Features

NFPA Journal®, May/June 2007

By Robert Duval

In the late evening hours of February 20, 2003, a fast-moving fire spread through The Station nightclub in West Warwick, Rhode Island. This fire completely destroyed the building and resulted in 100 fatalities and over 200 injuries, becoming the fourth deadliest nightclub fire in U.S. history. This fire immediately invoked memories of other tragic fires in assembly occupancies, such as the Cocoanut Grove, the Rhythm Club, and the Beverly Hills Supper Club. Many common factors can be found when analyzing these tragedies, including combustible interior finish, overcrowding, and problems with egress.

WINDOWS MEDIA VIDEO CLIPS As part of the investigation into the Station Nightclub Fire, NIST researchers recreated the fire in a  real-scale environment. (96 seconds)  Dial-up (56 K)  ISDN/LAN (150 K)  Cable/DSL (300 K) A high level view of the same fire test. (83 seconds)  Dial-up (56 K)  ISDN/LAN (150 K)  Cable/DSL (300 K) Windows Media Player required (download the player for free). NFPA TIMETABLE OF EVENTS* Elapsed Time / Event 0:00 Pyrotechnics Activated 0:09  Flame Visible on Wall 0:19  Flames Progressing Upward - Crowd Begins to React 0:25  Flames at Ceiling 0:35  Band Stops Playing 0:48  Alarms Heard 1:00  Smoke at Ceiling Throughout Room 1:15  Cameraman at Front Door (Smoke at Ceiling and Out Front Door) 1:30  Fire Visible at Platform Door 1:43  Black Smoke at Bottom of Sunroom Windows 1:53  Black Smoke at Front Door - Occupants Piled at Door 2:00  Alarms No Longer Audible from the Outside of the Building 2:23  Occupants Exiting at Windows Near Bar (Left of Front Exit) 3:00  Black Smoke at All Front Openings (Windows and Doors) 3:25  Black Smoke Fills Entire Front Door (Victims Still Piled at Door) 4:00  Black Smoke Thickening at All Front Openings 4:30  Sirens Audible in Background 4:30-4:45  View of Platform Door - Fire on Floor, Heavy Black Smoke, and Dripping Materials from Ceiling 5:00  Fire Visible at Restroom Wing 5:23  Flames at Front Openings (Doors and Windows) * Time is based on TV News video.

Following months of study and analysis, several changes to key NFPA codes were completed resulting in new requirements that should help to mitigate similar occurrences in the future. These changes were made to NFPA 101®, Life Safety Code®, NFPA 5000®, Building Construction and Safety Code®, and NFPA 1, Uniform Fire Code™ relating to Assembly Occupancies.

This year's Featured Presentation at the World Conference and Safety Exposition® (WSC&E®) will review The Station fire and the response of NFPA to this tragedy, the report and research completed by the NIST-National Construction Safety Team on the fire, and the changes made to state fire codes by Rhode Island and Massachusetts because of the fire. The presentation is planned for June 5 from 2:15 p.m. to 3:45 p.m.

In addition, a panel discussion that will examine the legacy of the 1942 Cocoanut Grove nightclub fire in Boston from a multi-disciplinary approach will be held Tuesday, June 5, from 4:15 p.m. to 5:45 p.m. This Spotlight Presentation examines the fire that killed nearly 500 people and changed fire code enforcement, burn treatment methods, and manslaughter case law around the nation. Experts will examine the fire from multiple angles, including its lasting impact on Boston.

The Station
NFPA became aware of The Station nightclub fire in the early morning hours of February 21, 2003. As the magnitude of the incident became clearer, as NFPA's Senior Fire Investigator I traveled to West Warwick that morning, at the request of the Rhode Island State Fire Marshal's Office, to provide assistance immediately following the tragedy.

While on the scene in the hours and days following the incident, opportunities were taken to meet with investigators, fire officers, and fire fighters; to view the scene; and to perform an on-site study of the incident. The information gathered during the on-site activities and subsequent analysis of that information is the basis for this report.

Entry to the fire scene was made through the cooperation of the Rhode Island State Fire Marshal's Office. The information in this report is intended to serve as an aid to researchers, safety specialists, the fire service, and to the code- and standards-development activities conducted by NFPA and other organizations. The opinions expressed and conclusions drawn are those of the NFPA staff who prepared this report and do not, therefore, necessarily represent the official position of NFPA or of the NFPA Technical Committees that develop NFPA codes and standards.

All information and details regarding the fire safety conditions gathered in this report are based on the best available data and observations made during the on-site data collection phase and on any additional information provided during the report development process. It should be noted that the ability of NFPA staff to collect all relevant facts and draw definitive conclusions may have been limited by a variety of factors, including available time and access. This report is not intended to comprehensively document or analyze this fire incident. For such a report, see the National Institute of Standards and Technology (NIST) technical investigation report. Rather, this report focuses on some of the contributing factors that have been seen in the other nightclub fires summarized in the first part of this study. The purpose of the report is not to pass judgment on or fix liability for the loss of life and property resulting from the fire, but is rather to provide documentation and discussion that may help improve understanding of how to minimize or prevent such losses in the future.

The 2003 editions of relevant NFPA codes and standards were used as the basis for this analysis so that the information gathered about the fire could be reviewed in light of the editions of NFPA codes and standards available at the time of the fire. It is recognized, however, that these codes and standards may not have been in effect during the design, construction, and operation of the building. NFPA has not analyzed the building in West Warwick regarding its compliance with the local codes and standards in existence when the building was constructed and during its operation.

In addition, NFPA reviewed information included in the NIST-National Construction Safety Team report on the fire. The cooperation of the Rhode Island State Fire Marshal's Office is greatly appreciated. The author would also like to extend his appreciation to former Rhode Island State Fire Marshal Irving Owens, Chief Deputy State Fire Marshals Michael DiMascolo and Richard James, and their staff for their assistance during the on-scene portion of the investigation and in preparing this report.

Building construction and occupancy
The building that contained The Station nightclub was constructed in approximately 1946. The structure was utilized as a restaurant, tavern, and nightclub under various owners. Numerous renovations and repairs were completed on the building since construction. A fire damaged the club in March of 1972. The building remained closed until November 1974, when repairs were completed on the fire damage. At this point, the building was converted from a club into a restaurant and reopened. In February 1985, a change of ownership occurred and the facility was converted once again to a pub.

According to records, in 1991 the facility was converted to nightclub use. The building was a wood-framed structure with a mansard-type roof façade on the north side. The walls were of wood construction, with wooden exterior shingles. The wood frame roof structure was mostly flat with a built-up asphalt covering. A partial basement was located beneath the eastern portion of the building. Windows were located mainly on the north face of the building. Windows on the east side of the front entrance consisted of double-hung type, while the west side contained a "sunroom-type" window assembly. Small windows were located in the restrooms and office areas on the south wall of the building. These windows contained security bars. The interior of the building was arranged into two distinct areas: the bar and the club. The bar area was located in the northeastern portion of the building (to the left as one entered the front entrance). This area also included the kitchen and dart room portions of the facility.

The club portion, which encompassed the majority of the facility, was located west (right) of the front entrance. This area of the facility included the dance floor, the platform, and the sunroom, which contained billiard tables. (See Figure 6.) The entrance to the facility was arranged with a short corridor, approximately 15 ft (4.6 m) in length and 6 ft 6in. (2 m) in width. At the end of this corridor, there were doorways to the right and left. The bar area was located to the left, while the club area occupied the space to the right of this corridor.

The bar area contained a horseshoe-shaped bar in the northeast portion of the building. The kitchen was located immediately behind the bar. A room referred to as the dart room was located behind the kitchen. Access to the food and beverage coolers was located through the dart room. The southeast corner of the building contained the business office and the club restrooms. The club area of the facility contained small tables with chairs and a small number of booths along the southwest wall of the area. The tables and chairs could be rearranged or removed from the building in the event a large crowd was anticipated for a show. The billiard tables could be moved against the walls in the sunroom in order to make room for additional patrons. On the night of the fire, the tables were moved to allow for extra room. A raised platform was centrally located on the west wall of the club area. An alcove was located to the rear of the platform to allow for additional room on the platform.

When bands performed, the drummer was usually located in this alcove. The ceiling area directly above the platform was raised slightly to allow for the installation of a stage lighting unit. The interior finish at the time of the fire reportedly consisted of painted surfaces, wooden paneling, and expanded foam plastic insulation. In an effort to lessen the noise on the exterior of the club when bands performed at the club, expanded foam insulating material was installed on the walls of the building interior, around the platform, and within the drummer's alcove. The exact extent of the expanded foam plastic insulating material installation and its composition are unknown.

Egress arrangement
The building contained four exits:

• Front (main) doors
• Bar side exit door
• Platform exit door
• Kitchen exit door

The front entrance contained two doors (each 36 in. [0.9 m] wide) that swung outward. A ramp and step arrangement was located at the front entrance. A railing on the platform was installed parallel to the front wall of the building, making the platform at the entrance 6 ft 6 in. (2 m) wide. A single, outward-swinging door was located approximately 6 ft (1.8 m) into the corridor as measured from the front doors. The cross-corridor door was approximately 36 in. (0.9 m) wide. The corridor measured 6 ft. 7in. (2 m) in width. The front entrance corridor contained two openings into the main portion of the building, one on the bar side of the corridor and the other into the club. A counter for a ticket taker was located to the left at the end of the corridor. The bar and kitchen exits each contained a door 36 in. (0.9 m) wide that swung outward. Both doors were equipped with panic hardware. The exit near the platform measured 36 in. (0.9 m) wide and contained two doors mounted in series in the door opening: one interior and one exterior. At the time of the fire, the interior door swung inward, while the metal-clad outer door swung outward. The exterior door was equipped with panic hardware. Illuminated exit signs were located above each exit.

Fire protection
The building was equipped with a fire alarm system consisting of manual fire alarm boxes, heat detectors, and horn/strobe notification units. The heat detectors were located throughout the facility, including above and below the platform in the club area. The fire alarm system was not connected to a central station service or to the local fire department alarm office.

This facility was not protected with automatic sprinklers. Portable fire extinguishers were located throughout the facility, although the exact distribution and type could not be determined. The kitchen contained a chemical extinguishing system for the cooking area, as well.

The incident
On the evening of the fire, the nightclub was hosting a program with several bands, including a headlining act. The headlining band took the stage at approximately 11:07 p.m. Several seconds into the act, pyrotechnic devices called gerbs were activated in the center of the platform, directly in front of the drummer's alcove. A local television station was filming the evening's activities for an upcoming story on nightclub safety in the days following the fatal crowd crush incident at the Chicago E2 nightclub, which claimed the lives of 21 on February 17, 2003. This news video provided a firsthand account of the activities inside the club in the moments leading up to the fire, as well as the first terrifying moments after the fire. (A video account of such a tragic incident is rare, but has occurred before, as in the case of the Bradford Soccer Stadium Fire in England on May 11, 1985.)

In the news video, the viewer can see the lights dim as the band takes the stage and begins the first song. As the pyrotechnic devices activate, the sparks emanating from the gerbs ignite the material on the walls around the platform, near the opening to the alcove. Flames begin to expand slowly at first, at the two ends of the alcove opening, spreading upward. For the first few seconds, the crowd seems to think the fire is part of the pyrotechnic special effects and the band seems unaware of the fire. Within 10 to 20 seconds, crowd members begin pointing at the spreading flames on the walls, as members of the band become aware of the fire. The band stops playing and leaves the platform in less than 30 seconds.

At this point, the crowd begins to react and to attempt to egress the building. The cameraman's viewpoint is from the rear of the dance floor area and the video clearly shows patrons beginning to egress the building using the main entrance, which is to the cameraman's right. The fire alarm sounds at approximately 40 seconds from the time of ignition. The horns and strobes can be clearly heard and seen in the video. The cameraman merges into the exiting patrons and leaves the building approximately 70 seconds from the time of the ignition. As the cameraman exits, the video shows the fire growing rapidly on the walls near the platform and the smoke layer growing thicker throughout the building. As the cameraman enters the corridor near the front entrance, smoke can be seen on the video, growing heavier, from a light haze to a darker gray.

Once the cameraman is outside, the video displays the smoke growing thick, black, and billowing out the front doors and windows as patrons use both to escape. Within seconds, escaping patrons begin to pile up at the front doors, as those behind them struggle to escape. Those who have escaped attempt to free those trapped in the pile, as heavy smoke pours out over their heads. The video then shows the scene as the cameraman walks around to the west from the front of the building. As he trains the camera on the platform door opening, the viewer sees thick black smoke within 12 inches of the floor, and bright orange flames deep within the building. Approximately 4 minutes and 30 seconds have elapsed from the time of ignition.

At this point, sirens can be heard. As the cameraman walks back toward the front of the building, the situation has worsened. The black smoke has turned to flame at the front entrance and at the open windows along the front of the building. As the first fire apparatus arrives on the scene, a hoseline is stretched to the front entrance and water is aimed into the front corridor in an effort to save those trapped in the entrance corridor. From the time of ignition to the point where the facility was well involved in flames less than 6 minutes had passed. The initial 911 calls for assistance were received from cellular phones at the scene. The police officer stationed at the club on a paid detail notified his dispatcher of the fire as well. The West Warwick Fire Department, upon notification of the severity of the situation, requested mutual aid from surrounding communities for both fire apparatus and ambulances.

A Multiple Casualty Incident (MCI) was declared and the local MCI plan was put into effect. A triage area was established in a restaurant across the street from the nightclub. As fire and rescue units converged on the scene, victims were transported to nearby hospitals and trauma centers, quickly filling many to capacity. Over 200 victims were treated on the scene and transported to several medical facilities in the area in under 2 hours from the time of the fire. The initial death toll was 96 on the day after the fire. This rose to 100 over the course of the 70 days following the fire, as four of the most severely injured died in hospitals in Rhode Island and Massachusetts. With the transport of the last of the injured, the task of recovery of the victims within the building began, with units from the State Fire Marshal, State Medical Examiner's Office, and a task force of law enforcement agencies (local, state, and federal) taking part. The recovery phase was completed late in the day on February 21. (The last victim was identified on February 25.) The scene was secured as the investigation process began.

The aftermath
The investigation into The Station nightclub tragedy involved many local, state, and federal agencies. Under the direction of the State Attorney General's office and State Fire Marshal, an investigative team composed of investigators from the State Fire Marshal's office and a statewide task force of law enforcement agencies, as well as investigators from the Bureau of Alcohol, Tobacco and Firearms (ATF) was formed to conduct the detailed examination of the fire.

The fire scene was processed and witnesses interviewed by the members of the investigative team. The scene processing included the involvement of a forensic archeologist from Brown University, whose team divided the scene into small grids and further processed the site for articles of evidence and personal effects of victims. In the days following the fire, representatives from NIST (National Institute of Standards and Technology), operating under the National Construction Safety Team (NCST) Act, visited the scene as well to gather preliminary information that would lead to a full report on the fire. This report was released in June 2005.

On December 9, 2003, a state Grand Jury handed up indictments against the two owners of the nightclub and the manager of the headlining act. Each was charged with 200  counts of manslaughter. On February 7, 2006, the band manager pleaded guilty to 100 counts of involuntary manslaughter in a plea agreement. The trial for the club owners began in mid-2006.

When comparing The Station incident with the other historic fires in assembly occupancies, one of the common factors among them is the presence of combustible interior finish, contents, and furnishings. The presence of combustible interior contents can be linked to the fire spread in the Rhythm Club (dried Spanish moss hung from the ceiling rafters), the Cocoanut Grove (furnishings and decorations), and the Beverly Hills Supper Club (wall and floor coverings). In The Station fire, expanded foam insulating materials were reportedly in place on the walls adjacent to the platform and in the drummer's alcove space.

NFPA 101, Life Safety Code, has addressed interior finish in all occupancies, including assembly, for many editions of the document. The classes of interior finish (A, B, and C) are based on Flame Spread and Smoke Development Indexes. These indexes are determined by testing a material in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials (similar to ASTM E 84, Standard Test Method for Surface Burning Characteristics of Building Materials; or UL 723, Standard for Test for Surface Burning Characteristics of Building Materials).

In the 2006 edition of NFPA 101, the subject of interior finish is outlined in the following areas: Chapter 10 Interior Finish, Contents, and Furnishings 10.1 General. 10.1.1 Application. The interior finish, contents, and furnishings provisions set forth in this chapter shall apply to new construction and existing buildings. 10.2.3.4 Products required to be tested in accordance with NFPA 255, ASTM E 84, or UL 723 shall be classified as follows in accordance with their flame spread and smoke development, except as indicated in 10.2.3.4(4): (1) Class A interior wall and ceiling finish shall be characterized by the following: (a) Flame spread, 0-25 (b) Smoke development, 0-450 (c) No continued propagation of fire in any element thereof when so tested (2) Class B interior wall and ceiling finish shall be characterized by the following: (a) Flame spread, 26-75 (b) Smoke development, 0-450 (3) Class C interior wall and ceiling finish shall be characterized by the following: (a) Flame spread, 76-200 (b) Smoke development, 0-450 Existing interior finish shall be exempt from the smoke development criteria of 10.2.3.4(1)(b), 10.2.3.4(2)(b), and 10.2.3.4(3)(b). Chapter 13 Existing Assembly Occupancies 13.3.3 Interior Finish. 13.3.3.1 Interior finish shall be in accordance with Section 10.2. 13.3.3.2 Interior wall and ceiling finish materials complying with Section 10.2 shall be Class A or Class B in all corridors and lobbies and shall be Class A in enclosed stairways. 13.3.3.3 Interior wall and ceiling finish materials complying with Section 10.2 shall be Class A or Class B in general assembly areas having occupant loads of more than 300, and shall be Class A, Class B, or Class C in assembly areas having occupant loads of 300 or fewer.

Interior finish played a significant role in The Station fire in two ways. Not only was the interior finish easily ignited but it also allowed for the rapid spread of the fire within the building. According to the Life Safety Code, the interior finish is required to be Class A or B for general assembly areas with occupant loads of more than 300. Class C interior finish is permitted if the occupant load is 300 or fewer. In addition, the expanded foam insulating materials attached to the walls near the platform would be subject to the provisions for cellular or foamed plastic, which prohibit the use of this particular material as interior finish unless it is utilized in insignificant amounts or the material has been subjected to fire testing that substantiates the combustibility characteristics for the use intended under actual fire conditions. The presence of combustible interior finish in the area of the fire's origin affected the ability of the occupants to egress the building that night. The fire created conditions within the building that prevented many from reaching an exit before being overcome by smoke and heat.

When viewing the video taken that night in the club, one can see that most of the occupants headed for the main (front) exit when the fire began. This exit and its corridor soon became jammed as occupants rushed to escape the worsening conditions in the building. The bottleneck at the corridor and the extremely rapidly growing fire conditions within the building forced occupants to attempt to use windows as a means of escape. NFPA 101 has, for many generations of the document, addressed main entrance/exit requirements in existing assembly occupancies. In the 2003 edition, this requirement is outlined in the following paragraph: 13.2.3.6 Main Entrance/Exit. Every assembly occupancy shall be provided with a main entrance/exit. 13.2.3.6.1 The main entrance/exit shall be of a width that accommodates one-half of the total occupant load and shall be at the level of exit discharge or shall connect to a stairway or ramp leading to a street. The rapid spread of the fire and the large volume of smoke is validated by the research and modeling conducted by NIST during its investigation. When examining ignition sources from other historic fires in assembly occupancies, common forms were found to be lighting (gas, and then later, electric) coming in contact with combustible materials, or open flame, as was suspected in the Cocoanut Grove fire. However, The Station fire resulted from a form of ignition not often seen when comparing other fires in assembly occupancies: pyrotechnics.

NFPA 101, Life Safety Code, addresses pyrotechnics in existing assembly occupancies, as well as referencing NFPA 1126, Use of Pyrotechnics Before a Proximate Audience, in Chapter 13 on Existing Assembly Occupancies. Chapter 13 Existing Assembly Occupancies 13.7.2 Open Flame Devices and Pyrotechnics. No open flame devices or pyrotechnic devices shall be used in any assembly occupancy, unless otherwise permitted by the following: (1) Pyrotechnic special effect devices shall be permitted to be used on stages before proximate audiences for ceremonial or religious purposes, as part of a demonstration in exhibits, or as part of a performance, provided that both of the following are met: (a) Precautions satisfactory to the authority having jurisdiction are taken to prevent ignition of any combustible material. (b) Use of the pyrotechnic device complies with NFPA 1126, Standard for the Use of Pyrotechnics Before a Proximate Audience. A similar requirement is also located in NFPA 1, Uniform Fire Code (1:20.1.4.2).

Cocoanut Grove
The Cocoanut Grove nightclub was a popular destination in Boston in 1942. The club offered entertainment in a nightclub on the street level as well as more intimate surroundings in a small lounge on a lower level. In the months leading up to the fire, another lounge (Broadway Lounge) had been opened adjacent to the club on the main level by renovating several adjacent buildings and adding them to the club's footprint.

This renovation gave the facility the shape of two overlapping rectangles. The original building was constructed of concrete in 1916. In the years prior to its transformation into a nightclub, the building was used as a garage and film storage facility. It was bordered on three sides by Piedmont Street, Shawmut Street, and Broadway. The building measured 100 ft x 90 ft (30.5 m x 27.4 m) in an irregular shape. (See Figure 2.)

The building was mainly a single story (with a partial lower level), except for a small upper level above the new lounge that contained dressing rooms and restrooms. The lower level contained the Melody Lounge as well as the kitchen and liquor storage for the club. The main club area measured approximately 60 ft x 60 ft (18.3 m x 18.3 m). The Broadway Lounge measured 40 ft x 40 ft (12.2 m x 12.2 m), and the Melody Lounge measured 55 ft x 35 ft (16.8 m x 10.7 m). Exits from the facility were located on the Piedmont Street, Shawmut Street, and Broadway sides of the building. The main entrance was through a revolving door arrangement on Piedmont Street. This entrance opened into the lobby of the club.

Access to the Melody Lounge was via a single set of stairs from the lobby. There were no other means of egress from this portion of the club. The Shawmut Street exit was located approximately halfway along the wall in the main club area. Another door on the Shawmut Street wall, adjacent to the stage, was locked. The Broadway exit was located in the new cocktail lounge. A single door, in the lounge, leading to the outer doors on Broadway opened inward. All other doors within the building that would have provided access to the outside were locked or obscured at the time of the fire.

One of these locked doors was located on the Piedmont Street side, to the left of the marquee over the main entrance. Had this door been unlocked at the time of the fire, it would have provided a means of egress for the patrons in the Melody Lounge without their having to travel into the lobby and use the revolving door. (See Figure 2.)

Exits from the dressing rooms on the upper level were via stairs that terminated at the locked Shawmut Street door. Windows on the Piedmont Street and Shawmut Street sides of the building were covered so as not to be visible from the inside of the building. The interior of the nightclub was decorated with numerous fabrics and materials. These included artificial leather on walls and the bars and cloth on the ceilings. Suspended ceilings and false walls throughout the facility covered the original construction features of the building. Artificial palm trees were placed in the club and in the Melody Lounge. Lighting and the associated wiring were incorporated into these trees.

The Melody Lounge also contained rattan wood wall coverings. Many of the furnishings within the club and lounges were covered in artificial leather material as well. Reportedly, just eight days before the fire, fire department inspectors found "no flammable decorations" and sufficient exits and fire extinguishers. The only deficiency the city building inspector found in an inspection just prior to the fire was the lack of a steel fire door between the Broadway Lounge and the main dining area.

After the addition of the Broadway Lounge, the club had applied for a license as a restaurant with a capacity of 490 patrons. The reported capacity of all areas was approximately 600. On the night of November 28, 1942, the Cocoanut Grove was well over capacity, with estimates of over 1,000 occupants in the building at the time of the fire. The fire began in the area of an artificial palm tree in the Melody Lounge.

A popular account was that a busboy used a match to provide light as he investigated a faulty light bulb within the tree. Within seconds, the tree had ignited. The smoke, heat, and flames spread rapidly throughout the lounge, forcing patrons to flee, using the only exit passage toward the stairs and the lobby. Many were overcome before they could reach the exit.

The first indication of trouble for occupants on the main floor was when a young woman ran screaming through the lobby with her hair on fire, immediately followed by a wave of smoke and heat from the stairwell. Many headed toward the exit on Piedmont Street, having entered the club earlier through the revolving door at that entrance. The revolving door quickly became jammed as patrons pushed toward the door. Others within the main club headed toward the door on Shawmut Street. Many were able to exit through this door until smoke and toxic fumes, along with the tangle of hundreds of tables and chairs, overcame those remaining in the building.

Those in the Broadway Lounge were the last to know of the fire, being the most remote from the lobby area. Approximately 4 to 6 minutes from ignition, occupants from the main club area began to rush into the Broadway Lounge seeking an exit from the building. The smoke, heat, and fumes followed rapidly. The only remaining viable exit from the building was quickly jammed, as the inward-opening door was forced closed by the crush of people attempting to exit. The fire department, which had several units on the block for an automobile fire, was alerted by a passer-by to the commotion at the Cocoanut Grove. Arriving within seconds, fire fighters immediately went to work rescuing patrons near the entrances. Additional alarms were sounded as the magnitude of the situation became apparent. Windows were broken on the Shawmut Street side in an attempt to gain access to the building and as a means of removing victims. Fire fighters and civilians began to pull bodies from the building through any accessible point. Victims, suffering burns and smoke inhalation injuries, were transported by all available means to city hospitals. At this point, the fire had consumed the combustible interior finish and furnishings and was extinguished rapidly by the fire department.

Once fire fighters were able to gain access to the interior of the building, they were met with a horrific sight: bodies piled several feet high at the revolving door and near the exit in the Broadway Lounge. Approximately 200 bodies were found at the revolving door and 100 more were found at the Broadway entrance. The remaining fatalities were found throughout the facility, many at their tables, overcome so rapidly that they were unable to make an effort to escape.

In the days and weeks following the fire, the death toll became a staggering 492, making the Cocoanut Grove the deadliest nightclub fire in U.S. history. In the months following the Cocoanut Grove fire, changes were made to building codes across the country. The most notable advances were made in the areas of exits, combustible materials, emergency lighting, and automatic sprinklers. The definition of places of public assembly was also expanded.

Before the fire at the Cocoanut Grove, many jurisdictions did not consider restaurants and nightclubs to be places of public assembly. Notably, the 1942 edition of the NFPA Buildings Exit Code (the early version of today's Life Safety Code) did consider nightclubs to be essentially places of public assembly, in the same class as a theatre, but having a greater possibility of fire. Today, it is recognized that all assembly occupancies should have at least two separate and remote means of egress, and the necessary number, width, and types of reliable exits based on the expected occupancy should be available.

After the fire, Robert Moulton, NFPA's Technical Secretary and the secretary of the NFPA Committee on Safety to Life, indicated in a newspaper interview: "The most glaring feature of this tragedy was the lack of proper exits. Revolving doors have long been considered by the National Fire Protection Association Committee on Safety to Life as a menace under fire and panic conditions." That same edition of the Code required that "decorations of theatres and assembly halls shall be of fire-resistive or nonflammable materials. Fabrics and papers used for such purposes shall be treated with an effective flameproofing material."

A cautionary note warned: "Paper and cloth decorative materials should be kept to a minimum in places of assembly since such flimsy materials increase the hazard of the kindling and spread of fire." Largely as a direct result of the Cocoanut Grove fire, the Building Exits Code was adopted by many more jurisdictions across the country, due in large part to the efforts of the fire service. The Committee on Safety to Life reported on that increased usage at the 1945 NFPA Annual Meeting. It was during the 1945 NFPA Annual Meeting that the Committee on Safety to Life also recommended a change in the method of exit measurement, clarification of the need for stairway enclosure, provisions regulating loose chairs in nightclubs, and changes in lighting and signs. Those changes were incorporated into the 1946 edition of the Code, as was a special note on interior finish.