McHale Room, Toffolo quickly repositioned his aerial to rescue the remaining members 

of Engine 7’s and Truck 13’s crews from the east bar window. In the process of retracting the aerial 

to move to the bar windows, Lieutenant Smearage’s foot became caught between rungs, injuring it. 

This momentarily delayed efforts to reposition the ladder.

When the ladder reached the east bar window where Truck 13’s crew was waiting to be rescued, 

flames became visible from the west bar window. With heavy smoke pouring out over the heads of 

Truck 13’s crew, Lieutenant Smearage and the other firefighter placed a hose stream on the west window flames while the aerial was extended to the east bar window. Truck 13’s crew then abandoned 

their attack line and exited the east window to join them on the aerial ladder. A short time later, fire 

became visible through the east window as well.

Search and Rescue Operations

The plights of Lieutenant Smearage and the attack line crew were apparent to the incident commander and firefighters on the exterior fireground. However, the much more desperate situation of 

the other interior firefighters only became obvious as crews advancing second and third lines on the 

fire stumbled upon their downed comrades.

The magnitude of problems inside became apparent when Engine 5’s crew entered the third floor 

service corridor from the west stair. There they encountered Private Comparet unconscious in front 

of the hose cabinet. As they removed her back down the west stair through the second floor, they 

encountered Private Gate’s unconscious form lying in the corridor west of the monumental stair. 

Gates and Comparet were subsequently transported to area hospitals and treated for burns and smoke 

inhalation. Gates was treated and released; Comparet would remain hospitalized substantially longer 

with respiratory burns. (Both firefighters have subsequently returned to duty.)
USFA-TR-063/February 1992 13

Soon second alarm companies arrived and engaged the search. At approximately 12:52 a.m., Engine 

4’s crew located Corporal Gelenius’s body in the doorway between the elevator lobby and the service 

corridor on the third floor. Attempts began immediately to revive Corporal Gelenius, but he was 

pronounced dead at Methodist Hospital less than one hour later.

When second alarm companies arrived, Engine 11 stretched a 1-3/4-inch attack line (3rd line) up 

Truck 13’s aerial ladder from the Meridian Street (east) side. After firefighters pushed their way 

westward through the large dining room and gained control of the fire in the large dining room 

and east end of the corridor, they fanned out and located the body of Captain Spalding under a mass 

of ceiling debris just south of the corridor entrance. This occurred some 20 minutes after Engine 

11’s crew began their attack on the third floor, about seven minutes after Engine 4’s crew located 

Corporate Gelenius, and approximately 23 minutes after the flash fire forced Captain Spalding to 

begin his unsuccessful escape attempt. Captain Spalding was transported to the ground over Truck 

13’s tower bucket and removed to the hospital for treatment of smoke inhalation and critical second 

and third degree burns. (Captain Spalding remained off-duty for more than three months undergoing rehabilitative therapy to restore full use of the hand he burned operating his portable radio.)

Without a portable radio or PASS device, Private Lorenzano was unable to alert anyone of his predicament. Once the fire was reported under control, all interior crews had pulled out of the fire area, 

and rescue teams had evacuated all of the injured except Private Lorenzano, the incident commander 

ordered a roll call. When it became apparent that a member was unaccounted for, a systematic search 

of the building was ordered by then Acting Chief Keith Smith, who had assumed the role of incident 

commander. The search commenced at 2:08 a.m., and Private Lorenzano’s body was located a little 

more than 10 minutes later. He was examined and pronounced dead at the scene.

Rescue of Civilians

Efforts to rescue guests of the hotel trapped on upper floors started immediately after the fire was 

located on the third floor. With several of the occupants trapped on the eighth floor, high above the 

fire, attention focused on keeping people calm and preventing the vertical spread of the fire, while 

positioning aerials to bring those who could be reached to safety.

Upon their arrival, firefighters had been advised that one juror could not be accounted for and 

Engine 1’s crew was sent to the sixth floor to retrieve him. On their way up, the crew used the 

east stairway, which started on the third floor. By the time they retrieved the stranded juror and 

began their descent, the firefighters reported to the incident commander that the smoke had 

become dense and much hotter, and they discouraged any further attempts to use that route to 

access upper floors, fearing the fire had begun to spread via this avenue. This belief proved well 

founded when, after the fire, evidence demonstrated convincingly that the fire’s vertical spread had 

been most severe in this area.

Other stairs had become heavily charged with fire as well. The sole civilian victim--Thomas R. Mutz, 

a 71-year-old hotel guest from Willmette, Illinois--was found in the west service stairway between 

the sixth and seventh floors during a secondary search of the building 2-1/2 hours after the firefighters arrived on the scene. His actions prior to his death are unknown, but it is believed he was 

in the process of evacuating the building when he suddenly encountered heavy smoke conditions in 

the stairway. This stairway had been used by firefighters from Engine 5 when they reentered the third 

floor with a backup line to fight the fire after the flash fire in the McHale Room and the corridor.
14 U.S. Fire Administration/Technical Report Series

ANAlYSIS

After the fire, a great deal of attention focused on the coincidence that the fire occurred while the jury 

hearing testimony in the highly publicized and controversial Mike Tyson rape trial was sequestered in 

the building. Every effort was made to thoroughly and carefully examine the origin and cause of the 

fire to determine if it had been maliciously set. To ensure that these matters received thoughtful and 

thorough consideration, the results of the fire origin and cause investigation were reviewed by the 

Marion County Grand Jury, while the review and analysis of the fire and fire department operations 

were referred to a specially convened review panel.

Origin and Cause

Postfire investigation determined that the fire was caused by an electrical malfunction in or near 

a refrigerator in the third floor bar. Evidence at the scene was examined independently by fire 

origin and cause investigators from the Indianapolis Fire and Police Departments, Marion County 

Prosecutor’s Office, Federal Bureau of Alcohol, Tobacco and Firearms (ATF), and the insurance company underwriting the premises. All of the investigators concurred with the finding that the cause 

of the fire was accidental.

Because of the coincidence of a fire occurring in the hotel while the Tyson jury was sequestered there 

and rampant speculation that the fire may have been incendiary, evidence from the official investigation was presented to the Marion County Grand Jury by the prosecutor’s office. They too concurred 

with the findings and declared publicly that the fire was not related in any way to an attempt to 

disrupt or influence the outcome of the Tyson trial.

Fire Development

Once the origin and cause of the fire were established and agreed upon, efforts focused on determining how and why fire conditions deteriorated so quickly and unexpectedly. These conditions and 

the subsequent confusion and disorientation they produced led to the deaths of two firefighters, one 

civilian, and four serious injuries to firefighters.

Many accounts of this fire have suggested that at least one and as many as three separate flashovers 

occurred during this incident. While this is certainly true of the bar room where the fire originated, 

a more complex, destructive, and unpredictable condition produced the rapid growth and spread of 

the fire into the McHale Room, corridor, and large dining room.

Flashover is a common occurrence in most compartment fires. The commonly accepted definitions 

of flashover describe the phenomenon as the point at which all available combustible material in a 

compartment simultaneously reaches its autoignition temperature. It is also described as the transition point between the fire’s oxygen-regulated and fuel-regulated phases.

Evidence examined at the scene suggests that the events which led to the firefighter and civilian 

deaths and injuries do not fit the accepted definitions of flashover. The only room in which evidence 

strongly suggests that flashover occurred was the room of fire origin. (Low burning also occurred 

in the McHale Room; however, the extent of flame damage did not appear sufficiently uniform to 

suggest that this room had reached flashover as well.) It is unclear whether the flashover occurred 

in the bar before or after the arrival of the fire department.
USFA-TR-063/February 1992 15

In this fire, extensive low burning indicative of a post-flashover fire was observed in the immediate vicinity of the bar and the opening between it and the McHale Room. In fact, much of the 

available fuel in the McHale Room at or below tabletop level remained unburned. Those fuels 

which were significantly consumed appeared to be relatively lightweight, with very high flame 

spread index ratings, and high surface to mass ratios. These materials consisted mainly of interior 

wall and ceiling finishes.

Given these conditions, a more apt description of the fire development which occurred in the 

McHale Room and the east corridor appears to be that of a flash fire with accompanying rollover or 

flameover.

The rapid and unexpected development of these conditions may have been the result of four coincident factors:

•	 The deep concealed space above the suspended ceiling;

•	 The failure of fire streams during the initial attack;

•	 The failure to contain the fire within the bar area while waiting for fire suppression to

resume; and

•	 The uncontrolled low level ventilation of the fire area which resulted when windows in the

bar and large dining room were broken.

With the introduction of a fresh air supply from the broken windows in the bar and large dining 

room and access to unburned fuel in the corridor when the dutch doors were left open, the fire 

spread to the east corridor near the entrance to the large dining room. Fresh air entering the bar 

area, coupled with resumed firefighting efforts, permitted air to mix with the unburned combustion 

products trapped in the overhead combustible concealed space.

The introduction of fresh air from below precipitated the ignition and rapid expansion of the trapped 

hot gas layer. Openings in the ceiling would have provided an avenue for the expanding superheated 

gases to escape and ignite combustible wall and ceiling finishes.

Cooler smoke and fire gases below the lower suspended ceiling very likely obscured flameover and 

exacerbated conditions when they themselves were ignited. Firefighters unaware that the fire was 

extending over their heads in the combustible concealed space were caught off-guard when fire 

erupted in the McHale Room and spread into the corridor.

The development of a flash fire in the McHale Room produced a very hot, very rapid flame front 

which spread across the combustible interior finishes in that room and the corridor. The availability of more fresh air drawn up through the monumental stair allowed the fire to spread from the 

McHale Room into the elevator lobby and then pushed it toward the large dining room where fire 

was already spreading through the open dutch doors. The unenclosed east stairway then provided 

an ideal avenue for vertical fire spread, as evidenced by extensive fire damage on the fourth floor and 

heavy smoke and heat damage on several floors above. These conditions left the firefighters with a 

much larger, dangerous, and more difficult fire to control than they had originally confronted when 

they arrived on the third floor.
16 U.S. Fire Administration/Technical Report Series

Communications

Notwithstanding delays in identifying the need for additional companies, the acknowledgement and 

processing of the request for a second alarm was significant delayed. Some officials indicated that 

they felt the transition to a new 800 MHz trunked radio system only two weeks before this incident 

and lack of familiarity and confidence in the system played a part in these difficulties. 

The incident commander indicated in interviews that his initial request for extra companies was interrupted by a dispatch for another incident. He also reported that another incident had been assigned to 

the same talk group (channel). This could happen easily due to a human or system error.

The seven minute delay processing the second alarm request after it was received, may have been 

caused by a lack of familiarity with new computer-aided dispatch equipment or procedures as well.

The prompt response of two of the second alarm engine companies (Engines 4 and 19) may have 

been the result of these companies monitoring the radio traffic and responding in anticipation of the 

second alarm. This may be an example of how an old habit overcame a modern problem.

AFTER THE FIRE

Indianapolis fire officials began their efforts to recover from this devastating incident immediately. 

When it was determined to have been accidental, efforts quickly focused on reconstructing the 

events which led to the tragic loss of two firefighters and one civilian, and the injuries to four other 

fire department personnel and eight civilians.

Review Panel

Determined that the department learn from this incident, a review panel consisting of nine members 

of the Indianapolis Fire Department was convened. Atlanta Fire Chief David M. Chamberlin, Sr., 

was retained to facilitate the review panel inquiry. Review panel members were selected from each 

operating unit of the fire department to bring their particular areas of expertise to the deliberations. 

The review panel met for the first time on February 11, six days after the fire. In total, more than 

140 hours of deliberations, research, and investigation were conducted by the panel before issuing 

its recommendations. A summary of the panel’s list of “Lessons Learned or Reinforced” is provided 

in Appendix E.

Panel members used a process which began with a member or members identifying and framing a 

particular concern or issue within their scope of expertise. This issue was reinforced with historical 

background on the origin and development of the tactic or operating procedure involved. Finally, 

the committee’s recommendations for resolving the issue were presented. In all, 57 issues were 

identified and considered by the panel. At the conclusion of its deliberations, the panel issued a 

90-page report detailing these recommendations and summary of lessons learned.

One of the best ways to evaluate the outcome of an especially tragic incident is to consider its impact 

on future events. The review panel report and recommendations have been taken seriously and 

changes are being implemented to improve the operations of the department. The following is a 

brief summary of some changes already implemented in Indianapolis:
USFA-TR-063/February 1992 17

•	 Purchase and issue of fire-resistant protective hoods for all firefighters;

•	 Purchase and issue of PASS devices for each position on a company;

•	 Reorganization of the Fire Prevention Bureau under the new title of “Technical Services

Division” to reflect its support role (the duties of this new organization are still being 

defined); and

•	 Implementation of a general order requiring the use of the IFIC system at all incidents.

CRITICAl INCIDENT STRESS DEbRIEFING

Like many other emergency service organizations, Indianapolis fire officials had become concerned 

about the potentially debilitating effects of job-related stress before this tragic incident. Consequently, 

steps had been taken to organize and implement a CISD program in the department. Coping with 

the aftermath of the Indianapolis Athletic Club incident would be its first major test.

The command officers initially responsible for organizing and implementing the CISD program, 

Deputy Chief David Grider and Fire Marshal Timothy Whitaker, experienced the magnitude of the 

incident firsthand while operating on the fireground and activated the CISD program immediately 

after the incident was brought under control. Before the change of shifts the next morning, every 

firefighter assigned to the incident, approximately 70 in all, had received an initial debriefing at his 

or her fire station. Over the next several days and weeks, through the funerals, hospital visits, and 

subsequent duty shifts, members would receive continual reinforcement of the CISD message:

•	 Experiencing stress after a traumatic incident is natural...,

•	 Experiencing stress reactions means your mind and body are going through emotional

healing...,

•	 You can cope!

The value of the CISD program was evident in the immediate aftermath of the incident. Firefighters 

at Station 7 were observed practicing the coping strategies recommended in the program, such as 

discussing the incident and participating in physical exercise.

FUNERAlS

The deaths of Corporal Gelenius and Private Lorenzano were the first line-of-duty deaths in the 

Indianapolis Fire Department in 23 years. Such a long interval between tragedies had been fortunate, 

but as a result no plans or procedures were inplace for managing the notification of next-of-kin, 

assisting the families, planning the funerals, or providing for the flood of firefighters from across the 

Nation who would come to pay their respects to their fallen comrades.

The dedicated men and women of the Indianapolis Fire Department and their extended fire service 

family came together and helped the victims’ families and themselves through this trying and difficult period.

Two separate processions and funerals were held, highlighting the distinctive contributions each 

firefighter had made to his family, department, and community. In all, more than 1,000 firefighters 

from as far away as Texas and Maine were said to have been in attendance. Following the funeral 

ceremonies and interment, a formal wake was held at the downtown convention center.
18 U.S. Fire Administration/Technical Report Series

L

The Indianapolis Athletic Club fire demonstrates the value of retrospective code enforcement, and 

planning and preparing for those fires which cannot be prevented. Once the fire started, many 

conditions conspired to cause the deaths of two firefighters and one civilian, and the injuries to four 

firefighters and eight civilians. Considering the building conditions prior to the fire and the command, control, and communication problems which developed during fireground operations, the 

loss of life could easily have been substantially higher.

1. Fire departments have a vested interest in code enforcement.

Fire prevention regulations are generally viewed in the context of how they affect the public-

-both positively and negatively. The duty of the State to use its police powers to preserve the 

health, safety, and welfare of the public is often cited when justifying the adoption of fire 

codes. When opposing fire codes, the debate usually focuses on the economic costs of private 

fire protection features and the development options that are precluded by such investments. 

Firefighter safety rarely figures in the discussions.

The Indianapolis Athletic Club, like the One Meridian Plaza fire in Philadelphia, clearly demonstrates the need to consider the costs of failing to provide private protection for public servants--

our Nation’s firefighters. Most of the fire safety deficiencies at the Indianapolis Athletic Club had 

gone undetected and Indiana building and fire safety regulations make only limited provisions 

for retrospective enforcement. Without such code authority, deficiencies in unenclosed exits, 

nonconforming exit discharge, inadequate standpipe system, combustible interior finish, and 

mechanical system controls which permitted the system to recirculate smoke may never have 

been successful abated. 

2. An incident command system (ICS) should be routinely used by every fire department.

An ICS is absolutely necessary for ensuring effective command, control, and communication, 

especially at fires such as this. It is often said that practice makes perfect. ICS should not be 

reserved only for the big incidents. Every member of the department should be familiar with 

the operation of the ICS, and every officer should be skilled in its application. The Indianapolis 

Fire Department had adopted an ICS, and all officers had been trained in its use. However, the 

IFIC was not routinely used at fire and emergency incidents. It was reserved for “major” incidents and implemented at the discretion of the officer in charge.

The interior situation was complex and changing rapidly and the lack of a strong component of 

the ICS to direct interior operations was a serious handicap.

3. Firefighter accountability must be one of the principal functions of an ICS.

One of the key reasons for adopting and using an ICS is to aid in maintaining firefighter accountability during emergency operations. The ICS is designed to limit each officer’s span of control 

while maintaining unity of command. Company integrity should be maintained while carrying 

out task assignments during firefighting operations to ensure that each member is accounted 

for at all times. The lack of a cohesive and effective ICS may impact firefighter safety as well as 

company performance.

During the incident, several firefighters became separated and lost. An ICS cannot provide an 

absolute assurance that firefighters will not become separated in the adverse, dangerous, and 
USFA-TR-063/February 1992 19

confusing environment of interior fire attack, but effective incident command will ensure a 

more effective and timely response if assistance is urgently needed. Privates Comparet and 

Gates were located only by chance. Had Engine 5’s crew not literally tripped over their fallen 

comrades, the incident commander may have learned of their predicament too late. Similarly, 

Corporal Gelenius was located by a crew returning to the fire floor with an attack line to complete a task that had been interrupted by the flash fire.

Captain Spalding’s rescue was accomplished with considerable delay. The firefighters who eventually located Captain Spalding, the only injured firefighter whose predicament had been communicated before he collapsed, found him only after they had completed their primary task of 

attacking and controlling the fire on the eastern front. Private Lorenzano was located solely as 

the result of an organized search and rescue effort.

4. Communications equipment and systems need to be redesigned for firefighting service--

especially the radio.

Captain Spalding’s most serious injuries were a direct result of having to compromise his personal safety in order to send a distress signal. The 800 MHz trunked portable radios issued to 

fire company officers in Indianapolis incorporate a distress signal button. While the push-totalk switches could be operated with minor difficulty with a gloved hand, the emergency or 

distress button is virtually impossible to operate in the same manner. These expensive radios 

must usually be concealed in pockets or under turnout clothing to protect them from the harmful environment and abuse of interior firefighting operations. These factors detract from the 

laudable purpose of the distress signal feature.

Research and development should be undertaken to redesign portable radios especially for 

firefighting service. Particular attention should be paid to the emergency or distress signaling features. One possible modification would include an interface between PASS devices and 

portable radios so that distress signals could be transmitted locally via the PASS horn and to the 

communications center and incident commander through the portable radio. Modern trunked 

radio systems would permit this signal to be accompanied by a discrete unit identifier indicating 

which firefighter and company was assigned the radio. Under an effective ICS, this information 

can be used to quickly identify the downed firefighter’s assignment and location to aid rescuers. 

Fire department procurement specifications should highlight the need for such communication 

equipment features.

5. Dangerous and complex buildings such as multiple mixed uses, highrises, and places of 

assembly demand an immediate commitment of additional personnel and resources.

Complex mixed uses like the Indianapolis Athletic Club are among the most challenging environments in which firefighters must operate. With a hotel occupancy above a restaurant, offices, 

meeting rooms, and athletic facilities, it is often impractical or infeasible to evacuate all occupants before attacking a fire. Protecting occupants in-place and suppressing the fire must often 

be simultaneous objectives.

Adding to this complexity, open stairways at the Indianapolis Athletic Club forced firefighters 

to commit to an interior fire attack and exterior rescue operations. The inadequate standpipe 

and restricted access at grade level made stretching backup lines difficult and time consuming. 

Appreciable quantities of smoke pouring from the ventilation system, the extreme danger of 
20 U.S. Fire Administration/Technical Report Series

uncontrolled vertical fire spread, and the presence of guests on upper floors were all ominous 

indicators that additional companies were needed from the outset of the incident.

Although the incident commander reportedly requested extra companies as soon as the fire was 

located and confirmed on the third floor, a significant delay occurred in dispatching additional 

companies. According to fire department records, a second alarm was dispatched approximately 28 minutes after companies arrived on the scene. By this time, the flash fire had already 

occurred in the McHale Room and corridor on the third floor.

6. Communications systems, radio operators, and command personnel must be thoroughly 

familiar with equipment and procedures.

New radio equipment and lack of familiarity with its operation may have contributed to delays 

in acknowledging and processing request for additional companies. If so, these problems illustrate the need for thorough training before, during, and after the transition to new radio equipment and procedures. Many departments have found it useful or even necessary to maintain 

components of their old systems as backups during the early phases of such transitions.

7. Prefire plans should be prepared for all highrise buildings and other target hazards.

The incident commander and company officers had little knowledge of building features or 

conditions prior to their arrival and there was no prefire plan for the building. These factors 

placed the incident commander at a disadvantage from the start. Detailed knowledge of the 

unenclosed exit stairways, the large overhead concealed space, the lack of mechanical system 

controls to prevent recirculation of smoke, the highly combustible interior finish, and lack of 

automatic sprinklers would have been a major advantage for the incident commander.

The initial incident command strategy focused on locating the fire. All of the companies inside 

were actively engaged in efforts to locate a fire, and once the fire was located, a containment strategy was forced on the incident commander by the prospect that the fire already involved a vertical 

shaft. (The first report was that the fire was in a dumbwaiter.) The immediate priority of attacking 

the fire was compromised by the problems encountered with the standpipe system.

8. All departments should purchase and issue PASS devices, and all fireground personnel 

should be required to use them.

Identifying and locating distressed firefighters quickly is imperative. Three of the injured firefighters were found only by chance during firefighting operations. The two firefighters who 

died were both victims of smoke inhalation, even though they wore and used SCBA. Both 

firefighters apparently inhaled smoke and toxic gases after depleting their SCBA air supplies. 

Their companions had no way to know they were still in trouble or to find them before they 

succumbed.

PASS devices operate manually or automatically to achieve a distinctive distress signal when a 

firefighter becomes trapped, disoriented, or stops moving. Once activated, PASS devices help 

warn others that an emergency is occurring and help rescuers locate the victim.

9. Every fire department should adopt procedures for conducting investigations of serious firefighter injuries and line-of-duty deaths and developing critiques of significant incidents.

Despite the lack of a documented procedure for conducting a formal inquiry, the Indianapolis 

Fire Department assembled a review panel and proceeded to conduct a comprehensive and 
USFA-TR-063/February 1992 21

thorough review of the incident. As a result, changes are already being implemented to prevent 

future tragedies. More changes will certainly follow.

The official review avoided the pitfall of seeking to assign fault or responsibility and focused on 

the more important objective of learning from the experience. Indianapolis firefighters have 

embraced the purpose and intent of the inquiry with little hesitation, viewing it not as a head 

hunt, but as means of preventing future tragedies. The review panel inquiry seems to have produced a sense that the department will overcome the tragic loss of two of its members by building a lasting legacy of improved firefighter safety and fire department efficiency as a memorial 

to their fallen comrades.
22

APPENDIx A

Timeline of Events

Note: Events described in italics could not be fixed in time accurately from radio transmissions. 

Bold type identifies communications center alarm traffic.

Actual Time Elapsed Time Event/Activity

11:45 p.m. to 

12:00 a.m.

-- Employees smell smoke in the lobby and begin investigating. Smoke is observed 

coming from air registers, and desk clerk warns bailiffs guarding Tyson jury.

12:06 a.m. -- Fire department communications receives 9-1-1 call for odor of smoke in the building, 

350 North Meridian Street, Indianapolis Athletic Club.

12:08 a.m. -- First Alarm: Engines 13, 7, 5, and 1, Trucks 13 and 7, Rescue 13, District Chief (DC) 

3, Car 2 (Division Chief) dispatched.

12:10 a.m. 00:00 Engine 7 arrives on the scene, “nothing showing, will investigate.”

12:11 a.m. 01:14 Engine 7’s lieutenant reports heavy smoke in the lobby. DC3 (incident commander) 

orders Engine 13 to bring their high-rise pack to the lobby to backup Engine 7. Crews 

from Engine 7 and Truck 7 begin searching for the fire in the basement and on the 

second floor.

12:12 a.m. 02:08 Incident commander (DC3) places Captain Spalding (Truck 7) in charge of the ventilation sector. Captain Spalding reports he is in the basement and cannot locate the 

source of the smoke.

12:12 a.m. 02:51 Truck 13 firefighters find water dripping from the ceiling in the second floor changing 

room (directly under the fire area). Unaware that the building is unsprinklered and 

believing that the water may be coming from an activated sprinkler, they proceed to 

the third floor to investigate further.

12:17 a.m. 07:05 Firefighters locate the fire on the third floor. Approaching the fire from the east end 

of the corridor, they see flame peering through the crack between the two halves 

of a dutch door and report they have a “working fire in the dumbwaiter on the third 

floor.” Engine 7’s crew proceeds to the hose cabinet at the west end of the floor in 

the service corridor beyond the elevator lobby. Engine 13 is ordered by the incident 

commander to backup Engine 7’s crew on the attack line.

12:18 a.m. 08:51 Truck 7’s chauffeur (Private Toffolo) positions his aerial outside on the Vermont 

Street side and advises the incident commander (DC3) that he sees fire through the 

windows in the bar area.

12:19 a.m. 09:50 Incident Commander (DC3) orders Engine 5 to take a line into the building to backup 

the attack crew on the third floor. Engine 5 stretches a preconnected 1- 3/4-inch line 

into the building from the Vermont Street side and takes a 50-foot section of rolled 

hose with them.
USFA-TR-063/February 1992 23

Appendix A (continued)

Actual Time Elapsed Time Event/Activity

12:20 a.m. 10:07 Truck 13 reports that the fire is actually in a bar off of a dining or meeting room 

(McHale Room), and that the “whole room is engulfed.” An additional 50 feet of 

1-3/4-inch hose has been added to the 100 feet of occupant use hose pulled from the 

hose station in the service corridor, and firefighters in the McHale Room are waiting 

for water before attacking the fire in the bar.

12:21 a.m. 11:08 A bailiff advises that a juror staying in Room 657 is unaccounted for. Incident commander (DC3) assigns Engine 1’s crew (already en route to the third floor for search 

and rescue) to proceed to the sixth floor.

12:23 a.m. 13:13 Lieutenant Smearage (DC3A), the incident commander’s aide, reports from the third 

floor that there is a “working room fire” on the third floor and a window will need to be 

broken to bring a line in over an aerial ladder (presumably Truck 7). Meanwhile, the 

attack line is charged and the doors from the McHale Room into the bar and the dutch 

doors on the corridor side are forced open. The attack line is advanced into the bar 

area. Within a few seconds, the couplings between the hoseline and the firefighters’

1-3/4-inch line separate and water is lost at the nozzle. The companies retreat from 

the bar area and the crew from Truck 13 attempts to re-close the doors leading into 

the bar from the McHale Room to contain the fire. The dutch doors on the corridor 

side remain open.

12:25 a.m. 15:06 Lieutenant Smearage breaks a window in the large dining room on the Vermont Street 

side, just east of the windows to the bar area. Meanwhile, Engine 5’s crew is connecting a line to the standpipe hose outlet on the second floor.

12:26 a.m. 16:23 Engine 5 begins advancing their line up the west stairway to the third floor.

12:27 a.m. 17:06 Lieutenant Smearage reports to the incident commander (DC3) that heavy smoke 

is entering the large dining room from the corridor and he believes the fire is about 

to break in behind them. (This appears to be about the time that Engine 1’s crew 

descends the east stairway with the lost juror.)

12:27 a.m. 17:41 Fire enters the large dining room from the corridor cutting off Lieutenant Smearage 

and another firefighter. Lieutenant Smearage requests assistance from Truck 7 and 

the two firefighters are rescued from the window. At about the same time, Privates 

Gates and Comparet, who are running low on air, leave the bar area. Captain 

Spalding and Private Lorenzano, working in the McHale Room, are advised that 

Corporal Gelenius is running low on air in the elevator lobby and needs assistance 

evacuating.

12:28 a.m. 18:36 Captain Spalding and Private Lorenzano encounter Corporal Gelenius standing in 

the elevator lobby in obvious distress. Meanwhile, a flash fire erupts in the McHale 

Room and blows into the elevator lobby through the open doors. Outside, fire can 

be seen venting from the two eastern most windows of the McHale Room. Spalding, 

Lorenzano, and Gelenius become separated.

12:30 a.m. 20:39 Engine 5’s crew, entering the third floor from the west stairway, finds Private 

Comparet collapsed in front of the third floor hose cabinet. In the process of removing 

Comparet, Engine 5’s crew finds Gates unconscious in the second floor corridor west 

of the elevator lobby at the base of the monumental stair.
24 U.S. Fire Administration/Technical Report Series

Actual Time Elapsed Time Event/Activity

12:31 a.m. 21:31 Incident Commander (DC3) radios for a second alarm (not dispatched until 12:39:01). 

Seven firefighters from Engine 7, Engine 13, and Truck 13 are rescued from third floor 

windows by Truck 7. Truck 13 sets up on the Meridian Street (east) side. Firefighters 

advance a line (third line) up Truck 7’s aerial through the west window of the bar area.

12:32 a.m. 22:08 All firefighters except Captain Spalding, Corporal Gelenius, and Private Lorenzano 

have left or been evacuated from the third floor. Engine 11 (second alarm) arrives at 

the scene and reports to Car 2 on the Meridian Street side. 

12:32 a.m. 22:35 Incident Commander (DC3) requests more aerial ladders. Engines 4 and 19 arrive 

on the scene. Engine 4 is assigned to lay two 3-inch lines for a ladder pipe operation. 

After completing this operation, Engine 4 is sent to the third floor to take up Engine 5’s 

attack line and advance on the fire floor. Engine 19 is assigned to stretch a 1-3/4-inch 

line (4th line) to the fire floor.

12:33 a.m. 23:49 Fire is observed from outside engulfing the large dining room.

12:34 a.m. 24:29 Special Call: Truck 1 is dispatched.

12:35 a.m. 25:42 Captain Spalding activates the emergency button on his radio for the first time. It is 

now approximately 7 minutes since he became separated from Corporal Gelenius and 

Private Lorenzano.

12:36 a.m. 26:02 Captain Spalding again activates the emergency button on his radio.

12:36 a.m. 26:17 Captain Spalding transmits an inaudible radio message.

12:36 a.m. 26:21 Engine 19’s crew enter the building with their line.

12:36 a.m. 26:28 Captain Spalding again transmits an inaudible radio message.

12:36 a.m. 26:37 Division Chief Williams (Car 2) reports, “the whole third floor [is] engulfed.”

12:36 a.m. 26:47 Captain Spalding transmits a third inaudible radio message.

12:37 a.m. 27:13 Captain Spalding keys his radio without giving a message. He does this again 8 

seconds later, and once more 3 seconds after that.

12:39 a.m. 28:54 Engine 11 takes a 1-3/4-inch line (5th line) in over Truck 13’s aerial ladder from 

Engine 7 on the Meridian Street (east) side. They advance the line through the large 

dining room.

12:39 a.m. 28:55 Second Alarm: Engines 11, 4, and 19, and Truck 1 is struck. Engines 4, 11, and 19 

had already arrived and been committed at the scene. Truck 1 had been dispatched 

earlier on the special call.

12:40 a.m. 30:15 Captain Spalding keys his radio again without transmitting a message.

12:48 a.m. 38:08 Fire Marshal Whitaker assumes command of the north sector (Vermont Street side).

12:49 a.m. 38:34 Truck 1 begins making rescues from upper stories on the Vermont Street side. The 

sector commander is giving instructions over a vehicle public address speaker to 

building occupants.

12:50 a.m. 39:54 Special Call: Truck 14 is dispatched.

Appendix A (continued)
USFA-TR-063/February 1992 25

Actual Time Elapsed Time Event/Activity

12:52 a.m. 42:33 Engine 4 finds Corporal Gelenius in the doorway between the elevator lobby and the 

service corridor on the third floor. It is now almost 24 minutes since Corporal Gelenius 

became separated from Captain Spalding and Private Lorenzano.

12:54 a.m. 44:23 Fire Marshal Whitaker moves to the west sector to oversee aerial ladder rescue 

operations there.

12:57 a.m. 47:15 Corporal Gelenius’s body is removed from the building, placed in an ambulance, and 

transported to Methodist Hospital where he is pronounced dead less than an hour 

later.

12:59 a.m. 49:01 Engine 11 locates Captain Spalding beneath a layer of debris in the Grill Room.

1:00 a.m. 50:47 Truck 14 begins making aerial ladder rescues from upper floors on the south side of 

the building.

1:01 a.m. 51:01 Third Alarm: Engine 14 and Truck 27 are dispatched.

1:05 a.m. 55:10 Captain Spalding is removed from the third floor via Truck 13’s aerial tower bucket.

1:11 a.m. 1:00:59 Truck 27 and Engine 14 are rescuing occupants from the west side of the building 

using ground ladders to extend the reach of the aerial ladder.

1:14 a.m. 1:04:00 Deputy Chief Grider assumes command of interior sector operations. A ground ladder 

is being attached to the end of Truck 7’s aerial ladder so it too can be used for upper 

floor rescues.

1:20 a.m. 1:10:28 Chief Grider reports that the fire has been knocked down on the third floor, but fire 

may have extended upward.

1:21 a.m. 1:11:09 District Chief Pfisterer (DC3) is relieved as incident commander by Acting Chief Keith 

Smith. DC3 assumes command of the south sector.

1:29 a.m. 1:19:07 Chief Grider reports that the fire is under control with only spot fires burning now on 

the fourth floor.

1:38 a.m. 1:28:32 Incident commander (Chief Smith) and the medical sector commander, Chief Zickler, 

confer about plans for a comprehensive interior search. Chief Smith advises he wants 

a check for the accountability of all firefighters assigned to the incident.

2:05 a.m. 1:55:03 DC3 relieves Deputy Chief Grider as interior sector commander.

2:05 a.m. 1:55:35 Crews from Engines 11 and 19, and Truck 14 check for extension on the fourth floor.

2:08 a.m. 1:58 Systematic (secondary) search of building to locate missing firefighter and civilian 

victims begins.

2:18 a.m. 2:08:23 Private Lorenzano’s body is found in the McHale Room. He is pronounced dead at 

the scene.

2:38 a.m. 2:28:39 Civilian victim is found in east stairway between the sixth and seventh floors. 

Appendix A (continued)
26

APPENDIx b

Floor Plan
27

APPENDIx C

Additional Information About 

Fire Protection Deficiencies

This appendix contains additional information about key fire protection and life safety deficiencies 

which contributed to the delayed detection and suppression of the fire. This information is intended 

to supplement the information about these systems contained in the body of this report.

FIRE AlARM AND DETECTIoN SYSTEM

The arrangement and installation of the building fire alarm systems was complex and smoke detector coverage was incomplete. As a result, the elevator lobby detector was the only smoke detector 

on the third floor where the fire originated. The elevator lobby detectors were not connected to the 

building fire alarm system and did not initiate an alarm.10

Smoke detection was added to the existing manual fire alarm system in the late 1980s to comply 

with State regulations requiring such protection in hotels.11 However, these regulations were not 

interpreted to require smoke detection throughout mixed-use hotel occupancies. The system consisted of:

•	 Three separate systems: a high-voltage manual station system, low-voltage conventionalzoned corridor detection on guest room floors, and analog smoke detection in guest rooms 

and selected hazardous areas:

•	 Manual pull stations were provided in corridors and public areas:

•	 Conventional ceiling-mounted ionization smoke detectors installed at 30-foot intervals on

guest room floors; these detectors were connected to conventional-zoned control units on 

each floor, which in turn were connected to signal-line circuits and assigned addresses on the 

analog/addressable system:

•	 Photoelectric smoke detectors installed in individual guest rooms and throughout the basement workshop and storage areas; these detectors were of the analog/addressable type; 

the control unit was programmed to indicate the location of each addressable device upon 

activation:

•	 The analog/addressable system control unit was interconnected with the high-voltage manual station system which operated the fire alarm signals:

•	 The manual fire alarm system circuits, including the signaling circuits, were not supervised

for continuity and operability.

10 NFPA 72-(90), Section 3-7.3.3 requires that smoke detectors used to initiate elevator recall also activate the building 

fire alarm signals.

11 See Indiana Code 22-11-18, Smoke Detector Devices.
28 U.S. Fire Administration/Technical Report Series

Appendix C (continued)

Several aspects of this fire alarm system design contributed to delays in identifying the fire’s location 

and notifying occupants to evacuate:

•	 The fire alarm system was not supervised by a central, remote, or proprietary station; therefore, it was the responsibility of the desk clerk or security guard to notify the fire department 

in the event of an alarm:

•	 Fire alarm signals were installed in corridors, not individual guest rooms and may not have 

produced warning signals strong enough to wake sleeping occupants; a typical floor had two 

to three fire alarm signals:

•	 Single-station smoke detectors were installed in the elevator lobbies but were not connected 

to the fire alarm system and did not initiate a fire warning signal:

•	 Smoke detection was not provided in air handling equipment or beyond the elevator lobbies 

on floors one through five.

INADEQUATE ACCESS To THE PUblIC WAY

The provision of revolving doors as the sole means of egress at grade level was not a factor in occupant evacuation, but would have been had there been more occupants. These doors, located on the 

north and east sides of the building, provided the only grade level access from Vermont Street (north) 

and Meridian Street (east). Supplemental side-hinged doors were not provided to permit access or 

egress.

Although the revolving doors were collapsible, the fire department never broke down (folded) the 

doors to provide unobstructed access or egress. At some point, glass in the revolving door on the 

north side of the building was broken to allow a hoseline to be stretched into the building.
29

APPENDIx D

Fire Origin and Cause Determination Section from the 

Athletic Club Fire Review Board Report, Indianapolis 

Fire Department

Fire Origin and Cause Determination

NOTE: The origin and cause detemination of this fire was not included in the review panel’s

mission. It is included here because it is a relevant pan of the overall analysis of the incident.

On February 5, 1992 at 00:06 hours a fire occurred at the Indianapolis Athletic Club

located at 350 North Meridian Street. The building is nine and a half storks with approximate

dimensions of 100 feet by 200 feet, with approximately 20,000 square feet of area per floor.

Fire investigators from the Indianapolis Police and Fire Arson Investigation Unit

examined the entire Athletic Club Building. The examination revealed that the most severe

damage was on the third floor. Investigators were on the scene during the fire suppression effort

and were aware of the extent of the fire on the third floor, and they were also aware that a

flashover had occurred.

Although there was tremendous damage caused by the flashover conditions and resulting

fires, there appeared to be only one area of origin, in the bar area located on the third floor.

The heaviest damage was discovered behind the bar in the “back-bar” A large “V” pattern

was present emanating from the top of the counter to the ceiling. The counter top had been

burned through from the bottom in a semi-circular shape. The counter top had a large amount

of fire debris on top of it, particularly plaster that had been exposed to the high temperatures.

There was a small refrigerator under the counter top. The refrigerator was filled with

canned fruit juice, and it was beside a bottle cooler filled with beer. The counter top was

cleared off, one layer at a time, until the fire debris had been removed, exposing several

protected areas. These areas were documented and later compared with the statement given by

the bartender. The bartender indicated that the bar closed at approximately 4:30 pm, and that

he locked the bar at approximately 5:30 pm when he left. The counter top was then removed

using prybars, Halligan tools, and a sledge hammer. The refrigerator was then removed and

photographed.

The rear of the refrigerator showed a clear “V” pattern that perfectly matched the pattern

found behind it on the wall. There was no other low bum found anywhere else on the third

floor of the club, and this area was very carefully examined. The baseboard was removed and

inspected, revealing no signs of any flammable accelerant. Samples were taken for lab analysis

from the pan of the refrigerator, all; showing no signs of accelerants.

The fire extended upward, burning through a paneled wall that had been added in front

of the original plaster wall. It burned through a suspended ceiling and continued its travel

through the original plaster ceiling until its upward progression was halted by the concrete floor

deck of the fourth floor. Investigators discovered that there were numerous holes in the original

false ceiling that allowed the fire to progress. They also discovered numerous breaches in the

block walls which allowed the fire to spread into the rooms adjoining the bar area. These

INDIANAPOLIS FIRE DEPARTMENT

Athletic Club Fire Review Panel

March 4, 1992 15
30 U.S. Fire Administration/Technical Report Series

Appendix D (continued)

breaches allowed the heat and combustion byproducts to accumulate creating the deadly flashover

conditions. Investigators also found evidence that the flashover was particularly intense in the

lobby area near the stairwell where oxygen was able to further feed the fire. The numerous wall

coverings and additions of wood paneling to the walls contributed to the fire load on the third

floor. Investigators concluded that the thirteen foot ceiling height, with several with ceilings,

allowed the super-heated gases to accumulate above firefighters without their knowledge.

Because of the severity of the injuries and the presence of the Michael G. Tyson rape

trial jury, the Bureau of Alcohol Tobacco and Fireams (ATF) was asked to assist in the

investigation. ATF investigators conducted independent examinations of the fire scene. They

agreed with the conclusions of the IPD/IFD fire investigators. An electrical engineer familiar

with fire investigation was retained to assist in the investigation. The electrical equipment that

served the bar area was thoroughly inspected, and removed for further laboratory analysis, as

was the refrigerator.

AU of the investigators who have examined the Athletic Club have reached the same

opinion independently: the fire was accidental resulting from an electrical fault somewhere in

the plug, wiring, or components of the refrigerator. They also agreed that there was no

evidence whatsoever of tampering with any of these components.

On February 20,1992, the Marion County Grand Jury heard testimony about the fire and

the fire investigation. After deliberating, the jury agreed with the unanimous opinion of the

various investigators, commending their efforts and finding that no further investigation was

required. The Grand Jury ruled the fire accidental.

INDIANAPOLIS FIRE DEPARTMENT

Athletic Club Fire Review Panel

March 4, 1992 16
USFA-TR-063/February 1992 31

APPENDIx E

Lessons Learned or Reinforced Section from the Athletic 

Club Fire Review Panel Report

This list of lessons learned is reproduced from the report of the Review Panel convened to investigate the Indianapolis Athletic 

Club Fire.

•	 The inevitable fact is that disastrous incidents will occur.

•	 There is no substitute for proper training.

•	 Training is not an area to enact budget cuts.

•	 SOP's are necessary, and must be followed.

•	 Beware of “routine” situations; there is no such thing.

•	 Firefighters must be familiar with all buildings in their response district.

•	 Vertical and horizontal fire spread will be severe in buildings without sprinklers and adequate

compartmentation.

•	 Unprotected stairways are always dangerous.

•	 Always plan for your escape, poor visibility is assured.

•	 The “buddy system” works and must be utilized.

•	 Linen cabinet hose is not a good substitute for fire department attack hose.

•	 When using a standpipe system, always use the standpipe from the floor below the fire so

firefighters can use the hose as an escape route.

•	 Physical fitness is a necessary survival asset.

•	 Full turnout gear and SCBA are an essential part of safety.

•	 Helmet chin straps must be utilized at all times.

•	 The proper use of SCBA saves lives.

•	 When SCBA alarm goes off, get out immediately.

•	 Proper use of the ICS is vital to safety and organization on the fireground.

•	 It is important to formally establish command and/or assignments.

•	 It is important to know who is in charge.

•	 Plan ahead, have necessary suppression tools and equipment at hand.

•	 High-rise fires require a heavy commitment of personnel and equipment early in the

incident.

•	 Be prepared to affect aerial ladder rescue.
32 U.S. Fire Administration/Technical Report Series

•	 Inspection of a building must be made prior to occupancy to make sure that all systems are

operational and that they meet the needs of the fire department.

•	 Building fire protection systems must be tested regularly.

•	 Building occupants must be trained to report fires promptly.

•	 Radio discipline is important.

Appendix E (continued)
33

APPENDIx F

Photographs

The photographs on these pages were taken by Mark Chubb. These and other photographs and slides 

are in the master file for this investigation at the USFA.

This view from the monumental stairway looking up toward third floor ceiling shows 

relatively light damage to the cornice, but heavy damage to the combustible foil-backed 

wall coverings.
34 U.S. Fire Administration/Technical Report Series

This view of the third floor corridor looking east toward the large dining room shows the extensive damage to 

combustible wall coverings.

Appendix F (continued)
USFA-TR-063/February 1992 35

Appendix F (continued)

Entrance to ladies room adjacent to the dutch-style service door to the bar (room of fire origin). Note the air return 

register over the door and the air supply register over the opening to the dining room.
36 U.S. Fire Administration/Technical Report Series

Appendix F (continued)

Entrance to the McHale Room looking north from the elevator lobby. Note 

the fire damage to the wall coverings above the door and the relatively light 

charring of the door frame.
USFA-TR-063/February 1992 37

Appendix F (continued)

This view of the dutch-style service door to the bar room shows the deep 

charring to the door frame above the opening and the plywood paneling 

on the lower right side of the door opening.
38 U.S. Fire Administration/Technical Report Series

Appendix F (continued)

The inside of the McHale Room looking west. Shows the use of furring strips under the wall paneling. Much of the 

paneling at the remote west end of the room remains intact. Also note that the tops of the chair backs 

are only slightly blistered.
USFA-TR-063/February 1992 39

Appendix F (continued)

View of opening in suspended ceiling in the McHale Room. Note the 

charred 1-foot ceiling tiles (at left) glued to the underside of the plaster 

suspended ceiling and the remnants of the aluminum suspended 

ceiling frame.
40 U.S. Fire Administration/Technical Report Series

Appendix F (continued)

Remnants of occupant use standpipe hoseline used by Engine 7 and Truck 

13 firefighters in the initial attack. Note the plastic adjustable-stream fognozzle attached to the end (near center of photo).
USFA-TR-063/February 1992 41

Appendix F (continued)

View of third floor service corridor looking east from standpipe cabinet. 

Note the relatively minor damage. Most of the damage is confined to wall 

and ceiling finish materials.
42 U.S. Fire Administration/Technical Report Series

Appendix F (continued)

View of suspended ceiling damage above the location in the Grill Room where Captain Spalding was found unconscious 

and covered in debris.
USFA-TR-063/February 1992 43

Appendix F (continued)

View of east stairway connecting third through ninth floors. This stairway 

was open on the third floor (shown here) and the fourth floor permitting the 

stairway to fill with smoke and the fire to spread vertically to the fourth floor.
44 U.S. Fire Administration/Technical Report Series

Appendix F (continued)

View of fire damage in the fourth floor corridor looking west toward the 

center of the building.
USFA-TR-063/February 1992 45

Appendix F (continued)

Manual fire alarm system cabinet and tabular fire alarm enunciator above. 

This system provided power to the fire alarm signals on all floors.
46 U.S. Fire Administration/Technical Report Series

Appendix F (continued)

Analog addressable smoke detector control unit. This unit powered and 

supervised the in-room and basement smoke detectors, as well as monitoring the 

conventional-zoned control units which powered the corridor smoke detectors.