Board and Care Fire, Ste. Genevieve, Quebec
Saturday, August 31, 1996
8 People Killed

NFPA Report by Ed Comeau


A fire occurred on Saturday, August 31, 1996 at 12:30 p.m., in a board and care facility, which was occupied by 41 elderly residents. Seven residents died as a result of this fire.

The building was a two story structure that had an occupied basement, with a reinforced masonry exterior. The roof and floor structural systems were lightweight wood trusses. The ceilings were also either 1/2 inch (13 mm) or 5/8 inch (16 mm) sheetrock, which were attached to the bottom chord of the trusses.

The building was not sprinklered. It was equipped with a fire alarm system that was comprised of system heat detectors in each of the rooms, two system smoke detectors in each hallway and two system heat detectors in each hallway. Manual fire alarm boxes also were located in the hallways. The system reportedly transmitted a signal to a central monitoring station.

There were eight staff members on duty at this time.

The fire was determined to have started in Room 208, which was occupied at the time. A staff member on the third floor heard a noise and went to the second floor to investigate. Upon arrival she saw the fire in the closet in Room 208. She proceeded to remove the occupant from the room and then went to sound the alarm.

The fire spread from the second floor to the third floor via an open exterior window on the room of origin, traveling up the outside of the building and then re-entered the building through a window directly above the room of origin. Also, at some point, the roof structure was ignited by direct flame impingement on the exterior of the building.

Fire also spread through the interior of the building when it breached the ceiling in the closet in Room 208 and then spread laterally through the floor trusses between the 200 and 300 levels. The wall between the resident's rooms and the corridor did not extend fully through the combustible void space. Fire and smoke also spread through the open door to the room of origin, into the corridor on the 200 level. Since the corridor doors and the stairwell doors were propped open, fire was also allowed to spread via these avenues.

All seven fatalities were residents who were on the third floor. According to information provided by the facility, four were considered ambulatory patients and three required the use of wheelchairs. Their ages ranged from 74 years old to 90 years old.

Based on the NFPA's investigation and analysis of this fire, the following, significant factors were considered as having contributed to the loss of life and property in this incident:

  • Lack of automatic fire sprinklers
  • Fire spread through a combustible void space
  • Inadequate corridor separation
  • Combustible room contents
  • Combustible contents in the corridors
  • Delayed notification of the fire department
  • Staff response
  • Open doors on stairwells, on the occupant's rooms on the 300 level, and on the room of origin.

There have been seven fatal board and care fire investigated by NFPA since December, 1984. These seven incidents have resulted in a total of 50 fatalities over a period of 3-1/2 years. The other six incidents include:

A related article on board and care fires was written by Ed Comeau for NFPA Journal and can also be seen on-line.

© 1996 National Fire Protection Association, Quincy, MA
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