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ANSWER QUESTONS 1 & 2 IN APA FORMAT WITH 200
WORDS EACH.
1. Compare and contrast the types of prevention and detection
systems used for explosions. Why would it be more difficult to
design controls for a room containing explosive materials than a
room containing only flammable liquids?
2. Discuss the unique properties of combustible dusts. What are
some prevention and suppression controls that can be used for
areas containing combustible dusts? What methods would you
use to identify areas where combustible dust is present?
PREPARE A CASE STUDY WITH THE ARTICLE ATTACHED
The case study and any additional sources must be cited in the
text and references provided in APA style.
A case study about a fire in either a hotel or high-rise office
building. Write a review of the case that is a minimum of 300
words in length. Your review should answer the following
questions:
ing that contributed to
either the start of the fire or the size of the fire?
that hindered the fire response?
building design or maintenance that you believe would have
prevented the fire from starting or reduced the severity of the
outcome?
2 0 TiMELLNE
OF DEATH
Cleveland Clinic Disaster
ANY OHIO DISASTERS have announced
themselves with a bang. The 1944 East
Ohio Gas Company fire hegan with
I a blast heard fourteen miles away.
Y The 1916 Cleveland Waterworks
explosion likewise made impressive noise, as did the
1908 S. S. Kresge tragedy, which commenced with literally
deafening fireworks.
Not so with the calamity that hefell the Cleveland Clinic.
It came, initially invisible and unrecognized, through the
ductwork and pipe conduits of the clinic building. It first
accosted its victims as powdery flecks and puffs of smoke
emanating from heating vents and registers. And many of
its casualties may already have been dead when the first
blast came at about 11:25 A.M.. May 15, 1929.
Then, as now, the clinic was one of Cleveland's great
success stories. Founded in 1921, it was the joint inspira-
tion of Doctors George W. Crile, Frank E. Bunts, and
William E. Lowther. Galvanized by their service together
in Cleveland's Lakeside Unit during World War I, the trio
had decided to put the model of team medical practice
developed in France to peacetime use. Joining with Dr.
John Phillips and drawing on the example of the Mayo
Clinic, the doctors, in only eight years, had created a
cutting-edge treatment center. Already world renowned,
the clinic annually welcomed thousands of patients who
came to find comfort and cure within its walls.
July August 2002 21
THE CLINIC BUILDIMG, CLEVELAND. OHCO. M
The Cleveland Clinic was a
¡oint venture by a group of
physicians to provide medical
services incorporating the
latest in specialized research
while also providing a setting
for postgraduate education.
The four-story main building
was completed on the
southwest corner of East
Ninety-third Street and
Euclid Avenue in 1921.
deveiand Clinic Archives
Even in 1929, the clinic was physically impressive.
Located just west of East Ninety-third Street on
the south side of Euclid Avenue, the four-huilding
complex included a 184-bed hospital and a research
building used for special laboratories, such as
radioîogy. The main building was a four-story
structure of reinforced concrete and brick. It
housed both administrative offices and rooms
used for consultation and outpatient procedures.
Considered "fireproof" when built in 1920,
the main building's primary activities occurred
in dozens of examining and consulting rooms
on the upper three floors. An interior court
rose from the second-fioor waiting room up
to a thirty-hy-thirtj'-eight-foot skylight.
Two elevators and two staircases
provided access to the upper fioors
whose mezzanine-style balconies
flanked the interior court.
Like most buildings of the era,
the clinic building's environ-
mental infrastructure deployed
from a central basement
location. Encompassing
about one-third the square
footage of the 75- by 124-foot
building, the hasement housed
unused steam boilers (rendered
redundant by the complex's new
central heating plant), fans for the
ventilation system, and storage
rooms for files, supplies, and
drugs. Fataiiy, it also contained
a storage room for x-ray films.
22 TIMELINE
Clinic chief Dr. George W. Crile subsequently
would insist that there was "no precedent" for the
clinic tragedy. That was not quite true, whether he
knew it or not. In September 1923, gases generated
by burning x-ray film and dispersed through a
ventilating system had overwhelmed victims at
a Syracuse hospital. And, in March 1928, eight
persons in an Albany hospital had heen killed
by fumes from burning x-rays.
The villain in botb disasters was nitro-
cellulose x-ray film. The actual x-ray image,
composed of silver pariicles suspended in a
gelatin layer, was not a problem. The film's
transparent base was. It was made of nitro-
cellulose, a polymer derived from organic
cellulose. While fiexihle and clear, it couid
ignite at oniy thi-ee hundred degrees
Fahrenheit and could b u m without an
independent source of oxygen. Indeed,
the film was unstable and could decom-
pose if improperly stored, making it
even more dangerous. Eastman Kodak
had placed the film on the market in
Raised on a farm in Coshocton County, Dr.
George Washington Crile was the drtving
force behind the clinic. He had a lifelong,
consuming obsession with research and
worked diligently to improve the practice of
surgery in the nation. He was a pioneer in
the diagnosis and treatment of shock and a
skilled surgeon of the head and neok.
Cieveland Clinic Archives
the century's second decade and soon realized its
potential danger. The company introduced acetate-
base "safety" film in the mid-1920s but continued
to market the nitrate-base x-ray film until 1933.
Witbout question, Kodak's conversion to safety
film was accelerated by the clinic disaster.
Given its letbal contents, the clinic's basement
storage room was dangerous enough. The room
contained some seventy thousand x-ray sheets, at
least 4,200 pounds of film. Each pound was capable
of producing between three and six cubic feet o£
toxic gases. Several factors — most in iolation of
American Hospital Association guidelines — made
the situation even more perilous. Unhke those in
many other medical facilities, some Cleveland Clinic
x-rays were not stored in metal containers. Although
some were stored in metal filing cabinets, many
films were filed on open wooden racks, and aU were
filed in flammable paper or manila jackets. Unlike
many other large medical facilities, the clinic had
no fire-sprinkling system in the storage room or
anywhere else in the building. And, going against
an increasingly common practice in American
hospitals, x-ray films were not stored in an area
isolated from patient areas. Wor.st of all, the clinic
building's ventilation apparatus was also located
near the x-ray storage room.
Like most terrible disasters, the clinic tragedy
was the cumulative product of mundane and indi-
vidually innocuous circumstances. In early 1929,
Miss Enid Critcher asked chief custodian Waiter
Adams to do something about the lighting in the
x-ray storage room. Although the room was lit by
four one-hundred-watt drop fixtures, Critcber found
it difficult to see while filing films. Adams responded
by putting a Y double-outlet at the end of one of the
drop fixtures. Such an outlet could ser^iice either
Dr. John Phiiiips, a facuity member at Western Reserve
University, joined the ciinio staff shortiy after its establishment.
Born and trained in Canada, the internist was widely respected
for his teaching abilities and for his knowiedge of children's
dis-
eases. Cieveiand Ciinic Archives
two one-hundred-watt bulbs or one bulb and an
electrical outlet. Adams would later deny any
knowledge of an eight-foot extension cord that was
hooked up to a female end of that Y fixture. Or, as
Miss Critcher testified, that it was connected to a
o ne-hundred-watt bulb, which was looped over a
"big spike" and hung down near the film cabinets.
Nitroceiiuiose-base x-ray fiims, stored in the
northwest corner of the basement in both
steel cabinets and on open shelving, first
fueied the fire. Investigation initialiy focused
on the steel tire door between the tile room
and the adjaoent boiier room. A heat-activated
mechanism designed to automaticaliy close
the door in the event of fire had malfunctioned.
OiBveiand State University, Cieveiand Press
Coiiection
July * August 2002 23
The clinic's reception room
was on the second fioor. two
stories below the sky light,
Cieveiand State University,
Cieveiand Press Collection
A steamfitter with the unlikely
name of Buffery Boggs played
a key roie in the disaster
Cleveland Clinic Archives
There was no inkling of the woe to come when
a man with the improbably Dickensian name of
Buffery Boggs arrived at the main clinic building
about 9 A.M. on May 15, A steamfitter's helper
employed by the W, R, Rhoton Company, Boggs
had come to repair a leaking pipe in the x-ray
storage room. Moisture had already damaged some
films, which had been removed and placed on top
of the filing cabinets to prevent further damage.
Eoggs quickly located the leak. But the pipe was
too hot for patching work, so he requested that the
steam be shut oft, lie then lefi the building. Before
he departed, however, he noLiced the improvised
lighting that custodian Adams later disclaimed:
"Just a common everyday light bulb dropped down
on an extension cord from the ceiling,"
This article is adapted from They Died Crawling© 1995
by John Stark Beliamy li. It is printed here with permis-
sion of Gray and Company, Publishers.
Did Boggs smoke a cigarette or two while he was
working at that pipe? Investigators later focused on
the possibility that film ignition had been triggered
by a cigarette left by Boggs in the x-ray room. But
their persistent probing of his smoking habits would
seem to be a gratuitous slur, as no evidence was ever
produced to indicate that Boggs smoked in tbe
storage room on May 15,
Boggs returned to his leaky pipe after 11 A.M.
As he walked through the door to the x-ray room,
he heard a "hissing sound." Although he did not
smell any odor, he noticed that "the room was
warm, it was dam warm." Then he saw "thick,
yellowish smoke" coming from somewhere near
the north wall. Boggs ran out of the room and yelled
to chnic maintenance worker Sam Steel for a fire
extinguisher, "There's a ñre in that room!" Steel
handed Boggs a soda-acid extinguisher, and the
agitated steamfitter hcgan to spray water on the
spreading cloud of yellowish-brown smoke.
It didn't help. Just as he emptied the extinguisher,
Boggs was overcome by smoke and fell to the fioor.
"It stopped my breath," he recalled, "just as you
would shut off a valve." Coming to, he crawled
toward the open door. As he reached it, a "gigantic
force" picked him up and blew him through the door
and across tbe fioor on his stomach into a machine
room, Boggs related that "it was as if a million
cushions hit you at once."
Buffery Boggs's "gigantic force" was the disaster's
first explosion, and it came about 11:25 A.M. Any-
where from 250 to 330 people were in the building —
and most of the 129 dead may already have been well
on the way to tbe grave even before the first blast
came. Decomposition (Bameless combustion}, or
24 TIMELINE
"cooking," of the x-ray ñlms in the basement storage
room, caused by heat, had apparentiy been going
on for some time. By the moment of tbe initial
explosion at 11:25 A.M., lethal gases had thoroughly
penetrated both the piping chases and ventilation
system of tbe building right up to tbe roof. Bromine,
nitrogen dioxide, carbon monoxide, nitrous oxide,
nitrogen peroxide, hydrocyanic gas, hydrogen, and
oxygen gases were being forced tbroughout all four
floors as fast as tbe ventilation ducts and piping
chases could carry tbem. The first blast probably
came wben just enougb of tbe free bydrogen in tbe
walls came into contact with a convenient spark.
The first hints in the clinic proper that something
was amiss came when some employees and patients,
especially women, noted a peculiar, unpleasant odor
in the air, Herbert W, Decker, clinic pharmacist,
was on the ground floor wben he sensed tbe foul
smell and found a group of nurses gathered by its
apparent source in a register. Dorothy Hyde, a typist
in the pharmacy, noticed nothing until "some fine
powder, plaster or something" began falling on her
work. About tbe same time, Mrs. H. A, Brooks saw
yellow dust coming out of a bole in the wall, and
employee Maude Lehman noticed a pufi" of smoke
coming out of the wall. Sbe had just told a staft
doctor about it when the first blast shook the build-
ing, and choking clouds of dirty, yellow-brown
smoke enveloped all four floors.
All of what went on in tbe clinic building during
the next twenty minutes is known only to God.
Patterns of deatb, injury, and escape in the clinic
tragedy would later be pieced together, but everything
was just a maddened, incomprehensible chaos as at
least 250 persons frantically sought to escape suffo-
cating death. So lethal were the gases, especially the
nitrogen peroxide and carbon monoxide, that most
of tbe victims probably died within minutes of the
first blast, if not before. Patients died without a
sound on examination tables. Doctors suddenly fell
to tbe fioor, scalpels still in hand. Battalion Fire
Chief Michael Graham later described a corpse he
found sitting in tbe second-floor lobby: "He looked
as if be had just started to take a nap wben the
fumes began." Others died screaming and crawling
on the floors and windowsills, gasping for air.
It was a particularly gruesome death, as many
eyewitnesses would testify. Altbough the exact
chemical components and proportions of the lethal
gases were never determined, large amounts of
carbon monoxide and acidic nitrogen compounds
certainly were present. Dr. Torald Sollmann,
dean of the Western Reserve Scbool of Medicine,
described their devastating effects chnically: "tbe gas
gets fixed in tbe tbin walls of tbe lungs. The resulting
irritation makes these cells soluble, and as a result
the watery part of the blood stream begins to leak
Two sign painters were among the lirst rescuers on the scene.
Running from an adjacent job siîe, fhey threw their ropes up to
desperate people hangirtg out the windows. Later they
retrieved their ladders and began hauling out victims.
Cleveland Public Library. Photograph Collection
through tbem into the lungs. The lungs fill with
water, drowning tbe patient." Some witnesses
remembered tbat the faces of the corpses appeared
yellow, blue, and green. A more-graphic description
came fi"om Dr. William G. Epstein, who had brought
his wife, Florence, to the clinic. He was in anotber
building wben tbe first blast came and ran next door
to find bis wife: "It was too horrible to describe....
That gas is awful stuff. It bites into the skin like acid
— worse than acid. Because acid at least is local-
ized. This gas eats into the tissues — and eats and
eats and eats!...Her mouth was bleeding — ber eyes
and nose virere bleeding. She couldn't speak."
Florence Epstein died in her husband's arms.
Dr. Howard Karsner of the Western Reser'e Medical
School stated that he bad never, in a career of twenty
thousand autopsies, .seen conditions identical to
those of clinic gas victims.
July • August 2002 25
The situation was worst on the upper fioors.
Most of the people caught in the building were in
tbe dozens of examining and diagnostic rooms on
those floors, and the poison gas and explosion
caught some patients in various stages of undress.
Virtually every doctor and nurse behaved heroically
and began trying to take patients on tbese floors to
safety. Unfortunately, most patients were strangers
to tbe clinic, and their quest for safety took them
to the most obvious locations, the stairways and
elevators. This only increased their peril and panic,
as fires were already raging at blowtorcb beat in the
rear elevator well and stairway. Tbe toxic gases,
moreover, were concentrating in the interior court,
meaning that patients were safer staying in tbe side
rooms and awaiting rescue via tbe windows.
Few patients involved in tbe escalating disaster
knew tbat. Tbat is why most of tbe victims were
later found stacked, sometimes a dozen or more
together, in piles by the staircases and tbe second-
and third-floor elevator doors. So frantic was the
press of escapees by tbe third-fioor elevator that its
metal doors were later found partially pushed in
by the desperate victims, Tbeir hysteria was so
great that a man in a wheelchair, caught in the wild
panie, was later found with his feet jammed between
the half-open door and the gaping elevator shaft.
Coroner Arthur J. Pearse thought some died of
sheer fright, and one panicked man jumped to his
death from a fourth-fioor window.
Some escaped almost immediately from the
spreading gas and fire. Custodian Adams was the
first person out of the building, his clothes aflame,
Boggs, the unfortunate discoverer of tbe film fire,
was blown by tbe second blast into a windou» well
in the clinic's basement. He clambered out of it and
ran to the East (05th Street Fire Station, shouting,
"There's a terrible fire at the clinic, a big fire!"
Long before Boggs arrived, at 11:30 A.M, , the first
alarm was turned in from a firebox. The Eighth
An assortment of volunteers
joined the officiai rescue
squad and their equipment
on the rooftop, where they
struggled to revive victims.
Cleveland Public Library,
Photograph Collection
Traffic near the clinic quiokiy
became snaried. Police
set up a cordon to keep
the curious at a distance.
Cleveland Rublic Library.
Photograph Coilection
26 TIMELINE
A number of policemen and liremen
conducted rescue efforts via the clinic's
windows. The fire department's army-
surplus gas masks proved inadequate,
and oxygen-supplied helmets were
needed to complete the removal of
victims.
Cieveiand Public Library.
Photograph Coiiection
Triage and first aid were performed
on the front lawn of the clinic before the
victims were rushed to area hospitals.
Cleveland Pubiic Library.
Piiotograph Coitecticn
Fire Battalion, under Cfiief Graham, roared out of
the firehouse. They could smell and see the dense,
yeilow-hrown smoke before they got to the scene,
and, by the time they arrived at 11:40 A.M., fires were
raging in the film room, rear elevator, and rear stair-
well, with six minor fires elsewhere in the building.
Fortunately for those trapped in the clinic,
spontaneous rescue efforts had already begun.
A. W. Johnson and Roy Miller were up on forty-foot
ladders, painting a sign just west of the clinic, when
the first blast occurred. Seconds later, Johnson saw
dense clouds of "umher" smoke pouring out of the
building. He and MiUer grabbed their ladders and
ran with them to the west wall of the clinic. There,
joined by a young man named Walter Jackson, they
ran the ladders up to second-floor windows, where
terrified people were screaming and even hanging
onto the sills to avoid gas pouring out of the windows
Jackson, Miller, and Johnson, joined hy others,
climhed up and began to take frantic, often injured,
victims down, one by one. Except for Jackson, a
veritable Porthos on that fatal May day, as one
impressed witness later testified: "I saw him walk
with two people down the ladder the same as you
would go downstairs." Jackson soon topped that
feat, actually holding a ladder with his hands and
shoulders so rescuers cotJd climh higher.
Many others hecame heroes that terrible day.
Patrolman Ernest Staah was near the clinic when
the fire started and rushed into the building. He
pulled twenty-one bodies out before he collapsed.
Like many of the day's heroes who survived, he paid
a continuing price: he was subject to fainting spells
for months after the accident and suffered for years
from aftereffects.
Some heroes came in groups. One such was
composed of pupils from the Wilcox Commercial
School on Euclid Avenue at East 100th Street. Ignor-
ing the orders of firemen at the scene, they entered
the huming clinic and hegan ptilling victims out.
Eight doctors and six nurses died, most of them
succumbing as they tried desperately to save their
patients. Among them was Dr. John Philhps, one
of the clinic founders. Escaping from the clinic, he
worked outside for hours, treating the victims spread
out on the grass. That evening, he collapsed at his
My ' August 2002 27
A piece of clinic furniture became
a makeshift stretcher.
Cleveland State University,
Cieveiand Press Oailection
Ciinic interns worked aiongside
volunteers.
Cleveland State University,
Cieveiand Press Ooilection
apartment and expired, despite the frantic efforts of
Dr. George Crile, another founder, to save him.
William Erownlow, clinic medical artist, died
bravely. He was in his tbird-fioor studio and already
succumbing to gas wben usher Susan Brantweiner
ran in. As he attempted to smash a window, sbe
crawled across the floor to him and said, "Goodbye."
Brownlow muttered, "No, not goodbye," shattered
the window, grabbed Brantweiner, and thrust her
into the air outside. Firemen eventually rescued her,
but Erownlow refused to go until two other victims
had been removed from the room. He died soon
after. Many survivors would never forget coura-
geous nurses shouting, "Save the patients, save the
patients!" as death closed in.
A second and more-powerful explosion occurred
several minutes after the first firemen arrived on the
scene. It was probably a blessing, as it blew out
many windows and firemen could see victims who
had been hidden by smoke. It also blew out the
skylight, thus ventilating much of the toxic gas in the
three-story interior court. Within minutes, firemen
had snaked their new, eighty-five-foot motorized
ladder to the roof. Descending through the ruined
skylight, firefighters Howai-d McAllister and Peter
Rogers were lowered into the smoke- and gas-filled
interior court. Swinging from side to side, they
finally got inside the fourth-floor railing and began
puliing victims, packed four deep in some places, out
of the stairwell and elevator areas. They sent fifteen
victims to the roof, some dead, and some who were
revived by Pulmotors. So many bodies were taken to
tbe county morgue tbat tbey had to be laid out on
the floor for identification by stunned relatives and
clinic staff.
It was all over by 1:15 P.M., although a third
explosion came shortly after the second. All victims
had been removed, and all fires were under control.
It was not over, however, for many of the victims.
The lingering or delayed effects of the gas were
potently manifested in the fact that some victims
quoted in early newspaper accounts showed up in
later editions as fatalities. Some fought death for
hours, some for days; attorney Hemy Lustig battled
until June 13, almost a month alter the disaster.
The last two victims of the clinic disaster died
almost a year later from lingering efiects, ieaving
the final toll at 129.
If careless in the procedures and conditions that
produced the disaster, the clinic's personnel were
magnificent in response and recovery. Crile himself
28 TIMELINE
When the available ambulances were
overwhelmed, a fleet of taxicabs,
commercial trucks, and private cars
removed the injured and dead,
Cieveiand Pubiio Library.
Photograph Ooiiection
The telephone company set up a bank
of phones at the morgue and provided
an operator to answer calls from family
members. These emergency lines were
set up on a pole outside the clinio.
Cieveiand Clinic Archives
Shortly after one o'clock, officials reported that everyone had
been removed from the building. Some rescuers were served a
late iunch, Cieveiand State University. Cieveiand Press
Coiiection
was at his best throughout the disaster, a veritable
battlefield general who tirelessly marshaled resources
to heal the wounded and console the grieving. After
hours tending the injured, Crile established a new
clinic headquarters across the street in an old man-
sion and announced; "We must carry on. The cîinic
has its work to do and must go forward."
As the clinic's efforts to rebuild and recover went
forward, so, too, did efforts to explain the unprece-
dented accident. City, county, and state probes
commenced, supplemented by investigations by
the War Department, Western Reserve University,
the Bureau of Standards, and tbe National Board
of Fire Underwriters. The results of these various
inquiries are best summarized by noting that they
held no one liable for tbe tragedy, and they agreed
that tbe disaster never should have happened,
given existing knowledge about nitrate-base film.
Provoking much criticism. Coroner Pearse's inquest
was held in private, owing, he insisted, to the reluc-
tance of witnesses to testify in public. After lengthy
sessions involving dozens of witnesses, Pearse
concluded there was no need to call a grand jury
to investigate or apportion blame for the mishap.
Probably tbe most thorough inquiry was the
clinic's own, undertaken by some of the city's best
lawyers. Interviewing virtually all clinic employees
and disaster vritnesses, tbey narrowed tbe disaster's
origin down to three possibilities: (1) "spontaneous"
combustion of the fiim, owing to overheating of
the storage room; (2) film combustion caused by a
carelessly left cigarette or match (hence the persis-
July • August 2002 29
Among the federal officials who rushed to Cleveland to assist in
the disaster investigation was iHarry Gilohrist (right), chief of
the
army's chemical warfare service and a wartime friend of Crile
(left). He also advised clinic physicians on the treatment of fhe
gas victims. Crile's son, then a student, joined the two men in
examining the disaster scene.
Cleveland Public Library. Photograph Collection
tent inquiries about the smoking habits of Buffery
Boggs); or (3) film combustion caused by contact
with the extension cord light dropped over the "big
spike" near the film racks.
No one ever proved that Boggs, or anyone else,
was smoking in the film room that day, altbougb
charwoman Rose Rebar testified that she often saw
people smoking in the clinic basement. And, while
Fire Warden Joseph H. Andrews bad found a pack of
cigarettes in tbe film room only five days before the
fire, no tobacco evidence was found to support the
"careless smoker" tbeory.
Tbat left the one-hundred-watt bulb at the end of
the spike-draped extension cord as tbe probable cause
of tbe mishap. It was found in tbe ruins of the film
Tji.- CLEVELAND PLAIN DEALER EXTRA
Ü L L I D BY GAS AND FIRE ^
IN BLAST-WRECKED CLINIC:
BODIES OVERFLOW MORGUE
storage room, encrusted witb film residue, and
Enid Critcher tesfified that she had employed
it for several months up to the day of the
disaster. Custodian Walter Adams adamantly
insisted it wasn't there: "As for that light bulb
extension, if it was there after tbe fire, ghosts
must have placed it tbere. We took special
pains tbat the 100-watt bulbs were not within
three feet of the x-ray films." On May 24, the
Plain Dealer noted tbat one of the chief wit-
nesses in the city probe of the clinic disaster
had made "false statements" and that "tbey
concerned the ligbts in the basement room."
But no one was ever legaüy cbarged with
negligence or culpability in the clinic tragedy.
The National Fire Protection Association
was not so kind in its assessment. On June 12
it issued a report that blistered botb the city
and clinic for sloppy practice in handling and
rcguladng x-ray ñlms:
It is inconceivable that tbe conditions
responsible for the Cleveland hospital
disaster could have been permitted to
exist even for a single day bad the
management or tbe inspection authori-
ties appreciated the hazard....There was
a large quantity of nitrocellulose x-ray
film in tbe basement. It was stored in
As the county morgue rapidly filled, newspapers
published front-page lists of the dead,
Cleveland Clinic Archives
30 TIMELINE
A city inspector searches the x-ray tile roon
for ciues to the cause of the tragedy.
Cleveland Public Library,
Photograph Collection
An innocent-looking iighting fixture in the
fiie rocm received close scrutiny during
the investigations.
Cleveland Stats University,
Cieveiand Press Collection
obvious violation of proper precaufions for the
keeping of this material of known dangerous
property.
No expense or expertise was spared in trying to
ardve at a scientific understanding of the clinic
disaster. Elaborate tests were conducted to determine
the toxieity of tbe probable gases involved. Mice
exposed to burning gas-residue scrapings from tbe
clinic walls — tbere were copious yellow-brown
stains throughout the building — convulsed and died
uathin one to two minutes. The official probes and
harmless recriminations dragged on for months.
The clinic, however, had already put it all behind.
Tbe Cleveland establishment, led by philanthropist
Samuel Mather, rallied behind the clinic, and Crile
impressively rebuilt it from the ruins of May 15,
1929. The interior of tbe main building was radically
restructured, to spare the sensibilities of tbose who
migbt remember its original look. The insurance
claims were paid off. And the clinic only waxed more
glorious as a Cleveland, indeed global, in.stitution in
the years afier. It did, however, switch to acetate-
base film and enforce some safety regulations and
recommendations concerning x-ray film storage.
Why did tbe clinic disaster happen? No person
was ever held accountable, so it is now a moot point.
But some notes on the clinic's ñre inspections
during the 1920s raise intriguing questions about
municipal inspection procedures and enforcement.
On May 4, 1925, for example. Fire Warden Andrews
inspected the füm storage room and ordered the
clinic to keep its x-rays in metal containers and to
provide a fireproof vault for same. This, obviously,
was not done. Four months later, on September 15,
Andrews made his last inspection and warned clinic
officials not to allow smoking in tbe film area.
There is no evidence that any of his recommenda-
tions were ever implemented. "U-
July 'August 2002 31
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to multiple sites or posted to a listserv without the copyright
holder's express written permission. However,
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ANSWER QUESTONS 1 & 2 IN APA FORMAT WITH 200 WORDS EACH.1. C.docx

  • 1. ANSWER QUESTONS 1 & 2 IN APA FORMAT WITH 200 WORDS EACH. 1. Compare and contrast the types of prevention and detection systems used for explosions. Why would it be more difficult to design controls for a room containing explosive materials than a room containing only flammable liquids? 2. Discuss the unique properties of combustible dusts. What are some prevention and suppression controls that can be used for areas containing combustible dusts? What methods would you use to identify areas where combustible dust is present? PREPARE A CASE STUDY WITH THE ARTICLE ATTACHED The case study and any additional sources must be cited in the text and references provided in APA style. A case study about a fire in either a hotel or high-rise office building. Write a review of the case that is a minimum of 300 words in length. Your review should answer the following questions: ing that contributed to either the start of the fire or the size of the fire? that hindered the fire response? building design or maintenance that you believe would have prevented the fire from starting or reduced the severity of the outcome?
  • 2. 2 0 TiMELLNE OF DEATH Cleveland Clinic Disaster ANY OHIO DISASTERS have announced themselves with a bang. The 1944 East Ohio Gas Company fire hegan with I a blast heard fourteen miles away. Y The 1916 Cleveland Waterworks explosion likewise made impressive noise, as did the 1908 S. S. Kresge tragedy, which commenced with literally deafening fireworks. Not so with the calamity that hefell the Cleveland Clinic. It came, initially invisible and unrecognized, through the ductwork and pipe conduits of the clinic building. It first accosted its victims as powdery flecks and puffs of smoke emanating from heating vents and registers. And many of its casualties may already have been dead when the first blast came at about 11:25 A.M.. May 15, 1929. Then, as now, the clinic was one of Cleveland's great success stories. Founded in 1921, it was the joint inspira- tion of Doctors George W. Crile, Frank E. Bunts, and William E. Lowther. Galvanized by their service together in Cleveland's Lakeside Unit during World War I, the trio had decided to put the model of team medical practice
  • 3. developed in France to peacetime use. Joining with Dr. John Phillips and drawing on the example of the Mayo Clinic, the doctors, in only eight years, had created a cutting-edge treatment center. Already world renowned, the clinic annually welcomed thousands of patients who came to find comfort and cure within its walls. July August 2002 21 THE CLINIC BUILDIMG, CLEVELAND. OHCO. M The Cleveland Clinic was a ¡oint venture by a group of physicians to provide medical services incorporating the latest in specialized research while also providing a setting for postgraduate education. The four-story main building was completed on the southwest corner of East Ninety-third Street and Euclid Avenue in 1921. deveiand Clinic Archives Even in 1929, the clinic was physically impressive. Located just west of East Ninety-third Street on the south side of Euclid Avenue, the four-huilding complex included a 184-bed hospital and a research building used for special laboratories, such as radioîogy. The main building was a four-story structure of reinforced concrete and brick. It housed both administrative offices and rooms used for consultation and outpatient procedures.
  • 4. Considered "fireproof" when built in 1920, the main building's primary activities occurred in dozens of examining and consulting rooms on the upper three floors. An interior court rose from the second-fioor waiting room up to a thirty-hy-thirtj'-eight-foot skylight. Two elevators and two staircases provided access to the upper fioors whose mezzanine-style balconies flanked the interior court. Like most buildings of the era, the clinic building's environ- mental infrastructure deployed from a central basement location. Encompassing about one-third the square footage of the 75- by 124-foot building, the hasement housed unused steam boilers (rendered redundant by the complex's new central heating plant), fans for the ventilation system, and storage rooms for files, supplies, and drugs. Fataiiy, it also contained a storage room for x-ray films. 22 TIMELINE Clinic chief Dr. George W. Crile subsequently would insist that there was "no precedent" for the clinic tragedy. That was not quite true, whether he knew it or not. In September 1923, gases generated by burning x-ray film and dispersed through a ventilating system had overwhelmed victims at
  • 5. a Syracuse hospital. And, in March 1928, eight persons in an Albany hospital had heen killed by fumes from burning x-rays. The villain in botb disasters was nitro- cellulose x-ray film. The actual x-ray image, composed of silver pariicles suspended in a gelatin layer, was not a problem. The film's transparent base was. It was made of nitro- cellulose, a polymer derived from organic cellulose. While fiexihle and clear, it couid ignite at oniy thi-ee hundred degrees Fahrenheit and could b u m without an independent source of oxygen. Indeed, the film was unstable and could decom- pose if improperly stored, making it even more dangerous. Eastman Kodak had placed the film on the market in Raised on a farm in Coshocton County, Dr. George Washington Crile was the drtving force behind the clinic. He had a lifelong, consuming obsession with research and worked diligently to improve the practice of surgery in the nation. He was a pioneer in the diagnosis and treatment of shock and a skilled surgeon of the head and neok. Cieveland Clinic Archives the century's second decade and soon realized its potential danger. The company introduced acetate-
  • 6. base "safety" film in the mid-1920s but continued to market the nitrate-base x-ray film until 1933. Witbout question, Kodak's conversion to safety film was accelerated by the clinic disaster. Given its letbal contents, the clinic's basement storage room was dangerous enough. The room contained some seventy thousand x-ray sheets, at least 4,200 pounds of film. Each pound was capable of producing between three and six cubic feet o£ toxic gases. Several factors — most in iolation of American Hospital Association guidelines — made the situation even more perilous. Unhke those in many other medical facilities, some Cleveland Clinic x-rays were not stored in metal containers. Although some were stored in metal filing cabinets, many films were filed on open wooden racks, and aU were filed in flammable paper or manila jackets. Unlike many other large medical facilities, the clinic had no fire-sprinkling system in the storage room or anywhere else in the building. And, going against an increasingly common practice in American hospitals, x-ray films were not stored in an area isolated from patient areas. Wor.st of all, the clinic building's ventilation apparatus was also located near the x-ray storage room. Like most terrible disasters, the clinic tragedy was the cumulative product of mundane and indi- vidually innocuous circumstances. In early 1929, Miss Enid Critcher asked chief custodian Waiter Adams to do something about the lighting in the x-ray storage room. Although the room was lit by four one-hundred-watt drop fixtures, Critcber found it difficult to see while filing films. Adams responded by putting a Y double-outlet at the end of one of the
  • 7. drop fixtures. Such an outlet could ser^iice either Dr. John Phiiiips, a facuity member at Western Reserve University, joined the ciinio staff shortiy after its establishment. Born and trained in Canada, the internist was widely respected for his teaching abilities and for his knowiedge of children's dis- eases. Cieveiand Ciinic Archives two one-hundred-watt bulbs or one bulb and an electrical outlet. Adams would later deny any knowledge of an eight-foot extension cord that was hooked up to a female end of that Y fixture. Or, as Miss Critcher testified, that it was connected to a o ne-hundred-watt bulb, which was looped over a "big spike" and hung down near the film cabinets. Nitroceiiuiose-base x-ray fiims, stored in the northwest corner of the basement in both steel cabinets and on open shelving, first fueied the fire. Investigation initialiy focused on the steel tire door between the tile room and the adjaoent boiier room. A heat-activated mechanism designed to automaticaliy close the door in the event of fire had malfunctioned. OiBveiand State University, Cieveiand Press Coiiection July * August 2002 23 The clinic's reception room was on the second fioor. two stories below the sky light, Cieveiand State University,
  • 8. Cieveiand Press Collection A steamfitter with the unlikely name of Buffery Boggs played a key roie in the disaster Cleveland Clinic Archives There was no inkling of the woe to come when a man with the improbably Dickensian name of Buffery Boggs arrived at the main clinic building about 9 A.M. on May 15, A steamfitter's helper employed by the W, R, Rhoton Company, Boggs had come to repair a leaking pipe in the x-ray storage room. Moisture had already damaged some films, which had been removed and placed on top of the filing cabinets to prevent further damage. Eoggs quickly located the leak. But the pipe was too hot for patching work, so he requested that the steam be shut oft, lie then lefi the building. Before he departed, however, he noLiced the improvised lighting that custodian Adams later disclaimed: "Just a common everyday light bulb dropped down on an extension cord from the ceiling," This article is adapted from They Died Crawling© 1995 by John Stark Beliamy li. It is printed here with permis- sion of Gray and Company, Publishers. Did Boggs smoke a cigarette or two while he was working at that pipe? Investigators later focused on the possibility that film ignition had been triggered by a cigarette left by Boggs in the x-ray room. But their persistent probing of his smoking habits would seem to be a gratuitous slur, as no evidence was ever produced to indicate that Boggs smoked in tbe
  • 9. storage room on May 15, Boggs returned to his leaky pipe after 11 A.M. As he walked through the door to the x-ray room, he heard a "hissing sound." Although he did not smell any odor, he noticed that "the room was warm, it was dam warm." Then he saw "thick, yellowish smoke" coming from somewhere near the north wall. Boggs ran out of the room and yelled to chnic maintenance worker Sam Steel for a fire extinguisher, "There's a ñre in that room!" Steel handed Boggs a soda-acid extinguisher, and the agitated steamfitter hcgan to spray water on the spreading cloud of yellowish-brown smoke. It didn't help. Just as he emptied the extinguisher, Boggs was overcome by smoke and fell to the fioor. "It stopped my breath," he recalled, "just as you would shut off a valve." Coming to, he crawled toward the open door. As he reached it, a "gigantic force" picked him up and blew him through the door and across tbe fioor on his stomach into a machine room, Boggs related that "it was as if a million cushions hit you at once." Buffery Boggs's "gigantic force" was the disaster's first explosion, and it came about 11:25 A.M. Any- where from 250 to 330 people were in the building — and most of the 129 dead may already have been well on the way to tbe grave even before the first blast came. Decomposition (Bameless combustion}, or 24 TIMELINE
  • 10. "cooking," of the x-ray ñlms in the basement storage room, caused by heat, had apparentiy been going on for some time. By the moment of tbe initial explosion at 11:25 A.M., lethal gases had thoroughly penetrated both the piping chases and ventilation system of tbe building right up to tbe roof. Bromine, nitrogen dioxide, carbon monoxide, nitrous oxide, nitrogen peroxide, hydrocyanic gas, hydrogen, and oxygen gases were being forced tbroughout all four floors as fast as tbe ventilation ducts and piping chases could carry tbem. The first blast probably came wben just enougb of tbe free bydrogen in tbe walls came into contact with a convenient spark. The first hints in the clinic proper that something was amiss came when some employees and patients, especially women, noted a peculiar, unpleasant odor in the air, Herbert W, Decker, clinic pharmacist, was on the ground floor wben he sensed tbe foul smell and found a group of nurses gathered by its apparent source in a register. Dorothy Hyde, a typist in the pharmacy, noticed nothing until "some fine powder, plaster or something" began falling on her work. About tbe same time, Mrs. H. A, Brooks saw yellow dust coming out of a bole in the wall, and employee Maude Lehman noticed a pufi" of smoke coming out of the wall. Sbe had just told a staft doctor about it when the first blast shook the build- ing, and choking clouds of dirty, yellow-brown smoke enveloped all four floors. All of what went on in tbe clinic building during the next twenty minutes is known only to God. Patterns of deatb, injury, and escape in the clinic tragedy would later be pieced together, but everything was just a maddened, incomprehensible chaos as at
  • 11. least 250 persons frantically sought to escape suffo- cating death. So lethal were the gases, especially the nitrogen peroxide and carbon monoxide, that most of tbe victims probably died within minutes of the first blast, if not before. Patients died without a sound on examination tables. Doctors suddenly fell to tbe fioor, scalpels still in hand. Battalion Fire Chief Michael Graham later described a corpse he found sitting in tbe second-floor lobby: "He looked as if be had just started to take a nap wben the fumes began." Others died screaming and crawling on the floors and windowsills, gasping for air. It was a particularly gruesome death, as many eyewitnesses would testify. Altbough the exact chemical components and proportions of the lethal gases were never determined, large amounts of carbon monoxide and acidic nitrogen compounds certainly were present. Dr. Torald Sollmann, dean of the Western Reserve Scbool of Medicine, described their devastating effects chnically: "tbe gas gets fixed in tbe tbin walls of tbe lungs. The resulting irritation makes these cells soluble, and as a result the watery part of the blood stream begins to leak Two sign painters were among the lirst rescuers on the scene. Running from an adjacent job siîe, fhey threw their ropes up to desperate people hangirtg out the windows. Later they retrieved their ladders and began hauling out victims. Cleveland Public Library. Photograph Collection through tbem into the lungs. The lungs fill with water, drowning tbe patient." Some witnesses remembered tbat the faces of the corpses appeared yellow, blue, and green. A more-graphic description came fi"om Dr. William G. Epstein, who had brought
  • 12. his wife, Florence, to the clinic. He was in anotber building wben tbe first blast came and ran next door to find bis wife: "It was too horrible to describe.... That gas is awful stuff. It bites into the skin like acid — worse than acid. Because acid at least is local- ized. This gas eats into the tissues — and eats and eats and eats!...Her mouth was bleeding — ber eyes and nose virere bleeding. She couldn't speak." Florence Epstein died in her husband's arms. Dr. Howard Karsner of the Western Reser'e Medical School stated that he bad never, in a career of twenty thousand autopsies, .seen conditions identical to those of clinic gas victims. July • August 2002 25 The situation was worst on the upper fioors. Most of the people caught in the building were in tbe dozens of examining and diagnostic rooms on those floors, and the poison gas and explosion caught some patients in various stages of undress. Virtually every doctor and nurse behaved heroically and began trying to take patients on tbese floors to safety. Unfortunately, most patients were strangers to tbe clinic, and their quest for safety took them to the most obvious locations, the stairways and elevators. This only increased their peril and panic, as fires were already raging at blowtorcb beat in the rear elevator well and stairway. Tbe toxic gases, moreover, were concentrating in the interior court, meaning that patients were safer staying in tbe side rooms and awaiting rescue via tbe windows.
  • 13. Few patients involved in tbe escalating disaster knew tbat. Tbat is why most of tbe victims were later found stacked, sometimes a dozen or more together, in piles by the staircases and tbe second- and third-floor elevator doors. So frantic was the press of escapees by tbe third-fioor elevator that its metal doors were later found partially pushed in by the desperate victims, Tbeir hysteria was so great that a man in a wheelchair, caught in the wild panie, was later found with his feet jammed between the half-open door and the gaping elevator shaft. Coroner Arthur J. Pearse thought some died of sheer fright, and one panicked man jumped to his death from a fourth-fioor window. Some escaped almost immediately from the spreading gas and fire. Custodian Adams was the first person out of the building, his clothes aflame, Boggs, the unfortunate discoverer of tbe film fire, was blown by tbe second blast into a windou» well in the clinic's basement. He clambered out of it and ran to the East (05th Street Fire Station, shouting, "There's a terrible fire at the clinic, a big fire!" Long before Boggs arrived, at 11:30 A.M, , the first alarm was turned in from a firebox. The Eighth An assortment of volunteers joined the officiai rescue squad and their equipment on the rooftop, where they struggled to revive victims. Cleveland Public Library, Photograph Collection Traffic near the clinic quiokiy
  • 14. became snaried. Police set up a cordon to keep the curious at a distance. Cleveland Rublic Library. Photograph Coilection 26 TIMELINE A number of policemen and liremen conducted rescue efforts via the clinic's windows. The fire department's army- surplus gas masks proved inadequate, and oxygen-supplied helmets were needed to complete the removal of victims. Cieveiand Public Library. Photograph Coiiection Triage and first aid were performed on the front lawn of the clinic before the victims were rushed to area hospitals. Cleveland Pubiic Library. Piiotograph Coitecticn Fire Battalion, under Cfiief Graham, roared out of the firehouse. They could smell and see the dense, yeilow-hrown smoke before they got to the scene, and, by the time they arrived at 11:40 A.M., fires were raging in the film room, rear elevator, and rear stair- well, with six minor fires elsewhere in the building. Fortunately for those trapped in the clinic, spontaneous rescue efforts had already begun. A. W. Johnson and Roy Miller were up on forty-foot
  • 15. ladders, painting a sign just west of the clinic, when the first blast occurred. Seconds later, Johnson saw dense clouds of "umher" smoke pouring out of the building. He and MiUer grabbed their ladders and ran with them to the west wall of the clinic. There, joined by a young man named Walter Jackson, they ran the ladders up to second-floor windows, where terrified people were screaming and even hanging onto the sills to avoid gas pouring out of the windows Jackson, Miller, and Johnson, joined hy others, climhed up and began to take frantic, often injured, victims down, one by one. Except for Jackson, a veritable Porthos on that fatal May day, as one impressed witness later testified: "I saw him walk with two people down the ladder the same as you would go downstairs." Jackson soon topped that feat, actually holding a ladder with his hands and shoulders so rescuers cotJd climh higher. Many others hecame heroes that terrible day. Patrolman Ernest Staah was near the clinic when the fire started and rushed into the building. He pulled twenty-one bodies out before he collapsed. Like many of the day's heroes who survived, he paid a continuing price: he was subject to fainting spells for months after the accident and suffered for years from aftereffects. Some heroes came in groups. One such was composed of pupils from the Wilcox Commercial School on Euclid Avenue at East 100th Street. Ignor- ing the orders of firemen at the scene, they entered the huming clinic and hegan ptilling victims out. Eight doctors and six nurses died, most of them
  • 16. succumbing as they tried desperately to save their patients. Among them was Dr. John Philhps, one of the clinic founders. Escaping from the clinic, he worked outside for hours, treating the victims spread out on the grass. That evening, he collapsed at his My ' August 2002 27 A piece of clinic furniture became a makeshift stretcher. Cleveland State University, Cieveiand Press Oailection Ciinic interns worked aiongside volunteers. Cleveland State University, Cieveiand Press Ooilection apartment and expired, despite the frantic efforts of Dr. George Crile, another founder, to save him. William Erownlow, clinic medical artist, died bravely. He was in his tbird-fioor studio and already succumbing to gas wben usher Susan Brantweiner ran in. As he attempted to smash a window, sbe crawled across the floor to him and said, "Goodbye." Brownlow muttered, "No, not goodbye," shattered the window, grabbed Brantweiner, and thrust her into the air outside. Firemen eventually rescued her, but Erownlow refused to go until two other victims had been removed from the room. He died soon after. Many survivors would never forget coura- geous nurses shouting, "Save the patients, save the patients!" as death closed in.
  • 17. A second and more-powerful explosion occurred several minutes after the first firemen arrived on the scene. It was probably a blessing, as it blew out many windows and firemen could see victims who had been hidden by smoke. It also blew out the skylight, thus ventilating much of the toxic gas in the three-story interior court. Within minutes, firemen had snaked their new, eighty-five-foot motorized ladder to the roof. Descending through the ruined skylight, firefighters Howai-d McAllister and Peter Rogers were lowered into the smoke- and gas-filled interior court. Swinging from side to side, they finally got inside the fourth-floor railing and began puliing victims, packed four deep in some places, out of the stairwell and elevator areas. They sent fifteen victims to the roof, some dead, and some who were revived by Pulmotors. So many bodies were taken to tbe county morgue tbat tbey had to be laid out on the floor for identification by stunned relatives and clinic staff. It was all over by 1:15 P.M., although a third explosion came shortly after the second. All victims had been removed, and all fires were under control. It was not over, however, for many of the victims. The lingering or delayed effects of the gas were potently manifested in the fact that some victims quoted in early newspaper accounts showed up in later editions as fatalities. Some fought death for hours, some for days; attorney Hemy Lustig battled until June 13, almost a month alter the disaster. The last two victims of the clinic disaster died almost a year later from lingering efiects, ieaving the final toll at 129.
  • 18. If careless in the procedures and conditions that produced the disaster, the clinic's personnel were magnificent in response and recovery. Crile himself 28 TIMELINE When the available ambulances were overwhelmed, a fleet of taxicabs, commercial trucks, and private cars removed the injured and dead, Cieveiand Pubiio Library. Photograph Ooiiection The telephone company set up a bank of phones at the morgue and provided an operator to answer calls from family members. These emergency lines were set up on a pole outside the clinio. Cieveiand Clinic Archives Shortly after one o'clock, officials reported that everyone had been removed from the building. Some rescuers were served a late iunch, Cieveiand State University. Cieveiand Press Coiiection was at his best throughout the disaster, a veritable battlefield general who tirelessly marshaled resources to heal the wounded and console the grieving. After hours tending the injured, Crile established a new clinic headquarters across the street in an old man- sion and announced; "We must carry on. The cîinic has its work to do and must go forward."
  • 19. As the clinic's efforts to rebuild and recover went forward, so, too, did efforts to explain the unprece- dented accident. City, county, and state probes commenced, supplemented by investigations by the War Department, Western Reserve University, the Bureau of Standards, and tbe National Board of Fire Underwriters. The results of these various inquiries are best summarized by noting that they held no one liable for tbe tragedy, and they agreed that tbe disaster never should have happened, given existing knowledge about nitrate-base film. Provoking much criticism. Coroner Pearse's inquest was held in private, owing, he insisted, to the reluc- tance of witnesses to testify in public. After lengthy sessions involving dozens of witnesses, Pearse concluded there was no need to call a grand jury to investigate or apportion blame for the mishap. Probably tbe most thorough inquiry was the clinic's own, undertaken by some of the city's best lawyers. Interviewing virtually all clinic employees and disaster vritnesses, tbey narrowed tbe disaster's origin down to three possibilities: (1) "spontaneous" combustion of the fiim, owing to overheating of the storage room; (2) film combustion caused by a carelessly left cigarette or match (hence the persis- July • August 2002 29 Among the federal officials who rushed to Cleveland to assist in the disaster investigation was iHarry Gilohrist (right), chief of the army's chemical warfare service and a wartime friend of Crile
  • 20. (left). He also advised clinic physicians on the treatment of fhe gas victims. Crile's son, then a student, joined the two men in examining the disaster scene. Cleveland Public Library. Photograph Collection tent inquiries about the smoking habits of Buffery Boggs); or (3) film combustion caused by contact with the extension cord light dropped over the "big spike" near the film racks. No one ever proved that Boggs, or anyone else, was smoking in the film room that day, altbougb charwoman Rose Rebar testified that she often saw people smoking in the clinic basement. And, while Fire Warden Joseph H. Andrews bad found a pack of cigarettes in tbe film room only five days before the fire, no tobacco evidence was found to support the "careless smoker" tbeory. Tbat left the one-hundred-watt bulb at the end of the spike-draped extension cord as tbe probable cause of tbe mishap. It was found in tbe ruins of the film Tji.- CLEVELAND PLAIN DEALER EXTRA Ü L L I D BY GAS AND FIRE ^ IN BLAST-WRECKED CLINIC: BODIES OVERFLOW MORGUE storage room, encrusted witb film residue, and Enid Critcher tesfified that she had employed it for several months up to the day of the disaster. Custodian Walter Adams adamantly insisted it wasn't there: "As for that light bulb extension, if it was there after tbe fire, ghosts
  • 21. must have placed it tbere. We took special pains tbat the 100-watt bulbs were not within three feet of the x-ray films." On May 24, the Plain Dealer noted tbat one of the chief wit- nesses in the city probe of the clinic disaster had made "false statements" and that "tbey concerned the ligbts in the basement room." But no one was ever legaüy cbarged with negligence or culpability in the clinic tragedy. The National Fire Protection Association was not so kind in its assessment. On June 12 it issued a report that blistered botb the city and clinic for sloppy practice in handling and rcguladng x-ray ñlms: It is inconceivable that tbe conditions responsible for the Cleveland hospital disaster could have been permitted to exist even for a single day bad the management or tbe inspection authori- ties appreciated the hazard....There was a large quantity of nitrocellulose x-ray film in tbe basement. It was stored in As the county morgue rapidly filled, newspapers published front-page lists of the dead, Cleveland Clinic Archives 30 TIMELINE A city inspector searches the x-ray tile roon for ciues to the cause of the tragedy. Cleveland Public Library,
  • 22. Photograph Collection An innocent-looking iighting fixture in the fiie rocm received close scrutiny during the investigations. Cleveland Stats University, Cieveiand Press Collection obvious violation of proper precaufions for the keeping of this material of known dangerous property. No expense or expertise was spared in trying to ardve at a scientific understanding of the clinic disaster. Elaborate tests were conducted to determine the toxieity of tbe probable gases involved. Mice exposed to burning gas-residue scrapings from tbe clinic walls — tbere were copious yellow-brown stains throughout the building — convulsed and died uathin one to two minutes. The official probes and harmless recriminations dragged on for months. The clinic, however, had already put it all behind. Tbe Cleveland establishment, led by philanthropist Samuel Mather, rallied behind the clinic, and Crile impressively rebuilt it from the ruins of May 15, 1929. The interior of tbe main building was radically restructured, to spare the sensibilities of tbose who migbt remember its original look. The insurance claims were paid off. And the clinic only waxed more glorious as a Cleveland, indeed global, in.stitution in the years afier. It did, however, switch to acetate- base film and enforce some safety regulations and recommendations concerning x-ray film storage.
  • 23. Why did tbe clinic disaster happen? No person was ever held accountable, so it is now a moot point. But some notes on the clinic's ñre inspections during the 1920s raise intriguing questions about municipal inspection procedures and enforcement. On May 4, 1925, for example. Fire Warden Andrews inspected the füm storage room and ordered the clinic to keep its x-rays in metal containers and to provide a fireproof vault for same. This, obviously, was not done. Four months later, on September 15, Andrews made his last inspection and warned clinic officials not to allow smoking in tbe film area. There is no evidence that any of his recommenda- tions were ever implemented. "U- July 'August 2002 31 Copyright of Timeline is the property of Ohio Historical Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.