Remembering Santika
One year after a deadly nightclub fire killed 66 in Bangkok, a Thai fire expert continues to call for stricter fire-safety regulations based on NFPA codes and standards—and for a national will to enforce them

NFPA Journal®, January/February 2010

By Pichaya Chantranuwat

News Update: (Feb. 17, 2010) The BBC reports four people have been formally charged over the Santika nightclub fire in Bangkok.   Read more

In the early minutes of January 1, 2009, more than 1,000 people were packed into a nightclub in Bangkok called the Santika Pub. Most were young Thais, but there were also revelers from around the world, including the United States and Europe, who were drawn to the club for its reputation as one of the hottest nightspots in the city. The attractive space featured a large main-floor dance area, a stage, and mezzanine sections that overlooked the dance floor. The New Year’s Eve celebration was called "Goodbye Santika," because the owners of the club were planning to close the facility and reopen in a new location. The featured band for the "Goodbye Santika" event was a popular group called Burn.

Shortly after midnight, Burn was performing onstage. The dance floor was filled with people, many of whom photographed the band with cell phones. As part of Burn’s act, pyrotechnics were lit; sparks shot toward the ceiling. A video of the event, shot with a digital video camera found at the scene, shows the pyrotechnics going off; moments later, at about 12:15 a.m., sparks begin to fall back down from the ceiling, landing around the stage. Over the next minute or so, the video shows the singers for Burn, as well as people in the audience, looking up at the ceiling frequently as the falling sparks grow larger and more numerous. In the next minute, larger pieces of flaming material fall from the ceiling as the fire at the ceiling level grows. The fire was first reported to the Thong Lor Police Station at 12:20 a.m. The city’s fire rescue center, Rama Center, however, did not receive a call until 12:40 a.m. Two fire trucks from Phra Khanong and Bangkapi fire stations, located about 2.5 km from Santika, struggled through heavy traffic and arrived at the club at 12:48 a.m.

In the 28 minutes that elapsed from the time of the first call until firefighters arrived on the scene, fire engulfed the building. People inside made desperate attempts to get to one of the building’s four exits. The electricity failed and the lights went out, making escape even more difficult. More than 400 people tried to descend from the club’s mezzanine sections, worsening the situation at the already-crowded main entrance. As the smoke and flame intensified, and as large metal pieces began to fall from the ceiling, people diverted their escape attempts away from the main exit to the windows, the back doors, and the basement. People succumbed to the smoke and high levels of toxic gases. A large circular steel bar holding stage lighting and connected to the building’s roof structure collapsed, pulling a large portion of the roof down with it. Fumes and smoke escaped through the hole, but the sudden rush of air from the outside also intensified the flames inside.

As emergency workers tended to the injured, firefighters fought the blaze and attempted to rescue more people from inside. Additional firefighters arrived on the scene; 120 firefighters were joined by numerous volunteers and local police, until the rescue effort numbered more than 200 people. More than 80 vehicles were on the scene, including 50 fully equipped fire trucks. The blaze was brought under control at 1:15 a.m., and was extinguished at 1:30 a.m.

As the night went on, it became clear the fire had taken a terrible toll as body after body was removed from the charred remains of the building. In all, 55 people died at the scene, and another 11 died en route to or at local hospitals. Another 229 were injured. It was the worst nightclub fire in Thailand’s history, and the seventh-worst international nightclub fire on record, a list that now includes the Lame Horse nightclub fire that occurred in Russia in December.

The Santika fire, and the subsequent investigation, have alerted Thailand to the fact that there are still many potential hazards and vulnerabilities regarding fire safety in entertainment venues, from the most visible features like building construction materials and designs to the country’s inadequate or lax fire safety regulations and policies. It may be a turning point; in response to Santika, the Thai government has called for the national adoption and enforcement of fire-safety regulations, based on the recommendations in the NSCT report that we adopt new fire safety criteria and regulations based on the requirements in NFPA codes and standards.

Primed for a "disastrous outcome"
A police investigation concluded that the fire started when pyrotechnics shot from the club’s stage ignited a blaze on the club’s ceiling. A closer look at the building and the situation inside the club on the night of the fire show that conditions existed for a disastrous outcome in the event of a fire.

The three-level building included a ground floor with a main assembly hall of 306 square meters, a mezzanine with 236 square meters, and a 128-square-meter VIP room separated from the main assembly hall. There was also a small sub-basement where the bathrooms were located. Based on square-footage capacity guidelines in NFPA 101®, Life Safety Code®, Santika’s main floor could accommodate a maximum of 898 occupants. For the "Goodbye Santika" event, eyewitnesses estimated the crowd to be at least 1,200, far more than would be considered safe in countries where regulations exist to limit the number of people that can safely occupy a building.

The building had only one main entrance, located at the front. The widest opening of the door was slightly more than 2 meters. There was also another door at the side of the building, which opened both in and out. There was an entrance at the back of the building, which opened to a hallway that led to the main assembly hall. There were two double doorways in the hallway: one located near the back entrance, and a second, slightly narrower door located closer to the main hall. That door opened inward, opposite the direction of an emergency evacuation and a fundamental violation for egress doors in assembly occupancies.

There were not enough fire exits, and those exits were not designed with sufficient capacity, to facilitate the evacuation. There were also no regulations to force business operators, architects, or engineers to comply with the guidelines set forth in NFPA 101. According to NFPA 101 requirements, the main front entrance should have been more than 3 meters wide and sized to accommodate two-thirds of the allowable occupant load. Computer egress modeling showed that the estimated time for a complete evacuation under normal circumstances would be about nine minutes. This process would involve a long queue of people waiting to leave the building via the main exit, given the width of that exit. The primary exit became a trap; 32 of the 55 people who died inside the building were found just inside the main entrance.

The building that housed Santika was mostly made of steel. The ground floor was concrete construction, and the exterior walls were built with bricks. The truss-style roof structure was made of steel. There was no principal column in the main assembly hall, but rather a number of supporting columns that were partly covered by decorative fiberglass resin. The building’s windows and doors, with curved steel frames attached, were made with either plain or filmed glass.

A number of materials in the building were highly combustible. The metal roof was insulated with a combustible cellulose-like product, which likely provided the fire’s first fuel package. Sound proofing was provided by flexible foams made of polystyrene and polyurethane, each of which possesses thermal energy rivaling that of burning gasoline. Parts of the inner walls were also decorated with brick-shaped fiberglass resin and sponge-based padding, both highly combustible. The floors, walls, and ceilings of the mezzanine sections were covered with plywood sheets. It is likely that many people lost consciousness due to the toxic gases and smoke released by these materials, and eventually succumbed to the lethal mix that resulted from the products of combustion.

The situation inside the burning club was made worse by obstructions, including tables, chairs, and other items blocking the means of egress and the access to the exit doors. There were no fire exit signs, and no emergency lights, except for one in front of the kitchen area. There was no fire alarm system, and no sprinklers. There were three hand-held fire extinguishers, two of which were later discovered unused.

Away from the venue, communication between concerned parties was poor. Eyewitnesses did not report the fire to the fire rescue center, Rama Center, with its "199" hotline; instead, they called the Thonglor Police Station. The fire service was not notified of the fire until 20 minutes after it had been first reported, and it took another eight minutes to get crews to the site, a result of heavy New Year’s Eve traffic. Firefighters arriving at the scene said they could not reach it immediately because of the taxis parked in front of the building, and because of the number of people who had escaped the burning club and were attempting to drive their cars out of the parking lot.

In general, the problems that firefighters and rescue personnel faced were problems common to emergency situations in Thailand. The personnel and equipment that first reached the scene were inadequate and deployed inefficiently, and the overall effort was poorly coordinated; the approximately 20-minute delay in notifying the fire department is itself a major cause for concern. The first firefighters at the scene did not have the proper personal protective equipment, nor did they have self-contained breathing apparatus. Such equipment is necessary to allow the firefighters to gain entrance to the structure, commence any firefighting actions, and attempt the rescue of any occupants who would still need to be brought out of the building. They also had to help rescue workers move victims to waiting ambulances, which were about 100 meters away. Despite the difficulties they encountered at the scene, rescue workers managed to save a number of people with cardiopulmonary resuscitation.

Avoiding future Santikas
The fire-safety problems that exist in Thailand, a nation of more than 66 million people, are not the responsibility of any single group or authority. It is up to many different stakeholders to ensure this kind of disaster never happens again.

Business owners need to be critically aware of the safety management of a building. Maximum occupancy limits need to be established; the rule of no more than one person per one square meter of space—NFPA 101 allows one person per 0.65 square meter—should be rigorously enforced. Signs stating the building’s capacity should be clearly displayed on the front of the structure, along with its service permit, proof of insurance, and the names of the people in charge of the building. Rehearsals of fire evacuations, with staff leaders and crowd managers being clearly designated, should be held regularly. There should be a plan for managing traffic during an emergency. A building should also be annually inspected to ensure that basic fire safety features, such as adequate and clear/unobstructed exits and exit access paths, are maintained.

For architects, engineers, builders, and inspectors, NFPA codes should be applied in all design, construction, and permitting work. Fire alarm systems and signal transmissions to a fire station should be installed following NFPA 72®, National Fire Alarm and Signaling Code®; automatic sprinkler systems should be required to be designed and installed in accordance with NFPA 13, Installation of Sprinkler Systems; and smoke control and ventilation systems should be installed following NFPA 92B, Smoke Management Systems in Malls, Atria, and Large Spaces. In accordance with NFPA 101, all buildings should include exit signs and emergency lighting. Building construction type and materials should be fire resistive or noncombustible in accordance with NFPA 5000, Building Construction and Safety Code; glass materials and glazing should be safety rated. Any sound-proof insulation materials should be flame retardant and covered with gypsum boards or other noncombustible material if necessary. NFPA 101 also needs to be followed to determine the proper number, width, and distribution of exits.

Policy makers and government officials should undertake a number of short- and long-term efforts. Most immediately, they should strictly adhere to the guidelines set forth in the National Fire Safety development master plan. They should strictly enforce the Building Control Act, and develop new regulations with the help of the Council of Engineers. The "199" fire emergency hotline should be publicized more widely, and a new information center regarding fire safety should be established. More training resources should be developed and offered for nightclub staff and business operators. Specifically, any such training needs to outline the responsibilities of the trained crowd managers. Fire and rescue communications should be improved so that personnel can reach an incident within eight minutes of its being reported. Finally, a committee should be established to study the Santika incident and develop a plan to respond to and implement the recommendations made in the various investigative reports.

Longer term, a new National Fire-Safety Committee should be formed to assess fire safety in certain kinds of buildings. A national fire-safety institute should be established, along with a model fire station to help us develop greater efficiencies in both the notification and response to any emergency incident. Thailand’s databases regarding fire incidents and fire safety should be overhauled. A rigorous national building code should be implemented as soon as possible, and building inspection regulations should be amended to focus more on practical fire-safety measures during the use of a building.

Change is already beginning to happen. Thailand’s Department of Public Works, along with the Ministry of the Interior’s Town & Country Planning, are pushing for a new fire-safety regulation for entertainment venues. The regulation outlines requirements for fire-safety measures that include installations of fire detection, alarm, and suppression systems, fire exits and signs, emergency lights, venue capacities, and fire evacuation rehearsals. Advocates hope this regulation can be adopted within the next six months.

Pichaya Chantranuwat is managing director of Fusion Fire Safety Co., Ltd., a consulting firm in Bangkok.

SIDEBAR
A fire expert’s personal plea
The author’s in-depth Santika report helps spur a government to action

Pichaya Chantranuwat (pictured) is vice chairman of the Disaster Study, Research, and Development Committee for the National Safety Council of Thailand (NSCT), and is a member of the Technical Committee on Fundamentals of Life Safety and Means of Egress for the 2009 edition of NFPA 101®, Life Safety Code®. He is also managing director of Fusion Fire Safety Co., Ltd., a consulting firm in Bangkok.

This article is based on a report on the Santika fire that Chantranuwat prepared for the NSCT. The report examined in detail the underlying factors that resulted in significant loss of life in the fire, including occupant capacity, means of egress, and the building’s design and materials. Based on his findings, Chantranuwat’s report included a lengthy list of recommendations for improving fire safety in Thailand, including the adoption of NFPA codes and standards and a more organized, disciplined approach to enforcement.

Based on his report, and on his personal plea that fire safety be given more regulatory attention throughout the country, the Thai government is currently advocating for regulations designed to improve fire safety in entertainment venues. Chantranuwat and other supporters are hoping that those efforts can be turned into law sometime in 2010.

SIDEBAR
The enforcement problem

Much of the public outcry in the wake of the Santika fire has focused on the absence of inspection and enforcement of public buildings in Thailand, especially nightclubs. A 2007 law requires all public buildings, including bars and nightclubs, to undergo safety inspections. The BBC reported in April that of the 6,000 public buildings in Bangkok, about 3,000 had been inspected—but none were bars or nightclubs, and only 200 of the buildings inspected had passed.

"If you go to a nightclub in Bangkok, and you want to be safe, always check where the exit is, and stay close to it," a representative from the Engineering Institute of Thailand told the BBC.

According to press reports, a Ministry of Justice investigation found that Santika was licensed as a private residence rather than a club, and had therefore undergone no fire safety inspections. The BBC reported that police filed 47 charges of operating illegally against the club from 2004 to 2006, whereupon the charges abruptly stopped; it also reported that a senior police officer was a shareholder in the club, and was clearly listed as such in company documents.

Also fueling public anger is the apparent difficulty on the part of law enforcement to hold anyone accountable for the fire. The Bangkok Post reported in October that police were recommending indictments for seven people, including club owners and managers, along with a singer from the band Burn, whose act included the fireworks that police determined were responsible for the blaze. So far, no arrests have been made. A number of civil lawsuits have been filed against the owners of the club by survivors of the fire, as well as by the families of people who died.

In June 2009, NFPA signed a memorandum of understanding (MOU) with The Bangkok Metropolitan Council of the Kingdom of Thailand. The MOU program, NFPA’s leading international initiative, sets in place mechanisms to strengthen new and existing collaborations to promote the knowledge of fire, electrical, and life-safety standards in countries around the world. Through this particular MOU, NFPA will collaborate with the Bangkok Metropolitan Council to develop guidelines used for enacting fire-protection laws in Bangkok. Specific assembly occupancies were listed, including entertainment facilities, malls, theaters, and sports arenas. For more information on NFPA’s MOU programs, visit www.nfpa.org/international.

SIDEBAR
The global nightclub problem

As it did at Santika, and as it did at The Station nightclub fire in Rhode Island that killed 100 in 2003, the combination of pyrotechnics and a crowded club has again proved lethal.

As this issue was going to press, the story of the Lame Horse club in Perm, Russia, was criss-crossing the globe. A party at the club on Dec. 5 included a pyrotechnics display, which apparently ignited a plastic ceiling decorated with tree branches. Hundreds of people attempted to escape through the building’s single exit. At last count, 150 people had died, and more than 130 were injured, many in critical condition. The Associated Press reported that the city’s regional government resigned in the wake of the blaze, and that several regional fire safety officials had been fired. According to the AP, four people, including the club owner and a pyrotechnics supplier, have been jailed pending a negligence investigation.

Olga Caledonia, executive director for global operations at NFPA, points to a lack of legislation and an insufficient "culture of safety" in many countries as reasons for the ongoing problem of nightclub fires around the world. "The story of Santika has repeated itself in just about every international nightclub tragedy over the past decade," she says. "There is a common pattern: overcrowding, highly combustible interior finishes, insufficient exits, and an absence of automatic sprinklers."

Caledonia says NFPA’s efforts in Eastern Europe are through the International Association of Fire and Rescue Services, better known as CTIF. NFPA’s influence has "greatly increased" in the 50 CTIF member countries, including Russia, Caledonia says. She adds that NFPA is exploring the possibility of working closer with Moscow’s volunteer fire service.

Gary Keith, vice president of field operations at NFPA, says events like Santika or Lame Horse—or The Station—are proof that nightclub fires are a global problem that includes countries with comprehensive fire codes, including the United States. "In spite of the lessons learned from The Station nightclub fire and changes that were made to model code provisions, we know that the issue of use and enforcement of those provisions will require constant vigilance to minimize the risk of fire in nightclubs," Keith says. NFPA members can help minimize that risk, he says, by "supporting the adoption of NFPA model codes and standards, along with the level of enforcement necessary to affect their proper use in these venues."

No matter what hemisphere the risk is in, the best codes in the world mean nothing if they aren’t implemented, says Caledonia. "Otherwise," she says, "all of NFPA’s know-how and experience from the last 110 years will not have the impact that it could."