View images from the NFPA visit to the scene of the prison fire in Comayagua, Honduras.
NFPA Journal®, September/October 2012
By Jaime A. Moncada, P.E.
In the early-morning hours of Wednesday, February 15, I began receiving emails and text messages about a terrible fire in Honduras. Details weren’t completely clear, but a blaze had occurred the night before at a prison in the city of Comayagua. The two buildings used to house inmates were unsprinklered, and the fire moved rapidly through one of the structures, trapping and killing hundreds of prisoners. Early reports were that more than 350 inmates had died in the fire, which would make it one of the deadliest prison fires recorded during the modern era.
I immediately contacted Olga Caledonia, NFPA’s director of International Operations, who agreed that we should document this fire and that I should visit the National Prison of Comayagua, where the fire had occurred. We contacted Antonio Macias, NFPA’s regional director for Mexico, Central America, and the Caribbean, who agreed to accompany me on the trip. I also called Jaime Omar Silva, chief of the Honduran Fire Service, who pledged his support and encouraged our visit. Our objective was to observe the scene and interview as many people as we could, with the goal of summarizing how and why the fire happened and how the application of NFPA codes and standards could have minimized property damage and loss of life. We arranged to arrive in the Honduran capital of Tegucigalpa on Sunday, February 19, where we would meet with Chief Silva.
I was anxious about arriving in Comayagua, because this was no ordinary fire. Aside from the horrific loss of life, the fire brought into stark relief the country’s enduring problem of prison fires — this was the third major prison fire in Honduras since 2003 — as well as the larger problem of prison and jail fires across Latin America, which in recent years has experienced more than its share of some of the world’s worst fires in these occupancies. Some Latin American nations are taking steps to address this problem, which has killed hundreds, if not thousands, of people over the past decade, but much more needs to be done, starting with more widespread adoption of NFPA codes and standards. In Comayagua, neither smoke alarms nor sprinklers existed; if they had, the outcome of this devastating fire could have been vastly different.
We arrived in Tegucigalpa as planned on February 19, but events were already complicating our visit. The day before, a massive fire had destroyed a large complex of markets in the city, and Chief Silva told us he was consumed with the aftermath of the incident and would not be able to help us right away. After exploring other possibilities for accessing Comayagua and reaching only dead ends, Antonio had an idea. “Why don’t we just go up there?” he asked me one morning in our hotel. We had little to lose at that point. We gathered our things and were soon on the road in a hired car.
Comayagua is located in west-central Honduras, 55 miles (88 kilometers) northwest of Tegucigalpa. Comayagua, with a population of about 70,000, is a manufacturing center and hosts, at the nearby Soto Cano Air Base, the Joint Task Force–Bravo (JTFB) of the U.S. Department of Defense Southern Command. JTFB manages, among other things, a regional firefighter training camp at the base. The prison is located in the southwestern part of the city, in the Independencia neighborhood, and is surrounded by residential neighborhoods and commercial/light-industrial buildings.
We arrived at the gates of the prison dressed in our NFPA shirts and hats, and local officials at the scene were courteous and accommodating. “Fire investigators?” a policeman asked our driver. “Si,” he replied, and we were immediately escorted through the gates. Antonio’s hunch had been right.
The prison was still under investigation as a crime scene. The Honduran government had approached the U.S. Embassy in Tegucigalpa for assistance with the fire investigation, and the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) of the U.S. Department of Justice had dispatched its International Response Team to Comayagua to conduct an independent investigation. ATF personnel were still scouring the site. Through a Freedom of Information Act request, we later obtained a redacted copy of the ATF’s cause-and-origin fire investigation report; most of the details of the fire cited in this story are taken from that ATF report. (To view the ATF report, visit nfpa.org/prisonfires.)
The prison was also still in use, with the remaining residential building housing prisoners. As are most Honduran prisons, Comayagua is home to a large population of inmates that belong to gangs that are notoriously violent, and during our visit we were under heavy police protection. Even so, we were given full access to the fire scene under the escort of an officer from the Comayagua Fire Department. Local officials would only provide information on background, however, and none agreed to be quoted for this story by name.
Inside the prison compound, I was immediately struck by how small the two residential buildings were, and how cramped the conditions were inside those buildings. The prisoners had spent a lot of time and effort making their small bunk-bed cubicles their own, but in the process they had created a highly combustible cell. I could not believe that hundreds of people had lost their lives in such a small space.
The facility, defined as “Use Condition V–Contained” in NFPA 101®, Life Safety Code®, is a 1940s-era complex that was designed as a prison farm. The site covers 36 acres (14.6 hectares) and is surrounded by an 8-foot (2.4-meter) fence. A contained group of buildings, surrounded by farming land, is located at the core of the site, secured by walls, including the residential, assembly, and administrative portions of the prison. The prisoners sleep in two large structures constructed of brick-and-cinderblock walls, concrete-and-tile floors, and pitched roofs made of corrugated metal, with various amounts of wood.
The residential structures run parallel to each other and are separated by an uncovered walkway 16 feet (5 meters) wide. Each structure is roughly 96 feet (29 meters) long by 52 feet (16 meters) wide, with an approximate constructed area of 4,995 square feet (464 square meters), subdivided into five modules, or large cells. The cells are identified as Modules 1–5 on the south structure and Modules 6–10 on the north structure. (Although building construction type can be difficult to determine in Latin America, these buildings most closely resemble Type II  construction, per NFPA 220, Types of Building Construction.) The modules share interior walls; barred horizontal openings about 3 feet (1 meter) high run the length of the walls, opening the upper portions of the cells to neighboring modules. The prison was originally designed to house 520 inmates, but at the time of the fire it housed 852.
Module 6, where the fire started, was typical of the cells at Comayagua. The cell was 18 feet (5.5 meters) wide and 50 feet (15 meters) long, with a pitched metal roof 16 feet (4.9 meters) high at its peak. The cell housed 96 inmates in two rows of steel-framed bunk beds, each row against one of the module’s long walls. The beds were tightly packed, stacked four levels high and separated by 20 to 30 inches (50 to 76 centimeters). The rows of beds were separated by a 4-foot (1.3-meter) open corridor that led from the cell door to the bathrooms, located at the back of the module. A 34-by-80-inch (86-by-203-centimeter) opening, surrounded by a masonry wall, provided access to the bathrooms, which were constructed of non-combustible materials and included two sinks, two toilets, a bathing closet, and a clothes-washing table. The bathroom included a barred window measuring roughly 9 feet (3 meters) long by 3 feet (1 meter) high on the exterior wall. At the front of the module, a 55-by-80-inch (140-by-203-centimeter) barred cell door provided the only exit. Most of the prison’s modules were similar in their characteristics, with the exception of Module 9, which contained only a single level of beds and an inmate population estimated at between 12 and 20.
To create a bit of privacy for themselves in the cramped conditions, most inmates enclosed their individual bunks with a variety of items such as wood board and thin combustible cloth materials such as sheets, towels, bed covers, and drapery, which were often sewn together. Each bunk included a combustible mattress that was 4 inches (10 centimeters) thick, made of a polyurethane cushion wrapped with multiple layers of thin cloth.
According to observations made by the ATF, each module at the time of the fire included approximately 6,288 square feet (584 square meters) of draped cloth and 538 cubic feet (15.2 cubic meters) of mattress padding. Due to the orientation of these materials, most surfaces were exposed. In addition, bunks throughout the modules, including some in Module 6, were serviced by electrical extension cords connected to lights, hot plates, fans, radios, televisions, and microwave ovens.
There were no sprinklers, smoke detectors, fire alarm pull stations, manual extinguishers, or any other fire protection systems in any of the prisoner modules.
Fast fire, devastating consequences
The time the fire started on the evening of February 14 has not been precisely determined. The ATF estimates it at 10:20 p.m., but our interviews with first responders from the Comayagua Fire Department put the start time closer to 10:50 p.m. According to local fire officials, Honduras’s central emergency dispatch center in Tegucigalpa received several cellular phone calls, almost simultaneously and most likely from prisoners, reporting the fire. We were not able to confirm the time these calls were received. The Comayagua Fire Department, located a little over a mile (about 2 kilometers) from the prison, received a call from the emergency dispatch center at around 10:58 p.m. Two fire engines were dispatched immediately and arrived at the prison gate approximately two minutes later.
ATF interviews with survivors indicate that inmates in Module 6 saw, or were awoken by, fire in an upper bunk near the exit door, and that attempts were made to extinguish it with a pail of water. Initially, there was little commotion; one inmate, assuming the fire would be brought under control, even went back to bed. However, the fire grew out of control. Fueled by the cell’s available combustibles, it spread upward and outward to adjacent bunks, then downward, a result of drop down from burning polyurethane foam from the mattresses and other combustibles. The flames grew, and thick smoke filled the cell. Soon, the flames were reaching through the barred window opening into Module 7. Inmates could not contain the fire in Module 7, either, and the blaze continued its progression into the next module.
The commotion inside the cells as the fire rapidly spread alerted what many witnesses describe as a “medic” — this person may also have been an inmate who lived in the prison infirmary, according to the ATF report. The medic had access to keys to the module doors, and he ran to the fire scene to release the trapped prisoners. According to the ATF report, as he made his way to Module 6, he did not see flames coming from Modules 7–10, but he did see smoke. He arrived at Module 6, where he saw substantial flames, and lost time looking for the right cell key. He described the heat as being incredibly intense and as being above him, radiating downward. He found the correct key and unlocked the cell, and three inmates ran from the building.
The medic ran to Module 7 and opened the door. Three inmates exited, and several others escaped through a hole they’d managed to tear in the sheet-metal roof. The medic reported seeing flames in the upper portion of Module 7. He ran to Module 8, where he also saw flames, and opened the door, with two inmates exiting. He saw heavy smoke but no fire at Module 9, and continued past it to Module 10, where he saw flames. He opened the door, and four inmates ran out. He returned to Module 9, where a small but unknown number of inmates exited through the open door. He also saw inmates leave through the roof. He then proceeded to open Modules 2, 3, 4, and 5, located in the building facing the structure that housed Modules 6–10. He reported no smoke or flame in these modules. Module 1 had been opened by an inmate who had gotten out and retrieved a weight-lifting bar from the gym, which he used to pry the lock from the cell door.
The responding units from the local fire department arrived at the prison at approximately 11 p.m., but were held for about six minutes, as documented in the ATF report, before they were allowed entry. Although it is unclear why the responding units were held, it is probable that they were detained until the released prisoners could be secured. When the responding firefighters reached the modules, all the cell doors were open. Two hand lines were used to start extinguishment, one on Module 6 and the other on Module 10, working towards the middle of the building. Extinguishment was achieved within a few minutes. While the fire’s start time is not clear, the blaze may have lasted as little as 20 minutes from ignition to full extinguishment.
By then, however, there was little left to recover. The ATF report found that the fire had consumed virtually every speck of combustible material in Modules 6–10, and firefighters and rescue personnel were met with horrific scenes inside the blackened cells. During the fire, the prisoners in Modules 6, 7, 8, and 10 had retreated to the bathrooms in an attempt to escape the flames, in such numbers that the bodies were stacked four high. Estimates vary, but the number of inmates who died in those modules ranged from 77 in Module 7 to 100 in Module 6. In Module 9, anywhere from 6 to 10 bodies were recovered, including that of a woman. The fact that the fire started toward the front of Module 6, where the exit door is located, and spread to the fronts of the other modules supports the opinion that most of the prisoners moved to the rear of the cells and perished in the bathrooms. No fire deaths were reported outside Modules 6–10.
The building housing Modules 1–5 received radiant heat exposure. A building serving as a school for the prison, located to the west of the module buildings, and an administration building, located to the east, sustained thermal damage and arcing damage from melted electrical wires.
According to the ATF report, the fire was accidental. ATF concluded that the fire started within or around the top two beds on the fourth column of bunks, counting from the module’s door, against the western wall of Module 6. The cause of the fire is believed to be the unintentional application of an open flame or smoking material to available combustibles, possibly to one of the curtains or other combustible materials surrounding the bunk beds. According to the ATF fire investigation, the fire dynamics are consistent with this scenario. The bunk beds stacked four high in Modules 6, 7, 8, and 10 allowed combustible materials such as mattresses and curtains to be close to or at the smoke layer. This layer would have had high and uniform temperatures, sufficient to ignite mattresses and bedding and to spread from one module to the next through the barred horizontal openings at the top of the interior walls. Module 9 only contained single beds, which supported the medic’s claim that he only saw smoke and no flames.Based on survivor interviews, there were no arguments or fights before the fire. A supposed arson/suicide attempt by an inmate, reported in the local media, was also discounted.
At the conclusion of the ATF investigation, 361 fatalities had been reported. Most died at the scene, although a small number who survived and were hospitalized later succumbed to their injuries. The number of injuries associated with the fire is unknown.
Big picture: The Latin American prison fire problem
While Comayagua may be the deadliest prison fire ever recorded, it is not an isolated incident, either in Honduras or in Latin America.
Honduras has had more than its share of Latin America’s deadliest prison fires in recent years, including a fire in 2004 at the prison in San Pedro Sula that killed 101. The Honduran government said then that the nation’s prison system, designed to hold 8,000 but stretched to hold somewhere around 13,000, needed to be overhauled, and it repeated that message in the aftermath of the Comayagua fire.
Critics say that isn’t enough. A recent report by the Inter-American Commission on Human Rights accuses the Honduran government of all but abandoning its prison system, tolerating severe overcrowding and a lack of trained personnel to respond in a crisis. A commission investigator told the Associated Press (AP) in May that it was “likely that something grave will happen in the future in Honduras’ prisons, given that the situation hasn’t changed from what existed three months ago,” referring to the Comayagua fire. An inmate at the San Pedro Sula prison told the AP that, while the cells are locked at night, inmates have keys and crowbars to help them escape in case of fire, since “the police would run away and leave us in here.” Similar charges were leveled at guards at Comayagua; the prison director was dismissed, but the guards who fled the fire were reassigned to other prisons, the prison’s new director told the AP.
Honduras is emblematic of a much larger Latin American prison fire problem. Six of the 10 deadliest prison fires worldwide in recent years occurred in Latin America: three in Honduras and one each in Venezuela, the Dominican Republic, and Chile. Documented prison fires have killed at least 900 people throughout Latin America over the past 12 years, although the actual figure is probably much higher. Over roughly that same period, the U.S. prison system recorded eight fire fatalities through 2010. The International Centre for Prison Studies estimated the U.S. prison population at 2.3 million by the end of 2007, and the prison population in all of Latin America at 1.2 million. This means that the likelihood of dying in a prison fire in Latin America is more than 200 times higher than it is in the United States.
Many of the worst fires in Latin American prisons are the result of overcrowding and lack of adequate levels of fire safety. Curtains and other combustible materials surrounding prison beds are common in Latin American jails, as are electrical appliances and the resulting overloaded electrical outlets. In the 2004 San Pedro Sula fire, Honduran government officials reported 75
electrical appliances in a 33-by-49-foot (10-by-15-meter) cell. Fires such as the one in San Pedro Sula are sometimes a byproduct of inmate fights, where the mayhem, coupled with open flames, extension cords, and abundant combustible materials, can result in fires. While a lack of sprinkler and smoke detection systems is common in Latin American prisons, most detention and correctional facilities in the region do include fire hose cabinets and fire extinguishers. It is also common that a fire brigade is present.
Some countries are beginning to take action. Argentina is retrofitting its prisons with smoke detection systems but is not requiring sprinkler protection. Chile is protecting some of its prisons with sprinklers, but local contractors complain that the tender documents do not call for the tamper-proof institutional sprinklers typically found in prisons and other confined occupancies. In most jurisdictions throughout Latin America, local codes do not require acceptable levels of life safety or do not specify or recognize the unique fire protection and life safety challenges that are posed by correctional facilities.
The best way to address the problem throughout the region is via a code-driven solution, such as the one currently proposed for Honduras. Despite being one of the poorest nations in the Western Hemisphere, the country has a well-developed fire department system, but it must contend with a local building code that is very basic and with code enforcement that is ineffective and not well developed. NFPA is currently working with the Honduran Fire Department and the Honduran Ministry of Interior on a bill that would adopt the 2009 edition of NFPA 1, Fire Code, in Spanish, as the Honduran Fire Protection and Life Safety Code. Under the current procedure, and typical of similar adoption projects elsewhere in Latin America, Honduras would modify Chapter 1, “Administration,” of NFPA 1, and would leave the rest of the code intact. NFPA would provide assistance in training and application of this code to the local authorities having jurisdiction. NFPA 1 includes detailed information on how to define detention and correctional facilities, as well as which life safety and fire protection measures must be implemented, regardless of whether the facility is new or existing.
In detention and correctional facilities, as in many other occupancies — mercantile, health care, assembly, storage, and high-rise, to name a few — NFPA codes have demonstrated an exceptional record of fire safety that is ready for adoption, particularly in the developing world. In these countries, many large new buildings resemble those in the developed world but lack critical fire safety features.
Although construction types may not be exactly the same, what is more common worldwide is an increased fire load of building contents, whether it is an office, a residence, a warehouse, or a hospital. Many of the contents and interior finishes in those structures have not been investigated for their burning characteristics. For example, many of the finish materials used in buildings and sold in the developing world do not have flame-spread, smoke-development, or heat-release rate information, nor have they undergone formal interior finish fire testing to establish flame-spread and smoke-development index properties.
Since 2000, most of the largest loss-of-life fires worldwide have occurred in developing nations. This trend is likely to continue, as we see ever-larger buildings being built in these nations without adequate concern for fire safety. In 2004, a fire killed 428 people at the Ycua Bolaños supermarket in Asunción, Paraguay. This was a modern building, constructed in 2002, but it did not contain an appropriate level of fire protection. In May, a fire at one of the most luxurious malls in the world, the Villagio Shopping Mall in Doha, Qatar, built in 2006, claimed the lives of 19 people, most of them children. Fires such as these should be extremely rare in a modern shopping center in a nation with a well-developed building code, where equivalent buildings are being designed — and, most importantly, commissioned — under increasingly stringent fire safety criteria. Enforcement and understanding of the code requirements through training and certification programs also cannot be overlooked.
For many developing countries, especially those in Latin America, the beginning of a long-term solution is imminent or well at hand. Adoption of NFPA codes and standards, already translated into Spanish, coupled with readily available training seminars and a local fire safety industry well-versed in NFPA requirements, can provide the start to a solution that may be impossible for local authorities to ignore.
While Antonio and I were in Honduras to document the Comayagua fire, we were invited to the presidential palace in Tegucigalpa for a ceremony marking the recent purchase of dozens of new fire trucks. Attendees included the country’s president, Porfirio Pepe Lobo, as well as the Honduran political hierarchy and the local press. As I listened to the politicians, I was reminded that our main challenge in Latin America is one of education, to help people — politicians, fire and building officials, the public — understand that additional fire trucks will not make this problem go away. The only way to address the root causes of this horrific trend, which includes not only fires in prisons but also in nightclubs, warehouses, high-rise buildings, hospitals, and many other large structures, is through clear, cost-effective fire codes, coupled with effective enforcement. Only then can we turn the corner.
Jaime A. Moncada, P.E., is a licensed fire protection engineer in Highland, Maryland. He is director of International Fire Safety Consulting, a fire protection engineering consulting firm specializing in Latin America. He is also the international fire safety training/NFPA joint venture director for Latin America.
[Editor’s note: NFPA’s record of international fires in detention and correctional occupancies may be incomplete. The incidents presented here are representative of some of the deadliest fires worldwide in those occupancies and should not be considered a definitive ranking.]
An NFPA code analysis of the Comayagua prison
NFPA codes apply the total-concept approach to life safety, complete with a defend-in-place strategy, for all detention and correctional facilities. As the Comayagua fire illustrated, people in the prison are incapable of self-preservation because of security restrictions. The facility in Comayagua, therefore, would be classified by NFPA as a Use Condition V–Contained (NFPA 101: 18.104.22.168.5), where free movement was restricted from the modules and staff controlled the manual release of each door. An existing correctional facility such as the one in Comayagua, with Type II (000) construction, would require some of the following life safety and fire protection features:
As we confirmed during our visit to the fire scene, the prison had an abundant supply of combustibles but lacked sprinklers, smoke detection, a fire alarm system, and smoke protection between the modules. It is likely that sprinkler protection, while not the solution to all of the fire protection problems facing the prison at Comayagua, would have significantly reduced the number of fire deaths.
Safer But Imperfect: The U.S. Model
By far the deadliest prison or jail fire in U.S. history was the 1930 Ohio State Penitentiary fire, in which 320 people died. Since then, no fire in this type of occupancy in the United States has had more than 42 deaths. There were a number of such fires from 1975 to 1982, when eight of the ten deadliest U.S. prison and jail fires occurred, and common factors cited in those incidents were a lack of sprinklers, lack of a secure area of refuge to which prisoners could be evacuated, and the loss of keys controlling the fire-involved areas.
NFPA’s Division of Fire Analysis and Research estimates that just under 700 structure fires per year are reported in U.S. prisons, jails, and police stations. The last major fatal fire in a correctional or detention facility was in 2002 at the Mitchell County jail in Bakersville, North Carolina, where eight people died. The latest NFPA report on sprinklers indicates that sprinklers were reported present in 53 percent of reported structure fires in prisons and jails, which means that nearly half of the fires were in facilities that remain unsprinklered. Even so, the percentage of sprinklered facilities is up sharply from NFPA estimates of the 1980s and 1990s.
While fire protection in U.S. prisons and jails is generally much better than that found throughout much of Latin America, the comparison is not as stark as it may initially appear. The U.S. prison population has quadrupled since 1980, and by the end of 2007 numbered more than 2.3 million, according to the London-based International Centre for Prison Studies. One result of this tremendous growth is that the prison system has been operating at or over capacity for some time. The Bureau of Justice Statistics reported that in 2008, state prisons were operating between 97 and 108 percent of capacity and that 13 states and the federal system were operating at more than 100 percent of their “highest capacity.” Experts have raised concerns that overcrowding diminishes living conditions for inmates while making it more difficult for thinly stretched staffs to maintain order. In addition, shrinking state and local government budgets have led to a significant increase in the use of makeshift housing arrangements at prisons and jails across the country.
It is critical for those who adopt and enforce code provisions for these occupancies to continue to maintain vigilance over the safety of the occupants, who in most cases have minimal control over their ability for self-preservation during a fire.
This article could not have been completed without the kind invitation of General Commander Jaime Omar Silva, fire chief of the Honduran Fire Service, or Second Lieutenant Jorge Turcios of the Comayagua Fire Department, who escorted us around the fire scene. Additional support was received from José Geovani Lara with the Asociación Hondureña de Maquiladores. Assistance was also provided by Supervisory Special Agent Chris Porreca, Agent Dan Heenan, and John L. Allen, P.E., fire investigators with the International Response Team of the Bureau of Alcohol, Tobacco, Firearms and Explosives, all of whom provided introductions and “opened doors” with the Honduran prison officials during our visit to Comayagua.
In this Section:
|Lessons of Comayagua
In the aftermath of a prison fire in Honduras that killed 361 people, Journal looks at how NFPA codes can improve fire safety in prisons and many other occupancies throughout Latin America.
|After Waldo Canyon
The costliest wildfire in Colorado history was a serious test of local mitigation and preparedness efforts. How effective was the mitigation, and how can it be improved?
|Fire Loss in the United States During 2011
Last year, U.S. fire departments responded to nearly 1.4 million fires, 4.4 percent more than the year before.
|Catastrophic Multiple-Death Fires in 2011
Last year, 23 catastrophic multiple-death fires resulted in 114 fire deaths, including 16 children under age six. An unusually high proportion of fires began with explosions.