South Charleston Fire Department Final Report Holiday Inn Express February 17, 2012
Executive Summary On January 31, 2012 The South Charleston Fire Department responded to a call at 95 RHL Boulevard, the Holiday Inn Express Room 511 for two males unresponsive. Upon arrival, Fire crews found 1 male unresponsive and 1 male deceased. Upon investigating the room for a cause of their episode, they found high levels of carbon monoxide. Investigators found the cause of the carbon monoxide leak to be contributed to a separated flue exhaust pipe. Agencies Involved South Charleston Fire Department South Charleston Police Department Charleston Fire and EMS Department Kanawha County Sheriff s Department Kanawha County Ambulance Authority WV State Fire Marshal s Office Kanawha Metro 911 Kanawha County Emergency Services Kanawha/Charleston Health Department Occupational Safety and Health (OSHA) State of West Virginia Bureau of Inspections Mountaineer Gas
Contributing Factors 1. Manipulation of the vent flue pipe at initial installation. 2. Dislodged vent flue pipe connected to the pool heater. 3. Pool heater not installed per manufacture s recommendations. Weather Clear skies in the mid to upper 50 s Investigation: The Response On January 31, 2012 Kanawha Metro 911 dispatched South Charleston Fire Department and Charleston EMS to 95 RHL Boulevard the Holiday Inn Express Room 511 for two (2) males unresponsive. South Charleston Engine 654 was the first unit to arrive on the scene. Fire crews advised that when they arrived up to the room in question, they could smell some type of odor but at that time they could not make out a determination of what it was. The crews immediately assessed both victims. Victim #1 a white male was found supine in the bed by the window. He was pulseless and apneic with levity. It was then determined he was deceased. Victim #2 a white male was found unresponsive with thick frothy sputum coming out of his mouth. The fire crews immediately rendered first aid care/lifesaving measurements. South Charleston Police was in the room also. While victim #2 was being attended to, the police and a two of firefighters searched the room for clues as to why these men were in this type of condition. The two coworkers gave an account of the two victims activities of the previous night. This consisted of going out and getting food from Burger King and returning back to their room. They returned back around 22:30 hours. When they missed their morning meeting, their two co-workers went to their room to see why. The General Manager of the hotel,
Manisha Patel opened the door for them. When they saw the two victims in their present state, the hotel manager immediately called 911. Two Charleston EMS paramedic units and their supervisor arrived and transported victim #2 to CAMC General Hospital. The other firefighters immediately began to help search for a cause. Fire Lieutenant Steve Bays grabbed a gas monitoring device and started to monitor the area. He received no initial readings in the hallways. When he arrived at room 511, as he was walking through the door into the room, the monitoring device alarmed for carbon monoxide at a level of 317. Everyone in Room 511 evacuated and shut the door behind them, and exited the building to get self-contained breathing apparatus. The fire officer in charge at that time, Captain William Tillis called for additional units to respond and to assist in the investigation. Fire crews then went to every floor, every room, to check for employees and guest of the hotel. Everyone they encountered, were made to evacuate the hotel. Once the hotel was evacuated, a systematic monitoring of every floor for carbon monoxide began. All rooms were secured, and all entrances were secured by the South Charleston PD. Charleston Fire Department was dispatched also for assistance. They responded with an engine, hazardous materials response unit, air cascade unit, and shift commander. Kanawha Metro 911 advised the Kanawha County Emergency Services of the incident. Investigation: The Search The systematic monitoring took place on every floor of the hotel. Every room, storage area, hallway, stairwell, was monitored. The monitoring started on the 5 th floor and continued downward. The heaviest concentrations on the floors 3 through 5 were by the windows in the bedrooms. There were NO readings on the 1 st and 2 nd floor. The 3 rd floor had slight traces in the hallway. Rooms 309 and 311 had reading of 200
ppm. Crews found no other rooms on the 3 rd floor with any carbon monoxide levels. As crews were monitoring the floors, the higher carbon monoxide readings were found in rooms 409,411,509,511. They ranged from 400-750 ppm. All other rooms were clear and no traces found. There were readings in the elevator shaft of 200-300 ppm as well. Due to doors opened to the stairwell on both ends of the 5 th floor there were readings in the hallway and stairwell. Multiple area specific gas monitoring devices were placed on floors 2 through 5 for continuous monitoring. The detection of carbon monoxide varied from floor to floor throughout the time frame of the investigation. As fire crews continued searching to find the carbon monoxide leak, they started back on the 2 nd floor to turn the ac/heating units to fan only. This was a process to be done on every floor. This was to create a positive pressure to the rooms in case the carbon monoxide levels started to build back up and to ensure they would not create a hazardous atmosphere in the rooms. While crew members were on the 2 nd floor when room 211 was reached, there was an access door found in the kitchenette. The door was opened, and an open shaft was located. There were no readings for carbon monoxide detected. The shaft was searched, and crews found a vent flu pipe that was connected down through the floor. This pipe was traced into the pool s mechanical room. The top of the vent flu pipe was not connected to anything. The vent flue pipe was double walled pipe. It also had an odd shaped bend at the top. Fire crews radioed their findings. Once in the pool mechanical room, it was noted that the breaker box s main power was shut off. It was asked to the hotel manager if the unit had been running in which she stated it had not and she did not know of anyone that would have ran that unit. The temperature was checked by a representative of the Kanawha Charleston Health Department. It read 83
degrees. Crews turned on the power to the pool heater unit and the opened the control panel. The current pool temperature on the control panel matched the temperature that the representative took from the health department. The fire crews then started the pool heater unit and let it operated for approximately 20 minutes, proceeded to room 211 to the access door and check the levels in the shaft. It was then noted at the floor level carbon monoxide levels were registered at 1149 ppm. It then climbed to over 1200 ppm. The crews immediately began to ventilate the shaft. Once the shaft was properly ventilated, there were no traces in the building. The shaft does have the timers to the lighting system of the hotel. It is accessed approximately 1 time a year to change the time for the lights. Investigation: Interviews Several people involved with this incident were interviewed about their participation in the incident. Manisha Patel is the General Manager of the Holiday Inn Express. Ms. Patel was asked several questions about the day of the event. Ms. Patel advised the investigators that two men came to her for assistance in gaining access to their co-workers room which was room 511. When Ms. Patel opened the door, all three entered the room. They then found both victims unresponsive victim #1 appeared not breathing and victim #2 seizing. She immediately called 911 from the room telephone. Ms. Patel then helped to start CPR on victim#1. Ms. Patel then exited the room to secure the elevator for the emergency crews so they could expedite to the room. Ms. Patel met the fire department crews and law enforcement when she exited the elevator on the 1 st floor in which she advised them to please hurry they are in room 511. Ms. Patel appeared to be in an upset emotional state.
Once the investigation began to finding a cause of the leak Ms. Patel was asked about any problems with the heating units or dryer units in which she advised there were no problems. It was then asked if the pool heater had been in use and she advised the best to her recollection no one had operated the pool heater. Ms. Patel stated it had not been operated for quite some time. Ms. Patel was very cooperative during the investigation. She assisted fire crews with gaining access to rooms and working with the investigators. Ms. Patel stated that in December there were problems with the pool heater unit. She contacted JP Mechanical to look at the unit. JP Mechanical advised her that the unit needed replaced so she purchased a new pool heater from Star-Pool in Venice, FL. Ms. Patel stated that she thought it would be best to call a pool company that installs pool heaters. Holiday Pools in Huntington, WV had given her a list of names of pool companies to do installations. That is when she contacted Premier Pools. Ms. Patel stated that she checked in from time to time at the workers working in the pool s mechanical room. Ms. Patel stated she has been in the shaft area with October being the last time. She stated the best to her recollection; the vent flue pipe was intact. Ms. Patel represented by legal counsel while being questioned. Jeremy Myers janitorial worker. Mr. Myers does general cleanup and minor maintenance at the hotel such as cleaning the parking lot, changing light bulbs, tightening toilet seats, and assisting with laundry services. Mr. Myers stated that he removed the old pool heater unit from the pool mechanical room and placed it by the dumpster for removal. He then placed the new pool heater unit in the pool maintenance room. He stated he did not hook up or remove anything on either pool heater unit. He did however remove the PVC piping to the water lines. Mr. Myers stated he was present when
JP Mechanical was checking out the unit. He said that the worker for JP Mechanical removed the top of the old pool heater to inspect inside for a leak. Mr. Myers stated the JP Mechanical disconnected the gas line, water line, and electric from the old pool heater. Mr. Myers stated that he gave Ms. Patel the owner s manual of the new pool heater. JP Mechanical John Providenti Mr. Providenti stated sometime prior to December 19 th he was called by the manager of the Holiday Inn Express Manisha Patel to check out a faulty pool heater. Mr. Providenti stated that he did inspect the unit however; he did not remove the vent flu pipe. He did disconnected the electric and shut off the gas only. He stated he did not remove the pipe. He advised Ms. Patel that there was leaking water in the heat exchange which was keeping the igniter from firing. He then helped Ms. Patel look for a new heat exchanger online. They found that a new heat exchanger cost as much as a new pool heater unit. Mr. Providenti also made a recommendation that the pool heater be relocated to the outside to have more room for the unit and the filter due to a tight area in which it was currently in. Mr. Providenti did not charge for the work done. Premier Pools Steve Combs and Lawyer Gary Pullins Mr. Combs stated that his wife Karen is the owner of the company. It has also been learned that Mr. Combs has a cease and desist order from the Department of Labor, is not listed on the Secretary of State Office as an officer on LLS, and is only licensed as a residential contractor and not a commercial contractor. Work was conducted on December 27 th and 28 th 2011.
Mr. Combs stated that Ms. Patel asked him to finish an installation of a new pool heater. When he arrived with a crew of 3 additional workers, he noticed there was limited room in the pool mechanical room due to a large pool filter in place. Mr. Combs also stated that Ms. Patel stated that another person was working on the unit and due to the tight area became frustrated and quit. (There was some discrepancy in this statement with Ms. Patel.) The pool filter and piping was intact to the pool filter prior to Mr. Combs arrival. Mr. Combs admitted the he connected the water and electric to the new heater unit as well as the flue vent pipe. He further went to say that the gas was already hooked up to the new unit and had a small leak. He fixed the leak. Mr. Combs also installed a new pool filter that was smaller than the previous one used. Mr. Combs stated while installing the vent flue pipe, it was raised approximately 6 to 1 foot vertically to clear the stub on top of the heater. At no time did Mr. Combs review the owner s manual for installation. He did not give Ms. Patel any documentation on the startup of the unit but did show Ms. Patel how to operate the unit. It was then the temperature was set for 84 degrees and not to be readjusted. Mr. Combs did not inspect any work to the vent flue pipe nor did he access the shaft area on the 2 nd floor to check.
Investigation: Summary Upon completing interviews and a thorough investigation, it has been concluded that the vent flu pipe was physically manipulated at the top to be connected to the outside vent. This was likely done when the unit was originally installed approximately 11 years ago. The removal and inspection of the old pool heater unit started the process of the vent flu pipe coming loose. The installation of the new pool heater unit further compromised the pipe. There were scratches in on the piping indicating that it had moved along the hole between floors against the concrete. Through vibration of the water filtration system and the pool heater unit, the vent flu pipe became dislodged thus creating a buildup of carbon monoxide in the open shaft area. The heat from the pool heater traveled through the vent pipe forcing the carbon monoxide to stay high in the ceiling area. This forced the carbon monoxide to travel to rooms on both sides of the shaft and into the elevator shaft. In Room 511, the heater ac unit was set to fan only so the movement of air was limited to the room. After installation of the new pool heater, there were no procedures followed as recommended by the manufacture of that particular unit. The unit was therefore not properly tested and inspected. There were no work permits obtained prior to or during any of the work performed. The City of South Charleston Building Inspectors and the South Charleston Fire Department had no knowledge that the work procedures had occurred therefore no inspections were made.
Investigator Information Captain Virgil C. White South Charleston Fire Department Mark Miller City of South Charleston Building Inspector Steve DeBarr City of South Charleston Engineer South Charleston Police Department Detectives Bureau OSHA State of West Virginia Bureau of Inspectors Kanawha Charleston Health Department
Attachments Timelines Monitor Readings Summaries Photos of area in question Receipts
Instrument: Multi-gas Monitor (PGM50-5P) Serial Number: 511943 User ID: 00000001 Site ID: 00000001 Data Points: 50 Data Type: Avg Sample Period: 60 sec Last Calibration Time: 06/09/2011 15:48 Start At: 11/26/2011 10:16 End At: 11/26/2011 11:05 Sensor: CO(ppm) VOC(ppm) H2S(ppm) LEL(%) OXY(%) High Alarm Levels: 200.0 100.0 20.0 20.0 23.5 Low Alarm Levels: 35.0 50.0 10.0 10.0 19.5 STEL Alarm Levels: 100.0 25.0 15.0 ----- ----- TWA Alarm Levels: 35.0 10.0 10.0 ----- ----- Sensor: CO(ppm) VOC(ppm) H2S(ppm) LEL(%) OXY(%) Peak Data Value: 520.3 0.0 0.0 0.0 20.9 Min Data Value: 0.0 0.0 0.0 0.0 20.3 TWA Data Value: 9.6 0.0 0.0 ----- ----- AVG Data Value: 92.3 0.0 0.0 ----- ----- Instrument: Multi-gas Monitor (PGM50-5P) Serial Number: 511932 User ID: 00000001 Site ID: 00000001 Data Points: 62 Data Type: Avg Sample Period: 60 sec Last Calibration Time: 01/17/2012 12:37 Start At: 01/31/2012 11:12 End At: 01/31/2012 12:13 Sensor: CO(ppm) VOC(ppm) H2S(ppm) LEL(%) OXY(%) High Alarm Levels: 200.0 100.0 20.0 20.0 23.5 Low Alarm Levels: 35.0 50.0 10.0 10.0 19.5 STEL Alarm Levels: 100.0 25.0 15.0 ----- ----- TWA Alarm Levels: 35.0 10.0 10.0 ----- ----- Sensor: CO(ppm) VOC(ppm) H2S(ppm) LEL(%) OXY(%) Peak Data Value: 625.4 0.0 0.0 0.0 20.9 Min Data Value: 0.0 0.0 0.0 0.0 20.5 TWA Data Value: 9.1 0.0 0.0 ----- ----- AVG Data Value: 70.8 0.0 0.0 ----- -----
Instrument: Multi-gas Monitor (PGM50-5P) Serial Number: 511932 User ID: 00000001 Site ID: 00000001 Data Points: 64 Data Type: Avg Sample Period: 60 sec Last Calibration Time: 01/17/2012 12:37 Start At: 01/31/2012 13:08 End At: 01/31/2012 14:11 Sensor: CO(ppm) VOC(ppm) H2S(ppm) LEL(%) OXY(%) High Alarm Levels: 200.0 100.0 20.0 20.0 23.5 Low Alarm Levels: 35.0 50.0 10.0 10.0 19.5 STEL Alarm Levels: 100.0 25.0 15.0 ----- ----- TWA Alarm Levels: 35.0 10.0 10.0 ----- ----- Sensor: CO(ppm) VOC(ppm) H2S(ppm) LEL(%) OXY(%) Peak Data Value: 1149.9 0.7 0.0 0.0 20.9 Min Data Value: 0.0 0.0 0.0 0.0 20.0 TWA Data Value: 6.8 0.0 0.0 ----- ----- AVG Data Value: 50.7 0.0 0.0 ----- ----- Instrument: Multi-gas Monitor (PGM50-5P) Serial Number: 511958 User ID: 00000001 Site ID: 00000001 Data Points: 19 Data Type: Avg Sample Period: 60 sec Last Calibration Time: 01/17/2012 12:28 Start At: 01/31/2012 11:11 End At: 01/31/2012 11:29 Sensor: CO(ppm) VOC(ppm) H2S(ppm) LEL(%) OXY(%) High Alarm Levels: 200.0 100.0 20.0 20.0 23.5 Low Alarm Levels: 35.0 50.0 10.0 10.0 19.5 STEL Alarm Levels: 100.0 25.0 15.0 ----- ----- TWA Alarm Levels: 35.0 10.0 10.0 ----- ----- Sensor: CO(ppm) VOC(ppm) H2S(ppm) LEL(%) OXY(%) Peak Data Value: 272.9 0.0 0.0 0.0 20.9 Min Data Value: 0.0 0.0 0.0 0.0 20.5 TWA Data Value: 2.9 0.0 0.0 ----- ----- AVG Data Value: 72.8 0.0 0.0 ----- -----
Instrument: Multi-gas Monitor (PGM50-5P) Serial Number: 511958 User ID: 00000001 Site ID: 00000001 Data Points: 19 Data Type: Avg Sample Period: 60 sec Last Calibration Time: 01/17/2012 12:28 Start At: 01/31/2012 11:11 End At: 01/31/2012 11:29 Sensor: CO(ppm) VOC(ppm) H2S(ppm) LEL(%) OXY(%) High Alarm Levels: 200.0 100.0 20.0 20.0 23.5 Low Alarm Levels: 35.0 50.0 10.0 10.0 19.5 STEL Alarm Levels: 100.0 25.0 15.0 ----- ----- TWA Alarm Levels: 35.0 10.0 10.0 ----- ----- Sensor: CO(ppm) VOC(ppm) H2S(ppm) LEL(%) OXY(%) Peak Data Value: 272.9 0.0 0.0 0.0 20.9 Min Data Value: 0.0 0.0 0.0 0.0 20.5 TWA Data Value: 2.9 0.0 0.0 ----- ----- AVG Data Value: 72.8 0.0 0.0 ----- ----- Instrument: Multi-gas Monitor (PGM50-5P) Serial Number: 511958 User ID: 00000001 Site ID: 00000001 Data Points: 19 Data Type: Avg Sample Period: 60 sec Last Calibration Time: 01/17/2012 12:28 Start At: 01/31/2012 11:11 End At: 01/31/2012 11:29 Sensor: CO(ppm) VOC(ppm) H2S(ppm) LEL(%) OXY(%) High Alarm Levels: 200.0 100.0 20.0 20.0 23.5 Low Alarm Levels: 35.0 50.0 10.0 10.0 19.5 STEL Alarm Levels: 100.0 25.0 15.0 ----- ----- TWA Alarm Levels: 35.0 10.0 10.0 ----- ----- Sensor: CO(ppm) VOC(ppm) H2S(ppm) LEL(%) OXY(%) Peak Data Value: 272.9 0.0 0.0 0.0 20.9 Min Data Value: 0.0 0.0 0.0 0.0 20.5 TWA Data Value: 2.9 0.0 0.0 ----- ----- AVG Data Value: 72.8 0.0 0.0 ----- -----