The word Summerland today conveys long pleasant golden days--the Lotus-Eaters' land in which it seemed always afternoon, a realm where the sun never set and the tiresome seasons never changed. This is because hardly anyone remembers what it meant to British holidaymakers in the dawn of the 1970s, or what it meant the morning of Friday, August the 3rd, 1973, when daylight revealed what was left of it.
It is interesting to compare the Summerland disaster to the King's Cross tube station fire. Fifty people died in Summerland, compared to thirty-one at King's Cross--but the King's Cross fire is mentioned far more often and gained far more media attention than did Summerland. Dr. Ian Phillips of the University of Birmingham has made what may be the most comprehensive and in-depth study of the Summerland disaster, which is well worth reading on its own; he muses that had a fire killed fifty holidaymakers in, say, Bournemouth, rather than on an obscure little island in the Irish Sea, it would have been a massive news story hailed as a national tragedy. He's right.
The Isle of Man is shaped roughly like a kipper. It is home to just over eighty thousand people, governed by the oldest parliament in the world, Tynwald; its flag shows a triskelion made of armored legs joined at the thigh. It has its own officially-recognised-as-a-legitimate-autochthonous-regional language, Manx Gaelic, and its indigenous Loaghtan sheep produce a particularly fine and much sought-after meat. And in 1971, it became home to a new concept in leisure: the first modern, completely climate-controlled, indoor holiday sports and entertainment center ever built in Britain.
Summerland in context
As the Sixties waned, the popularity of the British seaside holiday was fading in favour of cheap group tours to the Mediterranean. Spain in particular was attracting more and more lower-to-middle-class Britons who might otherwise have gone to Bournemouth or Minehead or even the Isle of Man for their summer hols. And honestly, anyone who's been to the British coastline in summer prior to, say, 2004 and the advent of summer temperatures regularly above eighty F would have to agree with them. British beaches are a) cold, b) windy, c) rainy, d) spiky or stony and e) all of the above at times, plus packed with hundreds of thousands of other determined holidaymakers and their porky children buying ice-creams and sticks of rock and cheap plastic pails and shovels to make sandcastles with. There's a certain dogged one-upsmanship associated with British holidaymaking: no matter how foully cold and rainy and disgusting it is, you are at the damn seaside and you are damn well going to paddle in the sea even if the sea is forty degrees fahrenheit and the colour of wet slate and everybody else is wrapped up in towels and anoraks and going "ooh isn't it cold." It is this mentality the planners of Summerland wished to exploit: instead of going off to Ibiza or Torremolinos or some other mucky foreign place where you were bound to get the runs, you could just nip off to the Isle of Man (a proper British holiday destination with regular ferries from places like Blackpool) and spend a fortnight in the endless tropical climate-controlled sunlight of Summerland.
The plot on which the Summerland/Aquadrome complex was constructed had long been used as a holiday/amusement park site. Located at one end of the promenade of Douglas, which became the Isle's capital in 1869, the site had first been developed in the 1790s for a structure called Derby Castle--at the time not even incorporated into Douglas, joined by a causeway. In the later 1800s the Castle property was bought by a gent who noticed the major uptick in tourist visits to the Isle and decided to capitalize on same by building what was in effect a prototype for Summerland: an entertainment center including a theater, ballroom, and restaurant/bar. There was even a roller-coaster and firework displays.
By the end of the 1800s the Derby Castle Company had merged with the other entertainment-venue companies vying with it for patrons. Through the World Wars, the entertainment center was used for various purposes such as factory work and storage for valuables from hotels used as internment-camps. It was said to be cursed; that anything built upon it would meet a sticky end.
After 1945 the Derby Castle property was bought by the "Douglas Corporation" in order to be redeveloped into a brand-new entertainment center designed to draw holidaymakers from the delights of the Mediterranean package holiday by replicating the attractions it theoretically offered. With the diminishing tourist trade and the lack of interesting and non-weather-dependent attractions in Douglas, the Isle wanted to create a center to entertain visitors even during truly awful weather. "The design presented," says a booklet produced by the Island's Development Company in 1972 (The Summerland Story, 1972, p.25), "is based on the idea of creating an environment where the sun always shines – an area in which the weather can be guaranteed and where every activity connected with a seaside holiday can be enjoyed by all ages. The scheme envisages, therefore, the maximum possible area enclosed by a structure designed to admit the maximum sunlight, implemented by artificial means, to create a permanent atmosphere of sub-tropical climate. Within this area it is aimed to produce a sense of being in the open air without the climatic hazards."
The arguments and agreements and parliamentary squabbling surrounding the development of what was to become Summerland are neither interesting nor uplifting. Suffice it to say that initially the swimming-baths (pool complex/Aquadrome) were definitely Wanted by the Isle government and money toward their construction was earmarked. At this point architects got involved--and at this point we start to see the inevitable confusion building. Perhaps Frank Gehry's architectural abortions aren't so bad after all: so far none of them has actively killed anybody.
The architects
James Philipps Lomas, a Douglas architect with two lowercase Ps, won the contract for Summerland because his ideas were "rather more imaginative" than his competitors' (in the words of Douglas' Borough Engineer, Byrom, 1971, quoted in Phillips, s2 p58). Here is Lomas and his colleague Mr. Brian Gelling looking at a model of their creation. Notice that the Aquadrome, in the foreground, backs up directly against the cliff on one side. (Also notice that it's a horrible Brutalist disaster.) Lomas had never worked on anything outside the Isle of Man, whereas Gelling had been employed at a larger firm with experience designing leisure centers on mainland Britain; this firm, Gillinson, Barnett & Partners, was eventually to be appointed "associate architects" for the Summerland/Aquadrome project and do all the working drawings and all the research into materials needed for the work.
This last is significant. Summerland was to shake up the world of architecture with its unprecedented use of particular materials, the properties of which could have used a little more research.
The construction of the Derby Castle Scheme had three components: the Aquadrome, Summerland itself, and a multistory car park which was never built. The Aquadrome featured two heated seawater pools with stadium seating, as well as a host of rather ominous-sounding other attractions including "aerotone, sauna, steam, hot, cold plunge, slipper, Vichy douche, massage, Russian vapour and Turkish baths." It opened in 1969 and was run by the Douglas Corporation (separate from Summerland). They had considerable difficulty sticking it to the cliff face that formed its fourth wall, and in fact had to bolt the cliff together to stabilize it, ending up with a messy and unbeautiful surface.
Summerland's plans had been drawn up in 1965. Construction didn't begin until 1968, and was disrupted in 1969 and 1970 by disagreements over the internal layout and what the probable tenant would end up doing with the building. An early model of the interior of the building shows a very different concept than what ended up being constructed. The Douglas Corporation waffled on a tenancy agreement for so long that in order to avoid expensive overruns the contract with the construction company was renegotiated to include just the building shell, rather than the internal structure. The shell was completed in December of 1970, just under the deadline. A new contract would have to be drawn up with the eventual tenant regarding the furnishings and fitting-out of the building. This is also significant, because the separation of internal and external structures involved a lot of fire code waivers and wriggling out of having to actually take structural precautions against disaster.
Douglas Corporation finally signed the UK hotel group Trust House Forte (THF) to a 21-year lease in December of 1970, which separated the managements of the Aquadrome and Summerland. Patrons would have to pay separate admission fees to the two attractions, and could not walk from one to the other without going outside, contrary to the original Scheme. The tenancy agreement did allow for work on the interior design and construction of Summerland to begin, and here is where the tragic flaws of the building begin to become manifest. The interior structure of Summerland was entirely done by the associate architects, Gillinson Bartnett & Partners, and not by Lomas and Gelling. Lomas's plans could not have taken into account design decisions made by Gillinson Barnett, and therefore could not have included an appropriate system of staircases and exits in the shell design to match the interior usage of the building.
After the fire, the investigation into Summerland's design unearthed this factor, which was used as an excuse by the architects: "The Commission was told that, during the long process of designing Summerland, the details of escape in case of fire could not be considered because the kind of occupancy, usage and activities were not decided, as no tenant had been nominated." (Summerland Fire Commission report, para 216, pg 21, quoted in Phillips, chapter 2.6, pg. 71.) The Commission wasn't having any of it, however, and concluded that Gillinson Barnett damn well could have made some educated guesses.
Materials
The revolutionary nature of Summerland as a concept was not so much based on its functioning as a leisure center but as a "weatherproof enveloping structure" within which visitors could enjoy the pleasures of a summer seaside holiday all year round. In order to create such a vast enclosed space, the associate architects turned to what was then a highly innovative building material, the polymethylmethacrylate sheeting sold as Oroglas. No one had ever used Oroglas on such a scale before: they created a whole roof and much of two walls of Summerland out of the stuff. This was not explicitly stated in minutes from the Tynwald discussions during the planning stages of the project: all the references to the construction used the words "glass" or "glass-like material," implying that the building would be constructed using largely traditional materials. Remember that it wasn't Lomas who was responsible for choosing materials, but the associate architects, Gillinson Barnett.
"The decision was taken to use Oroglas for Summerland by Mr Clifford Barnett at an early stage, and was confirmed amongst the architects before the Derby Castle Development Scheme brochure was presented to the Finance Committee of Douglas Corporation in August 1965 (chapter 2). Mr Barnett was not only insistent on an acrylic solution for Summerland; but a solution that involved the use of a particular type of acrylic sheeting manufactured by an American company that at the time had not been used on an extensive scale in Europe. His commitment to using Oroglas is picked up by the Summerland Fire Commission report (SFC Report, Paragraph 207, Page 69): “He [Mr Barnett] was clearly committed to it [Oroglas]”, the
report states....The architects wanted to create a building that was “unique and compelling” (The Summerland Story, 1972, Page 25). In the same brochure, the claim is made that Summerland would “set the architectural world alight for nothing had ever been designed to include so much of the transparent sheeting”." (Phillips, chapter 3, pg 98).
We don't need to point out the irony of the phrase "setting alight."
What did this marvelous material end up looking like in place? It looked like this. "Each panel catches the light to
provide an interesting and varying pattern on the façade," says the brochure. To modern eyes, it looks perhaps less interesting and innovative than "spiky," but at the time I.M. Pei had not constructed the Louvre pyramids and the Early Seventies Awful school of architecture was firmly in power.
Rohm and Haas, the manufacturers of Oroglas, themselves state that “There is no building code in America which would allow it [Oroglas] to be used overall as it was at the Summerland
centre. A structure like that would just not have been allowed in America.” U.S. fire codes require a comprehensive sprinkler system to be installed wherever Oroglas was used on a large scale, and in fact the UK subsidiaries of Rohm and Haas were aware of these codes and requirements...but did not pass them on to the Isle of Man chief fire officer.
The manufacturers knew Oroglas was combustible. Phillips refers to an ad hoc experiment conducted in Warwickshire by a council considering the use of the material in a project, in which a sample of Oroglas was set alight with a cigarette lighter and burned like merry hell: “The sample did not have chance to smoulder, as it burst into flames with a ferocity that I had not seen since like all young boys do, [I] set light to a ping-pong ball. It spat and flared, and we got a bit panicked that it would cause problems with the stuffy staff either side of our office.” An internal Rohm and Haas UK memo admitted that Oroglas could burn “in quite a frightening manner”. The letter warned that the material might not even fall free from its frame in the event of a fire. “The ways in which Oroglas may behave if involved in fire are not easy to predict and you should be cautious in discussions on this problem. The method of installation, size of panel and, in some circumstances, even the colour of material can have some effect.” (Phillips, chapter 3, pg 104.) One of the properties touted by the proponents of Oroglas was that it would soften and fall out of its frame at temperatures far below its ignition point, which was apparently known not to be the case. Rohm and Haas admitted after the fire that this information should have been provided to Mr. Pearson, the island's chief fire officer, but was not.
After the fire there was much throwing about of brains regarding whose fault it was that Oroglas was used in such amounts without a sprinkler system and whether the use of Oroglas had in fact been the cause of the fifty deaths. As it turned out it wasn't "Horrorglass" at fault for the disaster after all: it was another building material entirely, a substance called "Colour Galbestos," rolled steel sheeting coated in bitumen and asbestos.
Waive this for me
Isle of Man by-law 39 "requires a building’s external walls to be non-combustible and have a fire resistance of two hours." Both of these requirements were waived during the construction of Summerland, which is precisely why the disaster happened. Use of Oroglas was permitted due to a waiver requested by Lomas and granted on the understanding that, while Oroglas did not have a fire resistance of two hours, in case of fire it would theoretically soften and fall out of its frames, allowing people to escape through the gridwork of the walls. The Borough Engineer who recommended the by-law be waived to allow the use of Oroglas did so believing it to be non-combustible, which is rubbish. It's repeatedly stated that Lomas and the other architects assured the Douglas Corporation of Oroglas's non-combustibility, and this inaccurate statement of the material's properties shows up in promotional literature for the building. Post-fire investigations of Lomas and Gillinson Barnett show rather predictable mutual attribution of blame: Mr. Barnett calls Mr. Lomas cavalier in his approach to regulations, and Mr. Lomas claims that Mr. Barnett and his partners should have done their research and he trusted them when they said that Oroglas was totally safe. Either the architects didn't know they were telling porky pies or they didn't care. I don't know which is more disturbing.
The use of Colour Galbestos on the building's east wall was even more of a violation of Law 39, as it is neither non-combustible or fire resistant. It was used in place of concrete or regular steel sheeting because it was cheaper, and permitted due to a truly astounding sequence of failures to communicate: the Borough Engineer suggested Law 39 be waived for it because "he considered it an adequate material in all the circumstances;" the Douglas Corporation meant to ask the Local Government Board for the waiver but never got around to it; the Local Government Board received plans including the use of Colour Galbestos without being notified that its use required further Law 39 waivers; the Chief Fire Officer was never consulted about the use of Galbestos because nobody twigged that it was, in fact, lethally inappropriate. Similarly, the decision to use combustible plastic-coated fiberboard Decalin for the interior wall of the amusement arcade was made off the cuff and never discussed amongst the architects and designers with regards to the fact that it caught fire like anything.
Opening
Reaction to Summerland when it finally opened in 1971 was mixed. The building's promoters, unsurprisingly, thought it was just wonderful: “[Summerland] stands as a pulsating memorial to the foresight of its planners and supporters. It can only confound the critics of the controversial scheme when they see for themselves what has been achieved…The result can only be a source of pride to the whole Island...It will undoubtedly attract the widest publicity – not only because it is unique in the western world, but because it caters so ideally for leisure and relaxation in the unreliable climate of the United Kingdom," according to a full-page advertisement appearing in the Isle of Man Examiner on 16th July, 1971. Others were not convinced. John Carter, the travel journalist and TV presenter (Holiday and Wish you were here?) commented in The Times (19th May, 1973):“The centre’s glossy brochure claims it has ‘Attractions for every taste’, but I must beg to be excused from that generalization. I do not like motorway restaurants, either, but that is another variation on the theme.” (Phillips, chapter 3, pp. 116-118.)
Inside, Summerland offered a wide range of attractions including children's entertainment and play facilities, cafes, restaurants, and bars, amusement arcades, bingo, shuffleboard and artificial waterfalls, a tanning room, shops, and of course the Solarium--which was used for mass performances.
Despite the fact that its logo looks a bit like a gigantic pimple (or possibly the Eye of Sauron) the pictures convey a certain enthusiastic sort of gaiety. To modern eyes, Summerland drips with 1970s kitsch; James Lileks would have gone mad over the Marquee Showbar's purple and red awnings and plastic chestnut trees, or the bingo arcade's dental-appliance-pink and dog-diarrhea-yellow colour scheme. It's the apotheosis of Organized 1970s Fun, and not unlike one specific concept of Hell.
Now imagine all of this on a drizzly August evening in 1973, packed with around two thousand people listening to accordion music, dancing, drinking, roller-skating, tanning, eating, and generally spending money. It's still light outside as eight o'clock draws near. Outside on the terrace, where the mini-golf course is set up, three boys are hiding in a disassembled kiosk set up against the Galbestos part of the promenade wall, sharing an illicit cigarette.
The fire
The Summerland fire was started by a discarded match. While they were smoking, shortly before 7:40 pm, one of the boys lit a match which caught something inside the kiosk on fire. Apparently not realizing this or not thinking it would burn out of control, he joined his friends and some other boys on the terrace to talk about football. Soon afterward, they smelled something burning, and found that the floor of the kiosk was on fire. They tried to put it out, but the fire was beyond their control, and they ran away in fear.
By itself the kiosk fire would not have caused the disaster had Summerland been constructed of materials adherent to by-law 39. The fact that the fire was located right up against a wall made of Colour Galbestos doomed the center and fifty people inside it. An extremely fuzzy photograph taken between the fire's ignition and the full involvement of Summerland itself shows smoke and flames rising from the kiosk on the outside of the promenade wall: nobody knew that in fact it had also started a concealed fire inside the wall of the building. Holidaymakers alerted the staff to the fire around 7:55 pm, and staff members joined at least one patron in trying to fight the fire with chemical extinguishers and the building's fire hoses.
Even the staff thought the external wall was regular steel sheeting and would prevent the fire entering the building. In fact, it was already inside:
"The Colour Galbestos used at Summerland consisted of a zinc coated steel core, which was “covered with asbestos felt saturated with bitumen and then faced with a polyester resin coating” (SFC Report, Paragraph 152, Page 53). When the burning kiosk collapsed against Summerland, the Galbestos wall rapidly became red hot and ignited the material’s combustible coating (polyester resin and bitumen) probably after around 80 seconds (Sam Webb, RIBA, Personal Communication). Since the core (steel and zinc) of the Colour Galbestos has a high thermal conductivity, fumes were soon given off on the inner side of the wall after two-and-a-quarter minutes. “Strong flames” were coming from the Galbestos one minute later." (Phillips, chapter 6, pp.268-269.) The damaged Galbestos wall shows how the stuff buckled and twisted in the heat.
The inner wall, made of a plastic-coated fiberboard called Decalin, was also combustible. When the fire breached the Galbestos wall and entered the void, it ignited the inner side of the Decalin wall and spread across the eastern end of the building between the two walls. Phillips offers some chilling data: "It is estimated that the fire in the void started around 4-6 minutes after the external fire had become established in the remains of the mini-golf course kiosk. This internal fire then gained intensity – but at all times being confined to the void – over the next ten minutes between about 7.45pm and 7.55pm (Time estimate by Professor Rasbash; see SFC Report Paragraph 106, Page 38). It is not known what temperatures were reached in the void, but they may have reached 1000 degrees C close to and after the Decalin wall gave way..." (Phillips, chapter 6, p.273.)
When the fire broke through into the interior of the building, it did so at the ceiling of the amusement arcade (directly beneath the Marquee Showbar level), probably because the only firestopping within the void was located at that level (asbestos sprayed on metal girder). The flames roared across the ceiling of the arcade like a blowlamp, spreading rapidly across flammable furnishings and decorations. By the time the first flames were seen within the building, a considerable portion of the wall had already been burning for some time: with the breach of the inner wall, air rushed in and rapidly fed the fire. From the amusement arcade the fire spread, igniting the Oroglas promenade wall alongside the flying staircase, which caught fire after being exposed to flame for less than two minutes. Burning plastic dribbled to the Solarium below.
Eyewitness accounts agree that the fire spread incredibly rapidly--"as if the place had been doused with petrol," "like a bomb," "worse than the Blitz," "within ten seconds the whole place was on fire," "like wildfire," "the building went up like paper and was wrecked in no time at all." There was no warning, no fire alarm bell was sounded, and no official call was made to evacuate the building other than a terrified compere's shout over a microphone. People on the Marquee Showbar level and above had few escape routes from the building, all of which rapidly became jammed with struggling people. And the Oroglas--far from softening and dropping harmlessly out of its frames--was burning. Molten blobs of burning plastic rained on the screaming people struggling to get out, spreading fire across the Solarium floor. The gap between the terraces and the Oroglas wall acted as a chimney, sucking fire upward to the roof, which burnt out in perhaps ten minutes after ignition. The plastic panels had no time to soften and drop harmlessly from their frames: the temperature of the hot gases and of the flames themselves brought it up to ignition point in seconds. Recall the ad hoc experiment done in Warwickshire on a sample of Oroglas: once alight, it burned fiercely.
Of the vastly insufficient number of exits from the building, several were locked, including two of the main entrance doors and one fire exit immediately adjacent: some of these could be battered open, as the doors into the Aquadrome were, and some could not. People lost their way in the toxic black smoke and were overcome. Parents relaxing on the upper terraces were separated from their children playing in the lower-level skating rinks and the amusement arcade, some of them permanently. At 8:11 the lights went out as the manager shut off the power in the mistaken belief that it would improve safety by preventing electrical fires: the only light left was that thrown by the fire itself, obscured by billows of smoke. The emergency lighting, designed to come on in the event of a power failure, failed--either because the generators wouldn't start or because the switch to them was set in the "off" position. A supposedly safe enclosed exit stairway (the northeast service staircase) was not only not designed for use as an emergency exit but was also now pitch black and full of smoke.
The first alarm was called in to the Douglas fire station at 8:01 by a passing taxi driver; the second was from a boat offshore. Only after those did anyone in Summerland call for the fire brigade. No automatic fire alarm had been rung from the burning building whatsoever: this was investigated as having been either due to the setup of the alarm system or to fire destroying alarm wires. Once the fire engines arrived, however, there was little they could do: the fire had taken too great a hold and had too much fuel for them to hope to extinguish it. The main focus was then shifted to trying to prevent the Aquadrome from a similar fate.
By ten past nine--only an hour and a half after it began--the fire was under control, and by eleven the firemen were beginning to bring out the bodies.
The inquiry into the disaster published its report in May of 1974. Prior to the report's publication, most of the theories about the factors responsible for the deaths focused on the rapid fire spread due to the extensive use of Oroglas, the locked exit doors, and the delayed and disorganized evacuation of the building. In fact the Oroglas theory was still being cited as late as 2006 (Phillips mentions an article in the Isle of Man Examiner in March of 06 containing the line “Summerland was rebuilt without the lethal plastic dome, which had been responsible for so many deaths”). The Summerland Fire Commission report, however, scotches this theory, revealing the catastrophic combination of Galbestos and Decalin that had played a major role in the early development and spread of the fire. The combination of inappropriate material use, open plan design, insufficient staircases and exits, and delayed evacuation is what really caused the deaths of fifty people in Summerland.
The first three of these causes can be attributed to poor or nonexistent communication and research on the part of the architects and planners; the fourth could not be avoided, as there was no sign of the fire inside the building until twenty minutes after it had begun. People were still paying to enter Summerland for that twenty minutes after the boys' accidental ignition of the disassembled kiosk on the terrace. Nobody had any idea that the fire had penetrated the Galbestos and was burning fiercely inside the wall; the staff had had no reason to suspect that evacuation was necessary until after it was already far too late to save everyone inside.
Summerland's fire alarm system, like the Noronic's, had two stages. Public break-glass alarm points around the building would show up on an indicator panel in the "Control Room" when smashed, but would not sound the public alarm. A staff member monitoring the indicator panel would then be responsible for verifying the fire and sounding the alarms if necessary (by either smashing a staff fire alarm glass outside the control room or pushing a "test" button, not the Sound Alarm switch, on the console). The built-in delay was meant to allow for investigation of false alarms, but the fire station should automatically have been alerted when the public trigger was smashed. The fact that it wasn't indicates that the alarm panel itself had been taken apart and physically modified to extend the built-in delay to the automatic fire brigade alert, which Summerland had had done after prior false alarms without notifying the Chief Fire Officer. Which is a lethal version of "it's easier to ask forgiveness than permission."
As if the handy pre-sabotaged alarm system wasn't bad enough, the power supply to run it wasn't up to code, it turned out during the investigation. If the mains wiring was destroyed by fire, the backup generators were supposed to be able to provide power to run the alarm, but when these were examined after the fire they appeared to have been inoperable. Furthermore, the operator in the Control Room had had no training on the fire alarm system, did not know how to use the system, and was not aware that running the system was part of her duties.
The Control Room was set on the first terrace level facing the Solarium and the three terraces against the east wall, allowing the operator a continuous view of most of the interior. It was used in actual practice as the sound and light/announcer's booth for the Solarium, and in fact the operator on duty at the time of the fire reported not to the Fire Officer but to the Entertainments Manager, which gives you an idea of the room's role in the running of the building. There was in effect no fire and safety oversight from the Control Room, nor had there been under the management in place at the time of the fire. (It is worth pointing out that the first manager to run Summerland did take the Control Room seriously and its operators under his oversight were trained in emergency responses.)
When the fire started, the 19-year-old operator in the control room was not bothered because it appeared to be outside the building and no fire alarm station had buzzed on her panel as having been smashed. Even after the first public alarm glass had been smashed, no indicators were received in the Control Room, suggesting that the alarm system was already dead due to fire in the wall burning through the wiring. The operator could have sounded the actual alarm and sent a signal to the fire station, but did not do so. According to the report, "she felt that it was pointless to make an announcement because the fire was so evident in the building by this stage" (SFC report, paragraph 167, p 58, quoted in Phillips chapter 6 p. 278.)
The locked exit doors turned out, on analysis, not to have been as desperately fatal a factor as might be thought. Most of the deaths occurred on the terraces or the (few) staircases leading down from them to the Solarium floor or directly out of the building. From the third ("Cruise Deck", the highest point in the building) to the second terrace (Leisure Level) there was only one exit (the flying staircase); on the Leisure Level there was access to the flying staircase as well as the northeast service staircase which descended to the ground level and opened directly to the outside. From the first terrace one had a choice of the service staircase, the flying staircase, or the "rustic walkway" (an afterthought, not in the original plans). People struggling to escape from the terraces joined the throng on the Solarium floor running for the exits if they were lucky: if they weren't, they were stuck either on the terraces as the fire spread or on the staircases jammed with panicked people screaming in terror. The flying staircase--for many people the only exit of which they were aware--became enveloped in flames, killing at least 13 as they were overcome by fire and fumes or leapt to their deaths in the blaze below.
No villains
The official report's conclusion that the disaster was an accident attributable to human error and not to any specific "villain" surprised many. Here's what they said:
“In all the above inadequacies and failings, it seems to the Commission that there were no villains. Within a certain climate of euphoria at the development of this interesting concept, there were many human errors and failures and it was the accumulation of these, too much reliance upon an‘old boy’ network and some very ill-defined and poor communications which led to the disaster. It would be unjust not to acknowledge that not every failure which is obvious now would be obvious before the disaster put structure and people to the test."
Death by misadventure was the coroner's verdict--times fifty--and this, too, infuriated those who had lost loved ones in the disaster. If the architects and planners, the companies who sold them the materials, and the management in place at the time of the fire could not be held responsible, who could? God? Bad luck? The "curse" of the Derby Castle site?
There are no answers, but the Corporate Manslaughter Act of 2007--a result of unsuccessful prosecutions in cases of disaster--means that if anything like Summerland ever happens again, it would be possible to find the management of the building liable. As with almost every disaster, Summerland spurred the creation of new and more stringent safety codes and regulations, meant to address the various elements of the situation that had led to the appalling death toll. This comes as cold comfort to the families of the victims.
We should remember Summerland not for its kitsch and its desperately misguided concept. We should remember it because it is still the deadliest building fire to have occurred in Britain since the end of World War Two. We should remember it because the decisions that led to disaster are individually small and perhaps understandable: decisions that are likely to have occurred over and over since 1973. We should remember it because new is not always better, and because regulations are not always there to be waived.
Summerland was rebuilt in a vastly subdued version after the fire, but struggled to break even: in 2006 it and the Aquadrome, which had survived the fire, were demolished. After forty years the Derby Castle site has rid itself of a lingering scar, and Douglas--and the Isle of Man--can move on.
Information in this post is from Dr. Ian Phillips's book detailing the results of his research into the Summerland disaster. The book is available on the Web at Dr. Phillips's Birmingham University page. All images in this post are from Dr. Phillips's book (complete with original caption and citations where possible) and moved to my own hosting for purposes of illustration. No copyright infringement is intended and no money is being made: the research was done by Dr. Phillips, not myself, and this post is intended merely to present in summary the conclusions detailed in his work.
Wiki's article on the disaster states variously that 50 and 51 people were killed: there is controversy over the above-50 death toll figure, but Dr. Phillips states that he was unable to find any evidence to support the notion that more than fifty died.
Thursday, July 30, 2009
![[Summerland]](http://img.photobucket.com/albums/v104/ceruleancynic/summerland/summerlandbrochurecover.jpg){kind=link}
Friday, July 10, 2009
What didn't happen at all: Ancient Egyptian Maser Technology
I trust most people out there are at least somewhat familiar with the Great Pyramid of Giza (also known as the Pyramid of Khufu, or Cheops if you want to be all Greek about it). It's a big sort of triangular hunk of stone, not far from this river that runs backward. Been around a while. Appears with an eye stuck on it on the reverse of the dollar bill.
Now I am not a trained Egyptologist, but I am at least aware that the reason these things were built has been the topic of considerable discussion and frothing academic vitriol for at least a thousand years. Tomb or cenotaph? Tomb, cenotaph, or monument? Most people who have not had their brains surgically removed and replaced with live novelty goldfish will probably agree that the pyramids had at least something to do with the memorialization of dead god-kings, whether the dead god-kings were actually laid to rest for all time inside them or not. Most people do not spend good money, time and effort trying to reverse-engineer the pyramids into giant hydrogen masers.
I will digress here into a brief explanation of the maser qua the maser, for the benefit of those of you who never took Pyramidiocy 101.
It may surprise you to know that the thing you call a laser was originally known as an optical maser. The term stands for “microwave amplification by stimulated emission of radiation.” Masers work on the principle that excited atoms (Eee! Eeee!) can amplify radiation at a certain frequency; that is, you get a bunch of atoms of something, say hydrogen, and you excite them, and then you pass a microwave beam through them, and the bouncy atoms amplify those microwaves. This does you no actual good unless you’ve confined the bouncy hydrogen inside a resonant cavity, that is to say an enclosed space in which waves bounce around with low loss; if you do this, and beam the microwaves into this cavity, you will get repeated and functional amplification. So what? So you can then use this microwave energy to do stuff like, I don’t know, cook Stouffer’s frozen French bread pizzas.
Now, the ancient Egyptians did not record their use of microwave energy to cook Stouffer’s frozen French bread pizzas, but a gentleman by the name of Christopher Dunn is of the opinion that they did use this energy to run ancient Egyptian power tools. Oddly enough none of the temple carvings or tomb paintings thus far discovered by archaeology have shown the black-and-yellow god Deh’Wawat drilling holes in people’s heads to let out demons, nor yet his consort Bak-An-Dekar using the Circular Saw of Ma’at to frighten away Apophis from trying to swallow the Sun, but Christopher Dunn proceeds dauntless.
His argument is based on the fact that a great many of the relics of antiquity found in Egypt show a precision which he considers impossible without the use of modern power tools. The black sarcophagi at the Serapeum, for example, he contends could not have been made without the use of precision tools. Therefore, the ancient Egyptians must have had some kind of power plant to provide the motive force to turn their drills and cut their stone into perfect right angles: and, since the Great Pyramid was just sitting there, without even a dead king in it to justify its existence, Dunn focused on that as his power plant candidate.
How did it work, you ask? In order to understand Dunn’s theory you will need to become familiar with the internal architecture of the Great Pyramid.
See figure 1.
I confess I do not own The Giza Power Plant, Dunn's seminal work, but I've read the bits of it and his other theories that appear on various woo-related sites around the internet, and I believe I have grasped the main thrust of his point.
Apparently the Pyramid was designed to focus "energy" on a resonant chamber at its heart (the King's Chamber). The Pyramid is supposed to resonate at exactly the same frequency as the Earth, and the internal architecture is designed, according to Dunn, to maximize that resonation and produce piezoelectric energy out of quartz crystals in the granite slabs that line the King’s Chamber. It is not clear whether somebody had to stand outside hitting the Pyramid with a tuning fork while they were building it so that they could be sure to match resonant frequencies, but we can assume this was done with the appropriate ritual and ceremony. He's terribly excited about the levels of granite beams above the King's Chamber and how they were "tuned" whilst being cut:
Each granite beam was shaped and gouged on the topside as it was tuned! Thousands of tons of granite were actually tuned to resonate in harmony with the fundamental frequency of the earth and the pyramid!
And I am the Seriph of Klatch. Dunn does admit that he hasn't actually got any proof of any of this, but forges merrily ahead anyway:
Without confirmation that the granite beams were carefully tuned to respond to a precise frequency, I will infer that such a condition exists in light of what is found in the area. While I have not found any specific record of anyone striking the beams above the King's Chamber and measuring their resonant frequencies, there has been quite a lot written about the resonating qualities of the coffer inside the chamber itself. The coffer is said to resonate at 438 hertz and is at resonance with the resonant frequency of the chamber. This is easily tested and has been noted by numerous visitors to the Great Pyramid, including myself.
"I can't prove this but I think other people said things that mean it might possibly be true, so I'm going to use it to base my theory on."
Dunn's idea centers on the Grand Gallery, in which he posits that twenty-seven racks of Helmholtz resonators were installed. As the earth's vibration flowed through the Great Pyramid, the resonators converted the energy to airborne sound, which then was reflected into the King's Chamber, where it bounced around sufficiently to cause the granite beams to vibrate like a bunch of enormous silicaceous bass strings. "Thus," he concludes, "[with] the input of sound and the maximization of resonance, the entire granite complex, in effect, became a vibrating mass of energy."
So we have a vibrating mass of energy. What do we do with it in order to get our mystic ancient drill-presses to work?
Let’s take this step by step.
Dunn believes that the Queen’s Chamber was used to produce hydrogen via a chemical reaction between hydrated zinc chloride and dilute hydrochloric acid. Where did these chemicals come from, you ask? Why, they were pumped up vertical shafts inside the Pyramid to the tops of the two shafts opening into the Queen’s Chamber, whereupon they filled up the shafts and seeped at a controlled rate through the blocks in the walls of the Chamber itself. When Rudolf Gantenbrink’s robotic exploration of these shafts ended at a limestone "door" with two copper spikes driven through it, Dunn was ecstatic—never mind the lack of vertical shafts for his chemicals, these bits of copper were clearly electrodes which would signal that more chemicals were needed when a circuit between them was cut by the electrolyte level falling.
I'll let you think about that one for a minute.
When the National Geographic robot drilled a hole through Gantenbrink’s Door and the expected vertical shaft/copper cables were not, in fact, there, did this deter Dunn? Not a bit of it. He promptly fired up Photoshop and decided he’d do a bit of off-the-cuff theorization and massive overuse of filters that would allow the vertical shaft to exist after all, even though it appears to be nothing more than a shadow. One must have faith in the Giza Power Plant theory, because faith is a vital part of any scientific investigation.
Dunn also (and more egregiously, in my view) ignores the fact that the shafts through which these chemicals are supposed to have run are made of limestone. Anyone who’s ever done any work on karst topography--or lived in south Florida or the Ozarks or the Dales or the Peak District--knows just how easy it is to wear away limestone with plain old water, never mind hydrochloric acid. Why didn’t the builders line the shafts with granite, if they were going to be running corrosive liquid down them? How come the Queen’s Chamber isn’t a big amorphous cave in the rock dissolved away by the chemical reactions supposedly going on inside? Where did the ancients get the ingredients to mix these chemicals in the first place/isolate them from naturally occurring substances? How were these technologies made possible before the construction of the Pyramid? Dunn does not relate.
Having made his hydrogen through this wildly improbable reaction, Dunn then takes us along the horizontal passage that links the Queen’s Chamber with the Descending Passage. The spent chemicals would trickle away down the shaft known as the “well,” which is something like 28” by 28” at the top. Why it needed to be that big, Dunn does not explain. The hydrogen, then, was wafted up through the Grand Gallery to the King’s Chamber.
As mentioned, the Grand Gallery supposedly contained stacks of Helmholtz resonators. During its journey up to the King's Chamber, the hydrogen would have been excited by all the good vibrations, and when it got to the resonant King's Chamber, it would have been seriously excited to the point where it could do some stimulating of radiation emission.
At this point Dunn leaves interesting fancy behind and goes right the hell over the edge into foaming-at-the-mouth insanity: he posits that at this point, a microwave signal from space came down the northern ventilator shaft ("wave guide") into the sarcophagus in the King’s Chamber so that the energized hydrogen atoms could amplify its signal exponentially. This amplified microwave signal then was collected by something in the other airshaft of the King’s Chamber, and beamed up out through the shaft into space where it hit a satellite and was beamed back down to earth to be used in power tools.
Mmhmm.
Alan Alford, one of the pyramid theorists whom I will not tar with the brush of pyramidiocy, due to his ability to see the massive howling gaps in the logic of most theories, has the following to say on Dunn’s King’s-Chamber flight of fancy:
Firstly, the mouth of the northern airshaft is cut too high in the wall to align with the sarcophagus, so any incoming microwave signal would have passed right over the top of it. It is not clear how it could have interacted with any equipment inside the box.
Secondly, Dunn assumes that the sarcophagus had no lid (pp. 189, 222) and that the signal interacted with hydrogen atoms inside the box. But there is clear evidence that the sarcophagus did originally have a lid and that it was hermetically sealed (see my book Pyramid of Secrets, pp. 73-74). I am not entirely certain how this affects Dunn’s theory, but there could not have been any hydrogen in the box.
Thirdly, the mouth of the southern airshaft is cut too high in the wall to align with the sarcophagus, so it is difficult to see how the output from the box could have been channeled into the shaft.
Fourthly - and worst of all - Dunn insists that the entire lengths of the northern and southern airshafts would have to have been lined with gold- plated iron in order to have an efficient conduit for the electromagnetic radiation (pp. 186, 221-22). This is quite simply at odds with the facts, as Dunn well knows. For both the shafts have been surveyed by robot and not a trace of a metal lining has been found (the iron plate found by Vyse in 1837 was embedded in masonry close to the southern shaft but it is not clear whether it actually formed part of the shaft). So, what happened to the iron? How was it removed from tiny shafts measuring approximately 8 by 8 inches to their entire lengths of 235 feet and 174 feet respectively?
The sum of all this ranting is but this:
If you are crazy enough and have enough disposable income to wander around Egypt and have your picture taken holding sciency-looking objects, you can get a lucrative book deal out of it and people will want to be your friend and write even more ludicrousfanficbooks based on your theory.
Or possibly “the world is full of gullible morons.” I’m no longer sure.
Epilogue: Dunn is almost charming in his excited attempts to reverse-engineer explanations for artifacts other than "we don't know." Here's his thoughts on the putative Helmholtz resonators:
One of the most remarkable feats of machining can be found inside the Cairo Museum. I have stood in awe before the stone jars and bowls that are finely machined and perfectly balanced. The schist bowl with three lobes folded toward the center hub is an incredible piece of work. With the application of ultrasonics and sophisticated machinery, I can understand how they could be made, but the purpose for doing so has long escaped me. It seems like a tremendous amount of work to go to just to create a domestic vessel! Perhaps these stone artifacts, of which there were over a thousand found at Saqqarra, were used in some way to convert vibration into airborne sound. Are these vessels the Helmholtz resonators we are looking for?
Information in this article is from the following:
Dunn's website
The Giza Death Star by Joseph Farrell, available on Google Books
The Giza Death Star Deployed by Joseph Farrell, available on Google Books
Alford's refutation of Dunn
Now I am not a trained Egyptologist, but I am at least aware that the reason these things were built has been the topic of considerable discussion and frothing academic vitriol for at least a thousand years. Tomb or cenotaph? Tomb, cenotaph, or monument? Most people who have not had their brains surgically removed and replaced with live novelty goldfish will probably agree that the pyramids had at least something to do with the memorialization of dead god-kings, whether the dead god-kings were actually laid to rest for all time inside them or not. Most people do not spend good money, time and effort trying to reverse-engineer the pyramids into giant hydrogen masers.
I will digress here into a brief explanation of the maser qua the maser, for the benefit of those of you who never took Pyramidiocy 101.
It may surprise you to know that the thing you call a laser was originally known as an optical maser. The term stands for “microwave amplification by stimulated emission of radiation.” Masers work on the principle that excited atoms (Eee! Eeee!) can amplify radiation at a certain frequency; that is, you get a bunch of atoms of something, say hydrogen, and you excite them, and then you pass a microwave beam through them, and the bouncy atoms amplify those microwaves. This does you no actual good unless you’ve confined the bouncy hydrogen inside a resonant cavity, that is to say an enclosed space in which waves bounce around with low loss; if you do this, and beam the microwaves into this cavity, you will get repeated and functional amplification. So what? So you can then use this microwave energy to do stuff like, I don’t know, cook Stouffer’s frozen French bread pizzas.
Now, the ancient Egyptians did not record their use of microwave energy to cook Stouffer’s frozen French bread pizzas, but a gentleman by the name of Christopher Dunn is of the opinion that they did use this energy to run ancient Egyptian power tools. Oddly enough none of the temple carvings or tomb paintings thus far discovered by archaeology have shown the black-and-yellow god Deh’Wawat drilling holes in people’s heads to let out demons, nor yet his consort Bak-An-Dekar using the Circular Saw of Ma’at to frighten away Apophis from trying to swallow the Sun, but Christopher Dunn proceeds dauntless.
His argument is based on the fact that a great many of the relics of antiquity found in Egypt show a precision which he considers impossible without the use of modern power tools. The black sarcophagi at the Serapeum, for example, he contends could not have been made without the use of precision tools. Therefore, the ancient Egyptians must have had some kind of power plant to provide the motive force to turn their drills and cut their stone into perfect right angles: and, since the Great Pyramid was just sitting there, without even a dead king in it to justify its existence, Dunn focused on that as his power plant candidate.
How did it work, you ask? In order to understand Dunn’s theory you will need to become familiar with the internal architecture of the Great Pyramid.
See figure 1.
I confess I do not own The Giza Power Plant, Dunn's seminal work, but I've read the bits of it and his other theories that appear on various woo-related sites around the internet, and I believe I have grasped the main thrust of his point.
Apparently the Pyramid was designed to focus "energy" on a resonant chamber at its heart (the King's Chamber). The Pyramid is supposed to resonate at exactly the same frequency as the Earth, and the internal architecture is designed, according to Dunn, to maximize that resonation and produce piezoelectric energy out of quartz crystals in the granite slabs that line the King’s Chamber. It is not clear whether somebody had to stand outside hitting the Pyramid with a tuning fork while they were building it so that they could be sure to match resonant frequencies, but we can assume this was done with the appropriate ritual and ceremony. He's terribly excited about the levels of granite beams above the King's Chamber and how they were "tuned" whilst being cut:
Each granite beam was shaped and gouged on the topside as it was tuned! Thousands of tons of granite were actually tuned to resonate in harmony with the fundamental frequency of the earth and the pyramid!
And I am the Seriph of Klatch. Dunn does admit that he hasn't actually got any proof of any of this, but forges merrily ahead anyway:
Without confirmation that the granite beams were carefully tuned to respond to a precise frequency, I will infer that such a condition exists in light of what is found in the area. While I have not found any specific record of anyone striking the beams above the King's Chamber and measuring their resonant frequencies, there has been quite a lot written about the resonating qualities of the coffer inside the chamber itself. The coffer is said to resonate at 438 hertz and is at resonance with the resonant frequency of the chamber. This is easily tested and has been noted by numerous visitors to the Great Pyramid, including myself.
"I can't prove this but I think other people said things that mean it might possibly be true, so I'm going to use it to base my theory on."
Dunn's idea centers on the Grand Gallery, in which he posits that twenty-seven racks of Helmholtz resonators were installed. As the earth's vibration flowed through the Great Pyramid, the resonators converted the energy to airborne sound, which then was reflected into the King's Chamber, where it bounced around sufficiently to cause the granite beams to vibrate like a bunch of enormous silicaceous bass strings. "Thus," he concludes, "[with] the input of sound and the maximization of resonance, the entire granite complex, in effect, became a vibrating mass of energy."
So we have a vibrating mass of energy. What do we do with it in order to get our mystic ancient drill-presses to work?
Let’s take this step by step.
Dunn believes that the Queen’s Chamber was used to produce hydrogen via a chemical reaction between hydrated zinc chloride and dilute hydrochloric acid. Where did these chemicals come from, you ask? Why, they were pumped up vertical shafts inside the Pyramid to the tops of the two shafts opening into the Queen’s Chamber, whereupon they filled up the shafts and seeped at a controlled rate through the blocks in the walls of the Chamber itself. When Rudolf Gantenbrink’s robotic exploration of these shafts ended at a limestone "door" with two copper spikes driven through it, Dunn was ecstatic—never mind the lack of vertical shafts for his chemicals, these bits of copper were clearly electrodes which would signal that more chemicals were needed when a circuit between them was cut by the electrolyte level falling.
I'll let you think about that one for a minute.
When the National Geographic robot drilled a hole through Gantenbrink’s Door and the expected vertical shaft/copper cables were not, in fact, there, did this deter Dunn? Not a bit of it. He promptly fired up Photoshop and decided he’d do a bit of off-the-cuff theorization and massive overuse of filters that would allow the vertical shaft to exist after all, even though it appears to be nothing more than a shadow. One must have faith in the Giza Power Plant theory, because faith is a vital part of any scientific investigation.
Dunn also (and more egregiously, in my view) ignores the fact that the shafts through which these chemicals are supposed to have run are made of limestone. Anyone who’s ever done any work on karst topography--or lived in south Florida or the Ozarks or the Dales or the Peak District--knows just how easy it is to wear away limestone with plain old water, never mind hydrochloric acid. Why didn’t the builders line the shafts with granite, if they were going to be running corrosive liquid down them? How come the Queen’s Chamber isn’t a big amorphous cave in the rock dissolved away by the chemical reactions supposedly going on inside? Where did the ancients get the ingredients to mix these chemicals in the first place/isolate them from naturally occurring substances? How were these technologies made possible before the construction of the Pyramid? Dunn does not relate.
Having made his hydrogen through this wildly improbable reaction, Dunn then takes us along the horizontal passage that links the Queen’s Chamber with the Descending Passage. The spent chemicals would trickle away down the shaft known as the “well,” which is something like 28” by 28” at the top. Why it needed to be that big, Dunn does not explain. The hydrogen, then, was wafted up through the Grand Gallery to the King’s Chamber.
As mentioned, the Grand Gallery supposedly contained stacks of Helmholtz resonators. During its journey up to the King's Chamber, the hydrogen would have been excited by all the good vibrations, and when it got to the resonant King's Chamber, it would have been seriously excited to the point where it could do some stimulating of radiation emission.
At this point Dunn leaves interesting fancy behind and goes right the hell over the edge into foaming-at-the-mouth insanity: he posits that at this point, a microwave signal from space came down the northern ventilator shaft ("wave guide") into the sarcophagus in the King’s Chamber so that the energized hydrogen atoms could amplify its signal exponentially. This amplified microwave signal then was collected by something in the other airshaft of the King’s Chamber, and beamed up out through the shaft into space where it hit a satellite and was beamed back down to earth to be used in power tools.
Mmhmm.
Alan Alford, one of the pyramid theorists whom I will not tar with the brush of pyramidiocy, due to his ability to see the massive howling gaps in the logic of most theories, has the following to say on Dunn’s King’s-Chamber flight of fancy:
Firstly, the mouth of the northern airshaft is cut too high in the wall to align with the sarcophagus, so any incoming microwave signal would have passed right over the top of it. It is not clear how it could have interacted with any equipment inside the box.
Secondly, Dunn assumes that the sarcophagus had no lid (pp. 189, 222) and that the signal interacted with hydrogen atoms inside the box. But there is clear evidence that the sarcophagus did originally have a lid and that it was hermetically sealed (see my book Pyramid of Secrets, pp. 73-74). I am not entirely certain how this affects Dunn’s theory, but there could not have been any hydrogen in the box.
Thirdly, the mouth of the southern airshaft is cut too high in the wall to align with the sarcophagus, so it is difficult to see how the output from the box could have been channeled into the shaft.
Fourthly - and worst of all - Dunn insists that the entire lengths of the northern and southern airshafts would have to have been lined with gold- plated iron in order to have an efficient conduit for the electromagnetic radiation (pp. 186, 221-22). This is quite simply at odds with the facts, as Dunn well knows. For both the shafts have been surveyed by robot and not a trace of a metal lining has been found (the iron plate found by Vyse in 1837 was embedded in masonry close to the southern shaft but it is not clear whether it actually formed part of the shaft). So, what happened to the iron? How was it removed from tiny shafts measuring approximately 8 by 8 inches to their entire lengths of 235 feet and 174 feet respectively?
The sum of all this ranting is but this:
If you are crazy enough and have enough disposable income to wander around Egypt and have your picture taken holding sciency-looking objects, you can get a lucrative book deal out of it and people will want to be your friend and write even more ludicrous
Or possibly “the world is full of gullible morons.” I’m no longer sure.
Epilogue: Dunn is almost charming in his excited attempts to reverse-engineer explanations for artifacts other than "we don't know." Here's his thoughts on the putative Helmholtz resonators:
One of the most remarkable feats of machining can be found inside the Cairo Museum. I have stood in awe before the stone jars and bowls that are finely machined and perfectly balanced. The schist bowl with three lobes folded toward the center hub is an incredible piece of work. With the application of ultrasonics and sophisticated machinery, I can understand how they could be made, but the purpose for doing so has long escaped me. It seems like a tremendous amount of work to go to just to create a domestic vessel! Perhaps these stone artifacts, of which there were over a thousand found at Saqqarra, were used in some way to convert vibration into airborne sound. Are these vessels the Helmholtz resonators we are looking for?
Information in this article is from the following:
Dunn's website
The Giza Death Star by Joseph Farrell, available on Google Books
The Giza Death Star Deployed by Joseph Farrell, available on Google Books
Alford's refutation of Dunn
Friday, June 26, 2009
It does matter what you do with your old equipment: Goiânia’s dance with cesium-flavoured death
This is a story with two subjects. On the one hand, we have another blatantly irresponsible organization failing to take the most basic safety precautions; on the other, we have the deadly results of ignorance. It’s far from the only tale of its kind; the list of radiological accidents in developing or less-developed countries is depressingly long.
In order to explain how Goiânia happened, we need to touch briefly on the nature of the machine that started the disaster. Radiotherapy for cancer can take many forms: teletherapy (now known as external beam radiotherapy), where the source of radiation is outside but focused on the body; brachytherapy, where sealed radioactive sources are placed inside or next to the part of the body needing treatment; and systemic or unsealed source radiotherapy, where a soluble radionuclide is injected or ingested into the body. Mostly when people think of radiotherapy they think of external-beam/teletherapy machines with the rotating gantry and patient couch.
These days EBRT is mostly performed using linear accelerators, which produce a powerful beam of beta radiation (electrons) or X-rays with the push of a button and do not require dangerous radioactive source capsules, but in the early days of teletherapy they didn’t have that option. The two most common radioactive substances used as teletherapy sources are cobalt-60 and cesium-137. Both of these will kill you quite quickly if you pick them up in your hands: the machines using them rely on massive lead shields to limit the radiation to a controlled, collimated beam. The cesium-137 source in the Goiânia accident was filled with highly soluble, highly dispersible powder, rather than pellets of metallic solid material. This would prove to be important.
The unit involved in the accident was a Cesapan F-3000, a 1950s Italian design containing what was probably a source capsule manufactured in America in the seventies. It would have looked a little something like this (images from IAEA report). The rather ominous-looking head was capable of moving up and down on its support pillar and rotating through a couple of horizontal axes, and contained the source capsule in a rotating assembly that could move to line up the window in the capsule with the radiation aperture in the head, as illustrated here. The window in the shielding of the capsule, through which radiation could escape, was made of iridium. According to the International Atomic Energy Agency (IAEA) report, the source itself was of standard international dimensions and potency.
This machine was left in the derelict premises of a private radiotherapy clinic in Goiânia, capital of Goiâs State, Brazil, after the partnership that owned it dissolved toward the end of 1985; a cobalt teletherapy unit from the same clinic premises was removed and transferred to a new facility, but the cesium unit stayed where it was. We aren't sure why.
Vagrants used the gutted building to shelter in; wildlife came and went, and the Cesapan F-3000 stood there growing quietly more obsolete. It is perhaps surprising that it remained unmolested for two years before enterprising locals considered its potential scrap value.
On September 10, 1987, two men, A and B, began to try to dismantle the machine. It took a while and several attempts, but by September 13 they'd managed to extract the rotating assembly from the massive shielding of the radiation head. Outside this shielding, the unprotected source was giving off 465 rads an hour, or 4.65 Gray if you want to be modern about it. For comparison, the accepted annual radiation dose for non-nuclear-workers in the USA is between 1 and 5 millisieverts, or ~ 0.001 to 0.005 Gray.
They put the assembly in a wheelbarrow and took it to A's house; A had suggested salvaging the machine for scrap in the first place. That day, both of them began to vomit; over the next few days, B developed diarrhea and edema of his hand, which subsequently would develop into a burn corresponding to the size and shape of the window in the source capsule. They attributed their symptoms to something they'd eaten, and in fact when B saw a doctor he was told his symptoms were due to a food allergy and he was to take it easy for a week.
The real horror begins
In the days between September 13 and September 18, A had been tinkering with the rotating source assembly, which he'd dumped under a mango tree in his yard. He was trying to get the source capsule free of the assembly. At some point he managed to break the iridium window of the source with a screwdriver.
He thought that perhaps the intensely radioactive cesium thus exposed might be gunpowder, and tried to light it.
On the 18th he managed to get the breached source free of the rotating assembly, and sold the whole mess to a third man, C, who owned a junkyard nearby. That night, C went into the garage where the bits were stored and noticed that the stuff in the broken capsule was emitting a blue glow, and brought the capsule into his house to show it to his wife. Because it was so pretty and so strange, they thought it might be valuable, or have supernatural powers, and invited their friends over to have a look. On the 21st one of these friends dug out some of the powder with a screwdriver and took it away with him to give to his family and friends. Quite a few of them rubbed it on their skin like body glitter. C received a total dose of 7Gy and survived. His wife (5.7 Gy) would not.
I know this reads like a horror novel. It gets worse.
More people were (unsurprisingly) suffering the symptoms of acute radiation sickness: C's vomiting wife was examined at a local hospital, diagnosed with food poisoning, and sent home to rest. Her mother came over to take care of her, and took home a dose of 4.3 Gy.
Two of C's employees were tasked with removing lead from the remnants of the assembly, and worked on it from September 22 to 24. Directly exposed to the breached source capsule, they would be among the four victims who did not survive.
The last of the four fatalities was C's six-year-old niece, whose father had visited C and taken away some of the glowing powder. This was left on the table and handled by the family during meals. The little girl had played with the powder and put her fingers into her mouth. According to one source, when international medical teams arrived to treat the victims, they found her in an isolated room in the hospital because the staff were afraid to go near her.
On the 23rd, B was admitted to hospital: his skin lesions were diagnosed as related to some exotic disease, and on the 27th he was transferred to the Tropical Diseases Hospital.
The authorities finally become aware of the accident
After doing its damage to C's friends and family, the source and rotating assembly were sold to a second junkyard. The sudden epidemic of vomiting and diarrhea among their acquaintances was not lost on C's wife, who became convinced that the glowing powder from the capsule was responsible for all the sickness. On the 28th, ten days after the source was transferred to C's ownership, she and one of C's employees went to collect the remains of the source and rotating assembly from the second junkyard, put it in a plastic bag, and took it by bus to a hospital, spreading contamination as they went. The employee and C's wife presented a doctor, P, with the source in its bag, and she told him that it was "killing her family."
By now the employee who had carried the bag was developing a serious radiation burn on his shoulder, where it had rested, and he and C's wife were sent to the Tropical Diseases Hospital, where B and several other contamination victims had been sent for treatment. One of the doctors at the TDH was beginning to suspect that in fact the nearly identical symptoms of this whole cohort of patients could have been caused by radiation, and he contacted a colleague who had independently been contacted by Dr. P. Dr. P had initially thought that the bag contained bits from X-ray apparatus, and became wary of it, moving it outside the facility (and thus probably saving his own life).
The doctors at the TDH had another look at the patients, with the mysterious bag's contents in mind, and agreed that it would be a good idea to contact the state department of the environment; when they did, it was recommended that a medical physicist examine the package.
On the 29th they found a medical physicist, W. He found a radiation monitor used for uranium prospecting, which had a range of 0.03–30 microgray/hour, and set off for the hospital where the source was currently located: quite some distance away he noticed that the monitor was pegged no matter where he pointed it. He assumed it was malfunctioning and went back to fetch a different one, which showed exactly the same thing as soon as he turned it on.
At this point W realized that something was desperately wrong. At the hospital, Dr. P had become sufficiently concerned about the source in its bag that he had called the fire department, which had arrived and was preparing to chuck the whole thing into a handy river; W arrived on the scene just in time to prevent this. He convinced them to evacuate the hospital and make sure no one else got near it, and after talking with Dr. P they set off together to C's junkyard–where the monitor again read off the scale.
The official response begins
W, among others, managed after some effort to notify the secretary of health. Once the authorities had been convinced that yes, in fact, this was a huge deal and would require evacuation of a large number of people, steps began to be taken with considerably greater speed. The physicist and physician at the radiotherapy clinic's new location were notified, and the source was tentatively traced to the abandoned clinic and the cesium unit.
Civil defense forces were notified; the TDH was informed that a number of patients were contaminated; the known sites of contamination were resurveyed with equipment from the radiotherapy clinic; an emergency receiving and decontamination facility was set up in a local stadium. W, the physicist who had initially discovered the contamination, was contacted by an individual who had intended to cut up the source for C with an oxyacetylene torch (but had luckily forgot), who explained several useful details to the investigation.
International teams were sent in to decontaminate and treat the victims of the disaster. There is not a great deal that can be done in cases of radiation sickness: therapy consisted of dealing with the acute period of bone marrow suppression and subsequent immune deficiency, treating the burns, removing radiation from the body (decorporation), and general support. It's rather terrible to consider that many of these patients recontaminated their skin repeatedly by sweating; the cesium in their bodies found its way out in everything. Chelation with Prussian blue helped a significant number of the victims, a point which recalls the hopeless suggestion of treating Louis Slotin with methylene blue after his deadly exposure to plutonium criticality.
The final count of persons with significant contamination, out of the hundred thousand screened, was two hundred and forty-four. Most of those were lucky and received fractionated doses--spread over a long time period, giving the body's tissues a chance to attempt to recover from the damage. Some were not. The dead of Goiânia had to be buried in lead coffins surrounded by concrete.
Cesium didn't just destroy people in Goiânia, it destroyed property and livelihoods. Seven houses had to be demolished, so badly contaminated they could not be made safe. Topsoil was removed by the ton. In total 85 houses had to be decontaminated.
More than anything Goiânia stands as a blazingly vivid example of the importance of keeping sources secured. A number of factors conspired to make this accident as deadly as it was: criminal negligence on the part of the radiotherapy clinic which failed to remove and secure the capsule from the teletherapy unit, the nature of the radioactive material--its mysterious and magical blue glow entranced people, significantly increasing the scope of the disaster, and its powdery nature was easily dispersed and easily soluble--and the remote location of the disaster site. But the lesson of Goiânia applies to all source capsules, not just cesium in remote and unsophisticated locations.
Sadly, it's not a lesson that's been learned particularly well. In the years since Goiânia, unsecured radiation sources have caused at least four radiological accidents around the world. In Samut Prakarn, Thailand, a disused cobalt-60 teletherapy head was partially dismantled, taken from an unsecured storage location, and sold as scrap metal–in February of 2000. It's still happening. It will continue to happen as long as those in charge of radiation sources fail in their responsibility to keep them secure.
In many ways the eighties were a great time for death by radiation. You had Chernobyl, you had the 1983 Ciudad Juarez accident in Mexico–eerily similar to Goiânia–you had the Therac-25 linear accelerator deaths; but it hasn't stopped. People need to pay more attention to things that have happened, if they want to live very much longer; and people who take the responsibility to treat their fellow humans with lethal radiation must take the responsibility to prevent their fellow humans from dying of it.
Information in this article is from the IAEA report on the incident, available at www-pub.iaea.org/MTCD/publications/PDF/Pub815_web.pdf, and from Wiki.
In order to explain how Goiânia happened, we need to touch briefly on the nature of the machine that started the disaster. Radiotherapy for cancer can take many forms: teletherapy (now known as external beam radiotherapy), where the source of radiation is outside but focused on the body; brachytherapy, where sealed radioactive sources are placed inside or next to the part of the body needing treatment; and systemic or unsealed source radiotherapy, where a soluble radionuclide is injected or ingested into the body. Mostly when people think of radiotherapy they think of external-beam/teletherapy machines with the rotating gantry and patient couch.
These days EBRT is mostly performed using linear accelerators, which produce a powerful beam of beta radiation (electrons) or X-rays with the push of a button and do not require dangerous radioactive source capsules, but in the early days of teletherapy they didn’t have that option. The two most common radioactive substances used as teletherapy sources are cobalt-60 and cesium-137. Both of these will kill you quite quickly if you pick them up in your hands: the machines using them rely on massive lead shields to limit the radiation to a controlled, collimated beam. The cesium-137 source in the Goiânia accident was filled with highly soluble, highly dispersible powder, rather than pellets of metallic solid material. This would prove to be important.
The unit involved in the accident was a Cesapan F-3000, a 1950s Italian design containing what was probably a source capsule manufactured in America in the seventies. It would have looked a little something like this (images from IAEA report). The rather ominous-looking head was capable of moving up and down on its support pillar and rotating through a couple of horizontal axes, and contained the source capsule in a rotating assembly that could move to line up the window in the capsule with the radiation aperture in the head, as illustrated here. The window in the shielding of the capsule, through which radiation could escape, was made of iridium. According to the International Atomic Energy Agency (IAEA) report, the source itself was of standard international dimensions and potency.
This machine was left in the derelict premises of a private radiotherapy clinic in Goiânia, capital of Goiâs State, Brazil, after the partnership that owned it dissolved toward the end of 1985; a cobalt teletherapy unit from the same clinic premises was removed and transferred to a new facility, but the cesium unit stayed where it was. We aren't sure why.
Vagrants used the gutted building to shelter in; wildlife came and went, and the Cesapan F-3000 stood there growing quietly more obsolete. It is perhaps surprising that it remained unmolested for two years before enterprising locals considered its potential scrap value.
On September 10, 1987, two men, A and B, began to try to dismantle the machine. It took a while and several attempts, but by September 13 they'd managed to extract the rotating assembly from the massive shielding of the radiation head. Outside this shielding, the unprotected source was giving off 465 rads an hour, or 4.65 Gray if you want to be modern about it. For comparison, the accepted annual radiation dose for non-nuclear-workers in the USA is between 1 and 5 millisieverts, or ~ 0.001 to 0.005 Gray.
They put the assembly in a wheelbarrow and took it to A's house; A had suggested salvaging the machine for scrap in the first place. That day, both of them began to vomit; over the next few days, B developed diarrhea and edema of his hand, which subsequently would develop into a burn corresponding to the size and shape of the window in the source capsule. They attributed their symptoms to something they'd eaten, and in fact when B saw a doctor he was told his symptoms were due to a food allergy and he was to take it easy for a week.
The real horror begins
In the days between September 13 and September 18, A had been tinkering with the rotating source assembly, which he'd dumped under a mango tree in his yard. He was trying to get the source capsule free of the assembly. At some point he managed to break the iridium window of the source with a screwdriver.
He thought that perhaps the intensely radioactive cesium thus exposed might be gunpowder, and tried to light it.
On the 18th he managed to get the breached source free of the rotating assembly, and sold the whole mess to a third man, C, who owned a junkyard nearby. That night, C went into the garage where the bits were stored and noticed that the stuff in the broken capsule was emitting a blue glow, and brought the capsule into his house to show it to his wife. Because it was so pretty and so strange, they thought it might be valuable, or have supernatural powers, and invited their friends over to have a look. On the 21st one of these friends dug out some of the powder with a screwdriver and took it away with him to give to his family and friends. Quite a few of them rubbed it on their skin like body glitter. C received a total dose of 7Gy and survived. His wife (5.7 Gy) would not.
I know this reads like a horror novel. It gets worse.
More people were (unsurprisingly) suffering the symptoms of acute radiation sickness: C's vomiting wife was examined at a local hospital, diagnosed with food poisoning, and sent home to rest. Her mother came over to take care of her, and took home a dose of 4.3 Gy.
Two of C's employees were tasked with removing lead from the remnants of the assembly, and worked on it from September 22 to 24. Directly exposed to the breached source capsule, they would be among the four victims who did not survive.
The last of the four fatalities was C's six-year-old niece, whose father had visited C and taken away some of the glowing powder. This was left on the table and handled by the family during meals. The little girl had played with the powder and put her fingers into her mouth. According to one source, when international medical teams arrived to treat the victims, they found her in an isolated room in the hospital because the staff were afraid to go near her.
On the 23rd, B was admitted to hospital: his skin lesions were diagnosed as related to some exotic disease, and on the 27th he was transferred to the Tropical Diseases Hospital.
The authorities finally become aware of the accident
After doing its damage to C's friends and family, the source and rotating assembly were sold to a second junkyard. The sudden epidemic of vomiting and diarrhea among their acquaintances was not lost on C's wife, who became convinced that the glowing powder from the capsule was responsible for all the sickness. On the 28th, ten days after the source was transferred to C's ownership, she and one of C's employees went to collect the remains of the source and rotating assembly from the second junkyard, put it in a plastic bag, and took it by bus to a hospital, spreading contamination as they went. The employee and C's wife presented a doctor, P, with the source in its bag, and she told him that it was "killing her family."
By now the employee who had carried the bag was developing a serious radiation burn on his shoulder, where it had rested, and he and C's wife were sent to the Tropical Diseases Hospital, where B and several other contamination victims had been sent for treatment. One of the doctors at the TDH was beginning to suspect that in fact the nearly identical symptoms of this whole cohort of patients could have been caused by radiation, and he contacted a colleague who had independently been contacted by Dr. P. Dr. P had initially thought that the bag contained bits from X-ray apparatus, and became wary of it, moving it outside the facility (and thus probably saving his own life).
The doctors at the TDH had another look at the patients, with the mysterious bag's contents in mind, and agreed that it would be a good idea to contact the state department of the environment; when they did, it was recommended that a medical physicist examine the package.
On the 29th they found a medical physicist, W. He found a radiation monitor used for uranium prospecting, which had a range of 0.03–30 microgray/hour, and set off for the hospital where the source was currently located: quite some distance away he noticed that the monitor was pegged no matter where he pointed it. He assumed it was malfunctioning and went back to fetch a different one, which showed exactly the same thing as soon as he turned it on.
At this point W realized that something was desperately wrong. At the hospital, Dr. P had become sufficiently concerned about the source in its bag that he had called the fire department, which had arrived and was preparing to chuck the whole thing into a handy river; W arrived on the scene just in time to prevent this. He convinced them to evacuate the hospital and make sure no one else got near it, and after talking with Dr. P they set off together to C's junkyard–where the monitor again read off the scale.
The official response begins
W, among others, managed after some effort to notify the secretary of health. Once the authorities had been convinced that yes, in fact, this was a huge deal and would require evacuation of a large number of people, steps began to be taken with considerably greater speed. The physicist and physician at the radiotherapy clinic's new location were notified, and the source was tentatively traced to the abandoned clinic and the cesium unit.
Civil defense forces were notified; the TDH was informed that a number of patients were contaminated; the known sites of contamination were resurveyed with equipment from the radiotherapy clinic; an emergency receiving and decontamination facility was set up in a local stadium. W, the physicist who had initially discovered the contamination, was contacted by an individual who had intended to cut up the source for C with an oxyacetylene torch (but had luckily forgot), who explained several useful details to the investigation.
International teams were sent in to decontaminate and treat the victims of the disaster. There is not a great deal that can be done in cases of radiation sickness: therapy consisted of dealing with the acute period of bone marrow suppression and subsequent immune deficiency, treating the burns, removing radiation from the body (decorporation), and general support. It's rather terrible to consider that many of these patients recontaminated their skin repeatedly by sweating; the cesium in their bodies found its way out in everything. Chelation with Prussian blue helped a significant number of the victims, a point which recalls the hopeless suggestion of treating Louis Slotin with methylene blue after his deadly exposure to plutonium criticality.
The final count of persons with significant contamination, out of the hundred thousand screened, was two hundred and forty-four. Most of those were lucky and received fractionated doses--spread over a long time period, giving the body's tissues a chance to attempt to recover from the damage. Some were not. The dead of Goiânia had to be buried in lead coffins surrounded by concrete.
Cesium didn't just destroy people in Goiânia, it destroyed property and livelihoods. Seven houses had to be demolished, so badly contaminated they could not be made safe. Topsoil was removed by the ton. In total 85 houses had to be decontaminated.
More than anything Goiânia stands as a blazingly vivid example of the importance of keeping sources secured. A number of factors conspired to make this accident as deadly as it was: criminal negligence on the part of the radiotherapy clinic which failed to remove and secure the capsule from the teletherapy unit, the nature of the radioactive material--its mysterious and magical blue glow entranced people, significantly increasing the scope of the disaster, and its powdery nature was easily dispersed and easily soluble--and the remote location of the disaster site. But the lesson of Goiânia applies to all source capsules, not just cesium in remote and unsophisticated locations.
Sadly, it's not a lesson that's been learned particularly well. In the years since Goiânia, unsecured radiation sources have caused at least four radiological accidents around the world. In Samut Prakarn, Thailand, a disused cobalt-60 teletherapy head was partially dismantled, taken from an unsecured storage location, and sold as scrap metal–in February of 2000. It's still happening. It will continue to happen as long as those in charge of radiation sources fail in their responsibility to keep them secure.
In many ways the eighties were a great time for death by radiation. You had Chernobyl, you had the 1983 Ciudad Juarez accident in Mexico–eerily similar to Goiânia–you had the Therac-25 linear accelerator deaths; but it hasn't stopped. People need to pay more attention to things that have happened, if they want to live very much longer; and people who take the responsibility to treat their fellow humans with lethal radiation must take the responsibility to prevent their fellow humans from dying of it.
Information in this article is from the IAEA report on the incident, available at www-pub.iaea.org/MTCD/publications/PDF/Pub815_web.pdf, and from Wiki.
Tuesday, June 16, 2009
“No, I cannot say that I have:” a clueless crew and a firetrap ship, the SS Noronic
Nothing can beat the Apollo 1 launchpad fire in terms of flame propagation speed, but the cataclysmic fire that destroyed the SS Noronic in 1949 as she sat beside the docks of Toronto’s Pier 9 was impressively rapid nonetheless. The focus of investigations into the Noronic fire was not the point of origin--that was fairly obvious from eyewitness accounts--or the actual source of ignition: it was the rather horrifyingly laissez-faire attitude of the crew members regarding what to do in the case of a fire in dock.
The official "Report of Court of Investigation into the Circumstances Attending the Loss of the S.S. Noronic" contains quite a lot of direct quotes from examination of the various officers, included into the narrative to make the point abundantly clear: there was no official instruction given to crew members regarding their duties in case of fire in dock, and no attempts made to develop or distribute same, because “the ship had been running from 1913 without mishap.”
The Noronic, built (as mentioned) in 1913, was a cruise and package freight ship plying the Great Lakes. She had two sister ships, the Huronic and the Hamonic; this last, suffering under an even sillier name than Noronic, burned out in 1945. No apparent lessons were learned from the loss of the Hamonic, as demonstrated very clearly in the behaviour of the Noronic’s crew prior to and during the disaster.
She was vast for the time, capable of carrying six hundred passengers and two hundred crew on her five decks, and considered one of the most beautiful and luxurious cruise liners in Canada. Part of her luxury came from the fact that her interior walls were paneled in beautifully polished wood, into which thirty years of lovingly applied lemon-oil varnish had soaked. Some of the wood (the passenger accommodations on D deck) was painted rather than varnished, but the majority of the walls in the upper decks and communal areas were treated with this highly flammable oil.
She was also, being built prior to regulations passed in 1939, lacking the requisite fire-resistant bulkheads the regulations called for. The Chairman of the Board of Steamship Inspection was allowed to exempt existing ships from compliance with the regulations where it was “impracticable or unreasonable” to retrofit the ship to comply. In this case it was rather obviously “expensive” to do so, and Noronic remained a totally period-accurate vessel.
The series of legal loopholes through which the Noronic sailed to escape the installation of vital safety systems is impressive. Not only was she allowed to go around without fire-resistant bulkheads, she also did not have to comply with Regulation 3 of section 405 (1) c of the Canada Shipping Act, requiring “every ship…which is engaged on an international voyage, [to be provided with] an approved fire alarm or fire-detecting system which will automatically register at one or more points or stations in the ship, where it can be most quickly observed by officers and crew, the presence or indication of fire in any part of the ship…not accessible to a fire patrol system.”
Fire patrol meant that the crew was detailed to regularly make exhaustive rounds of the ship throughout the day and night to catch any hint of fire on board; the regulations stated that “all spaces in a passenger ship, except such spaces as cargo spaces, baggage and store rooms, may as a general rule be regarded as accessible to the patrol,” thereby exempting them from the requirement that an automatic alarm or detection system be fitted. Noronic was not considered international, as she only puttered around on the Great Lakes—an “inland voyage.” Even had she been considered “international” due to her route between Canada and the States and thus required to comply with Regulation 3, the Board of Steamship Inspection ruled in 1938 that Regulation 3 only applied to ships making international voyages on the ocean. Either it didn’t apply, or it didn’t apply.
Noronic did in fact have a manual fire alarm system that ran off batteries, of the in-case-of-fire-break-glass type. This alarm rang bells located a) in the officers’ quarters, b) on the port side of D deck, and c) in the engine room on E deck, registering the location of the pulled alarm. It did not activate the klaxons located around the ship which would alert passengers and crew to an emergency: in order to sound those someone would have to go up to the pilot house above A deck to manually flip the klaxon switch. The first and second officers informed investigators that it was “the duty of the officer on watch, upon hearing the bell alarm, to proceed to the locality from which the alarm had been given for the purpose of investigating whether the fire was serious enough to require the sounding of the klaxon alarm and, if he so concluded, then to return to the pilot hours above A deck where he would throw the switch which sounded the klaxon horns. If the officer on duty was away from the pilot house, the wheelsman who should be there was expected to find the officer on duty and report to him as to the locality at which the alarm had been sounded. To obtain this information he would first have to go to the bath-room in the mates’ quarters where the indicator was located.”
I quote the report again directly: It is, of course, obvious from the above that considerable time might be lost between the giving of the alarm at the point where the fire was first discovered and the giving of the klaxon alarm which could only be sounded from the pilot house.
No shit.
It goes on like that. There were supposed to be hydrants located all around the ship so that “at least two powerful jets of water can be rapidly and simultaneously brought to bear upon any part of each deck or space occupied by passengers or crew,” but the inspectors thought, eh, it’d be good enough if you could just run a hose down from the deck above if there weren’t enough hydrants on any given deck (even though the actual wording of the regulations states that “the hydrant shall be so placed on each deck that the fire hoses may be easily coupled to them").
It's apparent that nobody in a position to enforce safety regulations ever actually thought a fire could break out on the Noronic. Certainly they made every effort to weasel out of providing even the most basic of safety systems, taking advantage of the fact that as Noronic was merely sailing on a lake and not the ocean she did not strictly fall under the regulations requiring fire patrol. Whether this is due to some unknown dangerous quality in salt water as opposed to fresh is not explained. The report mentions tartly that in the judge’s opinion the regulations requiring ships to be equipped with working hydrants and extinguishers imply that there also should be crew members provided by the ship’s owner to use the aforementioned apparatus. Without an automatic fire detection system or a sprinkler system on board, Noronic really could’ve used a fire patrol. What they got was this:
Two crew members designated “Special Officers” switched off at 6-hour intervals to walk around the ship with a time clock and punch a series of keys located at various points on board “on the hour.”
Yeah. In 1942 Canada Steamship Lines issued a list of duties to be completed by the Special Officers, including:
“Each night from 9:00 PM until 6:00 AM the watchman clock shall be punched punctually on the hour. The dials are carefully checked by the Purser and the reason for not punching or the dials not being marked must be explained satisfactorily by the officer. During the round of punching, it is your duty to stop any excessive noise by passengers that are boisterous…Upon completion of your round and all passengers are quiet [sic], return to the rotunda where you are easily found should you be needed…”
The round of time-clock punching took about 15 minutes, which meant that for 45 minutes out of every hour there was pretty much zero fire patrol going on. One of Noronic’s Special Officers said that he thought he wasn’t supposed to do the patrol at all when the ship was in port, but remain instead at the gangplank; the other one understood his duty to be completing the rounds each hour and then returning to the gangplank. In fact neither of them were on board the night of the fire: both Special Officers’ rounds were conducted by a pair of wheelsmen who took the shortest possible routes between the time clocks.
This lack of clarity amongst officers and crew comes up over and over again throughout the investigation. This officer understood that this other officer was supposed to do something, but didn't check with anyone to see if this was in fact the case; that officer thought he was supposed to do this other thing but in point of fact was supposed to be somewhere else entirely and had no idea what to do in case of emergency. The card in the passengers' accommodations regarding fire stated confidently that the ship was equipped with "modern fire prevention apparatus" and patrolled "day and night by experienced watchmen." Or inexperienced wheelsmen doing the watchmen's jobs for them, either way.
Fire and lifeboat drills were regularly held on board the Noronic when she was moored in Duluth. Every Tuesday at ten in the morning, the signal was given for fire drill and the crew members assigned to "fire stations" (hydrants) gathered at their posts. The objective of the drill was to get to the hydrant, get the hose down from its rack, and couple the hose to the hydrant. Sometimes on the outside fire stations they'd squirt the hoses overboard, but obviously not indoors. A few crew members were expected to get the extinguishers down and wave them about, maybe discharge one or two. That was it for fire training of the crew.
In 1945, the General Manager at Canada Steamship Lines was apparently made aware of the fact that his ships were practicing a thoroughly useless excuse for a fire drill, and sent out a memo with an updated list of rules. The memo stated that the enclosed Lifeboat and Fire Drill Regulations were (I quote) serious business, and that masters of all passenger steamers must study them carefully and instruct all crew members accordingly. Let's see how the Norons did:
1) MUSTER STATIONS: The Master will designate locations of muster stations throughout the ship to which members of the crew will report for lifeboat and fire drills (and make sure all crew members know where these stations are and which signals call for them to muster).
1) a ALARM SIGNALS: General or Fire Alarm is indicated by one long, three short, one long blasts on whistle or alarm. Proceed at once to fire drill assigned station. Man Boats Alarm is indicated by General Alarm followed by two short blasts on whistle or alarm. Proceed at once to boat drill assigned station.
The Noronic's crew members each carried a blue card on which was printed his crew number, his fire station number, and his boat number. It clearly states the types of alarm and what one should do upon hearing them. However, in practice, the fire drill signal was a continuous blast on the klaxon horns, while the lifeboat drill signal was identical to the official "general or fire alarm" signal. Crew members had to learn to ignore the info on the blue card.
Passengers did not take part in either drill. The only information they received on what to do in case of fire was on the instruction cards in their rooms. The crew were the only ones who had any idea of emergency procedures, and their grasp on same was tenuous at best.
2) MUSTER LISTS: The Master will have a muster list prepared including the information of all crew members and their muster stations, as well as "full particulars" of the signals required to call members of the crew to muster. This list shall be posted in conspicuous places throughout the ship including the crew's quarters and every officer's room.
There was no such thing as a "muster list" on board the Noronic, nothing signed by the Master, and nothing hung in any officer's room. A "chart" of crew members apparently hung in the maids' quarters, in the crew's stairway aft, on either B or C decks, and in the crew's rec room. The first officer, Gerald Wood, used this chart to prepare a list of crew members and their blue card numbers, boat numbers, and hydrant numbers, and gave a copy to the chief steward. The captain was completely ignorant of all of this and only knew about the typed list because he looked over Wood's shoulder as he was filling it out. Who's on board? Whose job is it to do what? Who knows?
3) MUSTER CARDS: A card indicating the muster station for each crew member must be placed in his berth in such position that it cannot be obscured by baggage or clothing.
The only thing remotely similar to this in use on the Noronic was the blue card, which was kept wherever the crew felt like keeping it.
There was also a rule stating that the Master had to appoint Senior Officers to various parts of the ship in order to help direct passengers to their muster stations if necessary. Here is where the testimony really gets interesting: Captain Taylor said that he'd allocated the first officer to C deck, second officer to A deck, third officer to B deck, and chief steward and purser to D deck. Wood, the first officer, denies any allocation was made, and then proceeds to flip-flop like a gaffed pike (unsurprisingly, he stated that he had never seen or heard of the Serious Business memo):
Q: Was there any allocation that you know of of senior officers allocated to certain locations for the purpose of mustering passengers?
A: No there was not.
Q: Did you make any allocation?
A: No.
Q: Did anyone else to your knowledge?
A: Not that I know of.
Q (really trying here): Now I want to be fair with you. I thought the Captain did say to us that he had allocated certain senior officers in accordance with this and he said the allocation was the chief officer to C deck....do you know anything about that?
A: Well yes, I would be in charge of C deck.
Q: (wondering what he's smoking): Well that is what he told us, that you were in charge of C deck--then must that not mean that you were allocated in some way to C deck?
A: Yes, I would be allocated.
Q: How would you be allocated and what instructions did you have with regard to C deck?
A: I think by this chart [which indicated his duty was free to move about the ship].
(some back and forth about whether or not this allocation is the same as on other ships)
Q: Now what do you say as to whether or not any station was allocated to you as the first officer under this regulation?
A: Well he may have told me to go to my allocation on C deck.
Q: (between clenched teeth) Well he may and then I suppose he may not, but I am trying to get from you whether he did.
A: Well I have been there a number of years.
Q: Then is your statement to me that you do not know whether the Captain in the case of fire had told you that you were to go to C deck?
A: I am pretty sure--I might say that the captain did not tell me this year. He could have back in 1944 or 1945.
Q: Did you always go to C deck on fire drill?
A: No, I go all over the ship.
Q: Then you were really not allocated to C deck?
A: Not to stay there.
Q: Well was anybody allocated to C deck?
A: Well I think the officers were free--wherever we could be the most help.
This confusion is heightened by "the chart," which states that Wood was in fact in charge of deck A. Balancing out various testimonies against one another it becomes abundantly clear that this "chart" had become so obsolete by 1949 that it had nothing to do with any organization or lack thereof on board the ship and in fact the captain had no idea it existed at all. We are dealing with governmental levels of confusion here. The captain and first officer, when asked about duties to be performed by the officers and men at the fire hydrant stations, contradicted one another and made up answers to explain what the rest of the crew not assigned to hydrants would be doing (running away, is my guess).
The slipperiness of officials when faced with questions about the Noronic extends way up the ladder. General Manager of the line Captain Reoch had to admit under examination that in fact when he wrote the Serious Business memo he did not take into consideration the fact that, if a fire occurred while the ship was tied up to a dock, directing all the passengers to the muster stations on C deck would not do them a blind bit of good as the only gangplanks to the dock were on E deck three floors below. "Was it your intention under these rules when you drew them up, that in the event of a fire at a dock, the passengers from D deck would go up or be directed to C deck and then go back down to D [and then E] deck to get off onto the dock?" he was asked. After some squirming and repeated requests to answer the question, Reoch finally admitted that he didn't think that the rules he'd indicated would be followed in case of a dockside fire--or, more accurately, he'd not bothered to consider the possibility.
The really damning bit is when they are asked why they didn't increase the number of crewmen on fire patrol while the ship was tied up. "If there had of [sic] been any signs of an emergency, yes, but there was no reason why they would have. I can't see any reason why they would."
Maybe because you're in a floating firetrap lacking rudimentary safety systems, steeped in decades' worth of flammable varnish, and inhabited by people who are coming back from Toronto bars drunk off their tits and probably waving around lit cigars?
There was no way of knowing which crew members were on or off the ship while she was in port, as they were free to go ashore at any time they were not on duty. If there had been any organization amongst the crew for dealing with emergencies, it went directly out of the porthole as soon as crew members began to go ashore unremarked.
So we have the perfect setup for disaster. On the night of September 17, 1949, something in a linen closet on C deck aft caught fire. The closet contained bed linen, towels, and cleaning materials, as well as a box for rubbish and wastepaper collected from the cabins, and a switchbox controlling some of the stateroom lights. The presence of the box is controversial: a maid stated that the rubbish box was never placed in the linen closet; the chief steward said it might have been there, and an eyewitness stated that it was there. If the fire was due to a smouldering cigarette butt, this box would have represented a perfect point of origin. Passengers mentioned seeing maids smoking cigarettes in the linen closet during the voyage; in the absence of a major electrical fault it seems likely although not certain that a carelessly discarded butt was responsible for killing somewhere between 118 and 139 people.
A passenger, Don Church, noticed a haze in the starboard corridor around 2:30 a.m. and followed it to the linen closet, where he saw smoke coming from the sides and top of the locked closet door. He heard a faint crackling, rustling noise, and assumed someone was inside; this would have been the fire talking to itself. Church, unable to open the door, ran forward yelling that the boat was on fire and encountered the head bellboy, Earnest O'Neill. O'Neill ran back with him to the locker, whereupon their stories diverge: O'Neill stated that he ran back to the steward's officers to fetch the closet key, then went to fetch a fire extinguisher before unlocking the door. Church stated that he just unlocked the door as they arrived.
They opened the door and saw that the wall was in flames and a hanging sheet was beginning to burn. The extinguisher barely slowed it down: almost as soon as the door was opened, flames poured out along the ceiling, feeding on the beautifully polished wooden paneling. Church and O'Neill went for a fire hose, but when Church opened the valve nothing came out. At this point he thought sod this for a game of soldiers and went off to fetch his family and got the hell out of it.
O'Neill only now broke the glass on the fire alarm and ran down to E deck to find a wheelsman and inform him of the fire. It's uncertain how much time really elapsed between the discovery of the fire and the sounding of the alarm, but time was definitely lost in trying to put out the fire with ineffective means. If O'Neill had sounded the alarm at once instead of messing about with extinguishers, several senior officers could have responded at once and taken charge of the fire equipment: C deck was the most well-staffed in terms of hydrant stations. He didn't. The fire raged out of control.
The wheelman O'Neill had woken in turn woke Wood, who quickly sounded the klaxon alarm and pulled the whistle, which stuck open and drowned out the klaxons. By now the starboard side of the boat was "full of fire," and he could not go aft farther than the first three cabins on the port side, where he "banged on the windows" and shouted.
Just before Wood sounded the whistle, a night watchman on the pier was appalled to see flames breaking through a window on the ship's starboard side. He ran inside and called the fire department and gave the alarm, then called the police; someone else standing at the door told him to call for ambulances as well. After he'd told the police to send all the doctors and ambulances they could, the watchman--a Mr. Harper--went back outside to find a mass of flame engulfing the starboard side of the ship. Now the whistle was blowing--Wood had sounded the alarm--and the fire department was arriving. By now it was 2:41 a.m., eleven minutes since Church first saw the smoke, and half the ship's decks were on fire.
The man who had told Harper to call for ambulances was one of the first to escape the burning ship. He had seen people badly burned--a woman with her hair burned away, people with faces and arms scorched and bubbling. It was still only minutes after the fire had begun, and already it was lethal.
The captain was informed of the fire some time between 2:30 and 2:35, according to his testimony, but the times don't match up; he claims to have gone out to yell for help from the outside deck and observed people on the pier, but Harper the watchman had seen the fire begin to erupt and made the alarm call when there had been no other people on the dock.
There is considerable flip-flopping from Wood regarding the instructions he had given to the crew members as to what they ought to do in case of fire: should they notify the officer on watch or just any officer, should they use a hose or an extinguisher first, did he actually tell them anything at all. "Would this be fair," he was asked, "and now correct me if I do not say it correctly--that so far as the education of the crew in the event of fire was concerned, all they had was what they saw on the printed chart in the crew's quarters, which took them to their various stations in the event of hearing the alarm--is that all they had--apart from what you have just said as to what you might have told any particular member of the crew--does that cover the whole field?"
"Yes, that covers it."
There was no organization, and therefore there was no clear and evident list of duties for each member of the crew to perform. Some of the fifteen men on duty tried harder than others to waken passengers and shepherd them over the side on ropes and Jacob's-ladders; by now the fire department was there en masse and trying to reach the ship with aerial ladders, but so many people leapt on the first of these--Aerial No. 5--that it snapped and spilled the lot of them into the harbour. Other passengers leapt straight into the water, some of them screaming as they burned, some of them in eerie silence. Many people were asleep when the fire broke out, and woke only to find their cabins ablaze and the only way out blocked by a window-screen they could not break; some were pulled from burning cabins from the outside by crew members or fellow passengers who had broken the screens away.
GenDisasters offers a collection of quotes from eyewitnesses. Mildred Briggs of Detroit, one of the survivors, said the flames spread as if in a matchbox. "The fire just welled up along the corridors and spread faster than any fire I've ever seen," she said.
"There was a mob of men and women surging back and forth," said another survivor, Alberta Agia of Detroit. "Men were pushing women around, and many were knocked to the floor. The screaming filled the air. There was so much panic that I don't know how these people found anyway to safety. I slid down a rope."
Men rushed out in their nightclothes. One man got ashore naked.
Henry Maurer and his wife were sound asleep when someone pounded the door. When they reached the outside rail, his wife started down a rope ladder, "but it became horribly twisted from so many trying to get on it. She got tangled and trapped. I swung down on a rope to her side and got her free, and we both managed to get to the dock."
Sylvia Carpenter of Detroit said she screamed and headed for the outside rail when she saw smoke and flame billowing along the passageways.
"A rope was tossed over the rail and I put a hitch knot on it to hold it to a stanchion," she said. "As I did so, three men pushed in front of me and shoved some screaming women out of the way. They went down the rope."
The fire burned intensely enough to heat the steel hull white-hot. Glass melted from portholes; metal slumped and warped. Enough water was poured in by the firefighting equipment to list the burning ship toward the dock; operations had to be halted until the list righted itself, as the Noronic settled to the bottom of the harbour with only her top decks above the surface. By five in the morning the fire was out, but they had to let the hull cool before venturing inside to find the bodies.
Everything that could be consumed inside the hull was consumed. Luxurious fittings were reduced to ash, ceilings and columns melted and warped. All the stairways in the boat save one were utterly destroyed.
The fire stripped away identities, turning human bodies to calcined bone fragments; some victims were nothing but a skull or spine. There are touchingly gruesome tales of searchers entering the ship to find embracing skeletons in the hallways and the remains of the cabins. The remains had to be removed by shoveling them onto tarpaulins, as they crumbled when picked up. New advances in forensic odontology (including the use of X-rays) had to be made to identify Noronic victims; articles on the techniques developed as a result of this disaster are still being published today in forensic journals.
Newspaper articles covering the disaster began, as newspaper articles of this sort tend to do, with horrified pronoun-deficient headlines: 200 DIE ON FIERY SHIP. GREAT LAKES QUEEN BURNS. HOLOCAUST SINKS PLEASURE CRUISER AT TORONTO DOCK. 400 HOLIDAYERS ESCAPE FLAMING DEATH AMID SCENES OF HORROR.
The final conclusion of the Court report into the disaster placed the blame on the failure of the owners and captain in:
a) Holding a continuous fire patrol of the ship, instead of a cursory time-clock round every 45 minutes
b) Maintaining any organized system while the ship was in dock with passengers aboard by which “information as to the outbreak of fire could be promptly dispatched to some point from which men trained in the methods of dealing with fire could be immediately dispatched to the locality,” or “effective fire alarm and fire procedure”
c) Taking the threat of fire at a dock seriously and allowing all but fifteen of the crew to go play on shore and be potentially unavailable in the case of emergency
d) Developing and practicing any plan for waking and evacuating passengers in the case of a fire while in dock
e) Training the crew on what to do in case of fire or how to operate the extinguishers and hoses.
Or, to put it more baldly, being about as prepared for a dockside fire as a jumbo prawn would be to handle a credit-default swap. The scope of the failure to prepare for or anticipate anything of the sort is breathtaking. The owners knew perfectly well that there was no functional plan in place for dealing with this kind of disaster, and so did the captain–and there was nothing stopping him from taking any steps to remedy the situation. It’s the equivalent of driving a car with half the lug nuts loose and just sort of hoping the damn wheels won’t come off.
The Noronic fire may not have been preventable, but the loss of life associated with it was. Nobody ever did determine what started it, but my money’s on an indifferently butted cigarette tossed into the refuse box in the linen closet, which then spread rapidly throughout a ship lacking in regulation fire-resistant bulkheads, a ship lined with highly inflammable varnished wood, a ship without automatic fire-detection or sprinkler systems, a ship whose fire alarm system was Goldbergian in its unnecessary complexity and multiple stages, and a ship manned by a totally insufficient and untrained skeleton staff. The bellboy O’Neill could possibly have saved the ship had he sounded the alarm before attempting to put the fire out himself–but he didn’t. The story of the Noronic is a litany of “I didn’t,” “I don’t know,” “I cannot say that I have,” and “I can’t see any reason why they would.”
Captain Taylor lost his license for a year; an unknown number of people lost their lives. The steamship company paid out something like $3 million to the families of the victims. Rather horribly, another Canadian passenger ship, the SS Quebec, experienced a similar fire a year later: the Quebec fire was ultimately determined to be the result of arson and started in a linen locker. None of the safety regulations written after Noronic were put in place aboard Quebec, and the crew were just about as useless in trying to fight the fire and evacuate passengers. That was it for Canada Steamship Lines’ passenger cruises on the Great Lakes.
It’s too easy to make fun of the Noronic’s name, which I will now reveal is most likely in reference to Lake Noron, Quebec. It’s too easy to point out that “no we didn’t” and “moronic” overlap quite efficiently, so I will just leave you with First Officer Wood’s deathless turn of phrase:
“I think in cases of emergency, the officer goes where he can be the best help.”
In this case, over the side.
Information in this article is taken from the following sources:
CanadianHistory.suite101.com
www.centrenaufrages.ca, Courage Tales 5, accessed June 16, 2009
GenDisasters.com
Lost Liners
Report of Court of Investigation into the Circumstances Attending the Loss of the S.S. "Noronic" (1949), located at Tales of Tragedy and Triumph: Canadian Shipwrecks, a virtual museum exhibition at Library and Archives Canada
The Walkerville Times
Wiki
The official "Report of Court of Investigation into the Circumstances Attending the Loss of the S.S. Noronic" contains quite a lot of direct quotes from examination of the various officers, included into the narrative to make the point abundantly clear: there was no official instruction given to crew members regarding their duties in case of fire in dock, and no attempts made to develop or distribute same, because “the ship had been running from 1913 without mishap.”
The Noronic, built (as mentioned) in 1913, was a cruise and package freight ship plying the Great Lakes. She had two sister ships, the Huronic and the Hamonic; this last, suffering under an even sillier name than Noronic, burned out in 1945. No apparent lessons were learned from the loss of the Hamonic, as demonstrated very clearly in the behaviour of the Noronic’s crew prior to and during the disaster.
She was vast for the time, capable of carrying six hundred passengers and two hundred crew on her five decks, and considered one of the most beautiful and luxurious cruise liners in Canada. Part of her luxury came from the fact that her interior walls were paneled in beautifully polished wood, into which thirty years of lovingly applied lemon-oil varnish had soaked. Some of the wood (the passenger accommodations on D deck) was painted rather than varnished, but the majority of the walls in the upper decks and communal areas were treated with this highly flammable oil.
She was also, being built prior to regulations passed in 1939, lacking the requisite fire-resistant bulkheads the regulations called for. The Chairman of the Board of Steamship Inspection was allowed to exempt existing ships from compliance with the regulations where it was “impracticable or unreasonable” to retrofit the ship to comply. In this case it was rather obviously “expensive” to do so, and Noronic remained a totally period-accurate vessel.
The series of legal loopholes through which the Noronic sailed to escape the installation of vital safety systems is impressive. Not only was she allowed to go around without fire-resistant bulkheads, she also did not have to comply with Regulation 3 of section 405 (1) c of the Canada Shipping Act, requiring “every ship…which is engaged on an international voyage, [to be provided with] an approved fire alarm or fire-detecting system which will automatically register at one or more points or stations in the ship, where it can be most quickly observed by officers and crew, the presence or indication of fire in any part of the ship…not accessible to a fire patrol system.”
Fire patrol meant that the crew was detailed to regularly make exhaustive rounds of the ship throughout the day and night to catch any hint of fire on board; the regulations stated that “all spaces in a passenger ship, except such spaces as cargo spaces, baggage and store rooms, may as a general rule be regarded as accessible to the patrol,” thereby exempting them from the requirement that an automatic alarm or detection system be fitted. Noronic was not considered international, as she only puttered around on the Great Lakes—an “inland voyage.” Even had she been considered “international” due to her route between Canada and the States and thus required to comply with Regulation 3, the Board of Steamship Inspection ruled in 1938 that Regulation 3 only applied to ships making international voyages on the ocean. Either it didn’t apply, or it didn’t apply.
Noronic did in fact have a manual fire alarm system that ran off batteries, of the in-case-of-fire-break-glass type. This alarm rang bells located a) in the officers’ quarters, b) on the port side of D deck, and c) in the engine room on E deck, registering the location of the pulled alarm. It did not activate the klaxons located around the ship which would alert passengers and crew to an emergency: in order to sound those someone would have to go up to the pilot house above A deck to manually flip the klaxon switch. The first and second officers informed investigators that it was “the duty of the officer on watch, upon hearing the bell alarm, to proceed to the locality from which the alarm had been given for the purpose of investigating whether the fire was serious enough to require the sounding of the klaxon alarm and, if he so concluded, then to return to the pilot hours above A deck where he would throw the switch which sounded the klaxon horns. If the officer on duty was away from the pilot house, the wheelsman who should be there was expected to find the officer on duty and report to him as to the locality at which the alarm had been sounded. To obtain this information he would first have to go to the bath-room in the mates’ quarters where the indicator was located.”
I quote the report again directly: It is, of course, obvious from the above that considerable time might be lost between the giving of the alarm at the point where the fire was first discovered and the giving of the klaxon alarm which could only be sounded from the pilot house.
No shit.
It goes on like that. There were supposed to be hydrants located all around the ship so that “at least two powerful jets of water can be rapidly and simultaneously brought to bear upon any part of each deck or space occupied by passengers or crew,” but the inspectors thought, eh, it’d be good enough if you could just run a hose down from the deck above if there weren’t enough hydrants on any given deck (even though the actual wording of the regulations states that “the hydrant shall be so placed on each deck that the fire hoses may be easily coupled to them").
It's apparent that nobody in a position to enforce safety regulations ever actually thought a fire could break out on the Noronic. Certainly they made every effort to weasel out of providing even the most basic of safety systems, taking advantage of the fact that as Noronic was merely sailing on a lake and not the ocean she did not strictly fall under the regulations requiring fire patrol. Whether this is due to some unknown dangerous quality in salt water as opposed to fresh is not explained. The report mentions tartly that in the judge’s opinion the regulations requiring ships to be equipped with working hydrants and extinguishers imply that there also should be crew members provided by the ship’s owner to use the aforementioned apparatus. Without an automatic fire detection system or a sprinkler system on board, Noronic really could’ve used a fire patrol. What they got was this:
Two crew members designated “Special Officers” switched off at 6-hour intervals to walk around the ship with a time clock and punch a series of keys located at various points on board “on the hour.”
Yeah. In 1942 Canada Steamship Lines issued a list of duties to be completed by the Special Officers, including:
“Each night from 9:00 PM until 6:00 AM the watchman clock shall be punched punctually on the hour. The dials are carefully checked by the Purser and the reason for not punching or the dials not being marked must be explained satisfactorily by the officer. During the round of punching, it is your duty to stop any excessive noise by passengers that are boisterous…Upon completion of your round and all passengers are quiet [sic], return to the rotunda where you are easily found should you be needed…”
The round of time-clock punching took about 15 minutes, which meant that for 45 minutes out of every hour there was pretty much zero fire patrol going on. One of Noronic’s Special Officers said that he thought he wasn’t supposed to do the patrol at all when the ship was in port, but remain instead at the gangplank; the other one understood his duty to be completing the rounds each hour and then returning to the gangplank. In fact neither of them were on board the night of the fire: both Special Officers’ rounds were conducted by a pair of wheelsmen who took the shortest possible routes between the time clocks.
This lack of clarity amongst officers and crew comes up over and over again throughout the investigation. This officer understood that this other officer was supposed to do something, but didn't check with anyone to see if this was in fact the case; that officer thought he was supposed to do this other thing but in point of fact was supposed to be somewhere else entirely and had no idea what to do in case of emergency. The card in the passengers' accommodations regarding fire stated confidently that the ship was equipped with "modern fire prevention apparatus" and patrolled "day and night by experienced watchmen." Or inexperienced wheelsmen doing the watchmen's jobs for them, either way.
Fire and lifeboat drills were regularly held on board the Noronic when she was moored in Duluth. Every Tuesday at ten in the morning, the signal was given for fire drill and the crew members assigned to "fire stations" (hydrants) gathered at their posts. The objective of the drill was to get to the hydrant, get the hose down from its rack, and couple the hose to the hydrant. Sometimes on the outside fire stations they'd squirt the hoses overboard, but obviously not indoors. A few crew members were expected to get the extinguishers down and wave them about, maybe discharge one or two. That was it for fire training of the crew.
In 1945, the General Manager at Canada Steamship Lines was apparently made aware of the fact that his ships were practicing a thoroughly useless excuse for a fire drill, and sent out a memo with an updated list of rules. The memo stated that the enclosed Lifeboat and Fire Drill Regulations were (I quote) serious business, and that masters of all passenger steamers must study them carefully and instruct all crew members accordingly. Let's see how the Norons did:
1) MUSTER STATIONS: The Master will designate locations of muster stations throughout the ship to which members of the crew will report for lifeboat and fire drills (and make sure all crew members know where these stations are and which signals call for them to muster).
1) a ALARM SIGNALS: General or Fire Alarm is indicated by one long, three short, one long blasts on whistle or alarm. Proceed at once to fire drill assigned station. Man Boats Alarm is indicated by General Alarm followed by two short blasts on whistle or alarm. Proceed at once to boat drill assigned station.
The Noronic's crew members each carried a blue card on which was printed his crew number, his fire station number, and his boat number. It clearly states the types of alarm and what one should do upon hearing them. However, in practice, the fire drill signal was a continuous blast on the klaxon horns, while the lifeboat drill signal was identical to the official "general or fire alarm" signal. Crew members had to learn to ignore the info on the blue card.
Passengers did not take part in either drill. The only information they received on what to do in case of fire was on the instruction cards in their rooms. The crew were the only ones who had any idea of emergency procedures, and their grasp on same was tenuous at best.
2) MUSTER LISTS: The Master will have a muster list prepared including the information of all crew members and their muster stations, as well as "full particulars" of the signals required to call members of the crew to muster. This list shall be posted in conspicuous places throughout the ship including the crew's quarters and every officer's room.
There was no such thing as a "muster list" on board the Noronic, nothing signed by the Master, and nothing hung in any officer's room. A "chart" of crew members apparently hung in the maids' quarters, in the crew's stairway aft, on either B or C decks, and in the crew's rec room. The first officer, Gerald Wood, used this chart to prepare a list of crew members and their blue card numbers, boat numbers, and hydrant numbers, and gave a copy to the chief steward. The captain was completely ignorant of all of this and only knew about the typed list because he looked over Wood's shoulder as he was filling it out. Who's on board? Whose job is it to do what? Who knows?
3) MUSTER CARDS: A card indicating the muster station for each crew member must be placed in his berth in such position that it cannot be obscured by baggage or clothing.
The only thing remotely similar to this in use on the Noronic was the blue card, which was kept wherever the crew felt like keeping it.
There was also a rule stating that the Master had to appoint Senior Officers to various parts of the ship in order to help direct passengers to their muster stations if necessary. Here is where the testimony really gets interesting: Captain Taylor said that he'd allocated the first officer to C deck, second officer to A deck, third officer to B deck, and chief steward and purser to D deck. Wood, the first officer, denies any allocation was made, and then proceeds to flip-flop like a gaffed pike (unsurprisingly, he stated that he had never seen or heard of the Serious Business memo):
Q: Was there any allocation that you know of of senior officers allocated to certain locations for the purpose of mustering passengers?
A: No there was not.
Q: Did you make any allocation?
A: No.
Q: Did anyone else to your knowledge?
A: Not that I know of.
Q (really trying here): Now I want to be fair with you. I thought the Captain did say to us that he had allocated certain senior officers in accordance with this and he said the allocation was the chief officer to C deck....do you know anything about that?
A: Well yes, I would be in charge of C deck.
Q: (wondering what he's smoking): Well that is what he told us, that you were in charge of C deck--then must that not mean that you were allocated in some way to C deck?
A: Yes, I would be allocated.
Q: How would you be allocated and what instructions did you have with regard to C deck?
A: I think by this chart [which indicated his duty was free to move about the ship].
(some back and forth about whether or not this allocation is the same as on other ships)
Q: Now what do you say as to whether or not any station was allocated to you as the first officer under this regulation?
A: Well he may have told me to go to my allocation on C deck.
Q: (between clenched teeth) Well he may and then I suppose he may not, but I am trying to get from you whether he did.
A: Well I have been there a number of years.
Q: Then is your statement to me that you do not know whether the Captain in the case of fire had told you that you were to go to C deck?
A: I am pretty sure--I might say that the captain did not tell me this year. He could have back in 1944 or 1945.
Q: Did you always go to C deck on fire drill?
A: No, I go all over the ship.
Q: Then you were really not allocated to C deck?
A: Not to stay there.
Q: Well was anybody allocated to C deck?
A: Well I think the officers were free--wherever we could be the most help.
This confusion is heightened by "the chart," which states that Wood was in fact in charge of deck A. Balancing out various testimonies against one another it becomes abundantly clear that this "chart" had become so obsolete by 1949 that it had nothing to do with any organization or lack thereof on board the ship and in fact the captain had no idea it existed at all. We are dealing with governmental levels of confusion here. The captain and first officer, when asked about duties to be performed by the officers and men at the fire hydrant stations, contradicted one another and made up answers to explain what the rest of the crew not assigned to hydrants would be doing (running away, is my guess).
The slipperiness of officials when faced with questions about the Noronic extends way up the ladder. General Manager of the line Captain Reoch had to admit under examination that in fact when he wrote the Serious Business memo he did not take into consideration the fact that, if a fire occurred while the ship was tied up to a dock, directing all the passengers to the muster stations on C deck would not do them a blind bit of good as the only gangplanks to the dock were on E deck three floors below. "Was it your intention under these rules when you drew them up, that in the event of a fire at a dock, the passengers from D deck would go up or be directed to C deck and then go back down to D [and then E] deck to get off onto the dock?" he was asked. After some squirming and repeated requests to answer the question, Reoch finally admitted that he didn't think that the rules he'd indicated would be followed in case of a dockside fire--or, more accurately, he'd not bothered to consider the possibility.
The really damning bit is when they are asked why they didn't increase the number of crewmen on fire patrol while the ship was tied up. "If there had of [sic] been any signs of an emergency, yes, but there was no reason why they would have. I can't see any reason why they would."
Maybe because you're in a floating firetrap lacking rudimentary safety systems, steeped in decades' worth of flammable varnish, and inhabited by people who are coming back from Toronto bars drunk off their tits and probably waving around lit cigars?
There was no way of knowing which crew members were on or off the ship while she was in port, as they were free to go ashore at any time they were not on duty. If there had been any organization amongst the crew for dealing with emergencies, it went directly out of the porthole as soon as crew members began to go ashore unremarked.
So we have the perfect setup for disaster. On the night of September 17, 1949, something in a linen closet on C deck aft caught fire. The closet contained bed linen, towels, and cleaning materials, as well as a box for rubbish and wastepaper collected from the cabins, and a switchbox controlling some of the stateroom lights. The presence of the box is controversial: a maid stated that the rubbish box was never placed in the linen closet; the chief steward said it might have been there, and an eyewitness stated that it was there. If the fire was due to a smouldering cigarette butt, this box would have represented a perfect point of origin. Passengers mentioned seeing maids smoking cigarettes in the linen closet during the voyage; in the absence of a major electrical fault it seems likely although not certain that a carelessly discarded butt was responsible for killing somewhere between 118 and 139 people.
A passenger, Don Church, noticed a haze in the starboard corridor around 2:30 a.m. and followed it to the linen closet, where he saw smoke coming from the sides and top of the locked closet door. He heard a faint crackling, rustling noise, and assumed someone was inside; this would have been the fire talking to itself. Church, unable to open the door, ran forward yelling that the boat was on fire and encountered the head bellboy, Earnest O'Neill. O'Neill ran back with him to the locker, whereupon their stories diverge: O'Neill stated that he ran back to the steward's officers to fetch the closet key, then went to fetch a fire extinguisher before unlocking the door. Church stated that he just unlocked the door as they arrived.
They opened the door and saw that the wall was in flames and a hanging sheet was beginning to burn. The extinguisher barely slowed it down: almost as soon as the door was opened, flames poured out along the ceiling, feeding on the beautifully polished wooden paneling. Church and O'Neill went for a fire hose, but when Church opened the valve nothing came out. At this point he thought sod this for a game of soldiers and went off to fetch his family and got the hell out of it.
O'Neill only now broke the glass on the fire alarm and ran down to E deck to find a wheelsman and inform him of the fire. It's uncertain how much time really elapsed between the discovery of the fire and the sounding of the alarm, but time was definitely lost in trying to put out the fire with ineffective means. If O'Neill had sounded the alarm at once instead of messing about with extinguishers, several senior officers could have responded at once and taken charge of the fire equipment: C deck was the most well-staffed in terms of hydrant stations. He didn't. The fire raged out of control.
The wheelman O'Neill had woken in turn woke Wood, who quickly sounded the klaxon alarm and pulled the whistle, which stuck open and drowned out the klaxons. By now the starboard side of the boat was "full of fire," and he could not go aft farther than the first three cabins on the port side, where he "banged on the windows" and shouted.
Just before Wood sounded the whistle, a night watchman on the pier was appalled to see flames breaking through a window on the ship's starboard side. He ran inside and called the fire department and gave the alarm, then called the police; someone else standing at the door told him to call for ambulances as well. After he'd told the police to send all the doctors and ambulances they could, the watchman--a Mr. Harper--went back outside to find a mass of flame engulfing the starboard side of the ship. Now the whistle was blowing--Wood had sounded the alarm--and the fire department was arriving. By now it was 2:41 a.m., eleven minutes since Church first saw the smoke, and half the ship's decks were on fire.
The man who had told Harper to call for ambulances was one of the first to escape the burning ship. He had seen people badly burned--a woman with her hair burned away, people with faces and arms scorched and bubbling. It was still only minutes after the fire had begun, and already it was lethal.
The captain was informed of the fire some time between 2:30 and 2:35, according to his testimony, but the times don't match up; he claims to have gone out to yell for help from the outside deck and observed people on the pier, but Harper the watchman had seen the fire begin to erupt and made the alarm call when there had been no other people on the dock.
There is considerable flip-flopping from Wood regarding the instructions he had given to the crew members as to what they ought to do in case of fire: should they notify the officer on watch or just any officer, should they use a hose or an extinguisher first, did he actually tell them anything at all. "Would this be fair," he was asked, "and now correct me if I do not say it correctly--that so far as the education of the crew in the event of fire was concerned, all they had was what they saw on the printed chart in the crew's quarters, which took them to their various stations in the event of hearing the alarm--is that all they had--apart from what you have just said as to what you might have told any particular member of the crew--does that cover the whole field?"
"Yes, that covers it."
There was no organization, and therefore there was no clear and evident list of duties for each member of the crew to perform. Some of the fifteen men on duty tried harder than others to waken passengers and shepherd them over the side on ropes and Jacob's-ladders; by now the fire department was there en masse and trying to reach the ship with aerial ladders, but so many people leapt on the first of these--Aerial No. 5--that it snapped and spilled the lot of them into the harbour. Other passengers leapt straight into the water, some of them screaming as they burned, some of them in eerie silence. Many people were asleep when the fire broke out, and woke only to find their cabins ablaze and the only way out blocked by a window-screen they could not break; some were pulled from burning cabins from the outside by crew members or fellow passengers who had broken the screens away.
GenDisasters offers a collection of quotes from eyewitnesses. Mildred Briggs of Detroit, one of the survivors, said the flames spread as if in a matchbox. "The fire just welled up along the corridors and spread faster than any fire I've ever seen," she said.
"There was a mob of men and women surging back and forth," said another survivor, Alberta Agia of Detroit. "Men were pushing women around, and many were knocked to the floor. The screaming filled the air. There was so much panic that I don't know how these people found anyway to safety. I slid down a rope."
Men rushed out in their nightclothes. One man got ashore naked.
Henry Maurer and his wife were sound asleep when someone pounded the door. When they reached the outside rail, his wife started down a rope ladder, "but it became horribly twisted from so many trying to get on it. She got tangled and trapped. I swung down on a rope to her side and got her free, and we both managed to get to the dock."
Sylvia Carpenter of Detroit said she screamed and headed for the outside rail when she saw smoke and flame billowing along the passageways.
"A rope was tossed over the rail and I put a hitch knot on it to hold it to a stanchion," she said. "As I did so, three men pushed in front of me and shoved some screaming women out of the way. They went down the rope."
The fire burned intensely enough to heat the steel hull white-hot. Glass melted from portholes; metal slumped and warped. Enough water was poured in by the firefighting equipment to list the burning ship toward the dock; operations had to be halted until the list righted itself, as the Noronic settled to the bottom of the harbour with only her top decks above the surface. By five in the morning the fire was out, but they had to let the hull cool before venturing inside to find the bodies.
Everything that could be consumed inside the hull was consumed. Luxurious fittings were reduced to ash, ceilings and columns melted and warped. All the stairways in the boat save one were utterly destroyed.
The fire stripped away identities, turning human bodies to calcined bone fragments; some victims were nothing but a skull or spine. There are touchingly gruesome tales of searchers entering the ship to find embracing skeletons in the hallways and the remains of the cabins. The remains had to be removed by shoveling them onto tarpaulins, as they crumbled when picked up. New advances in forensic odontology (including the use of X-rays) had to be made to identify Noronic victims; articles on the techniques developed as a result of this disaster are still being published today in forensic journals.
Newspaper articles covering the disaster began, as newspaper articles of this sort tend to do, with horrified pronoun-deficient headlines: 200 DIE ON FIERY SHIP. GREAT LAKES QUEEN BURNS. HOLOCAUST SINKS PLEASURE CRUISER AT TORONTO DOCK. 400 HOLIDAYERS ESCAPE FLAMING DEATH AMID SCENES OF HORROR.
The final conclusion of the Court report into the disaster placed the blame on the failure of the owners and captain in:
a) Holding a continuous fire patrol of the ship, instead of a cursory time-clock round every 45 minutes
b) Maintaining any organized system while the ship was in dock with passengers aboard by which “information as to the outbreak of fire could be promptly dispatched to some point from which men trained in the methods of dealing with fire could be immediately dispatched to the locality,” or “effective fire alarm and fire procedure”
c) Taking the threat of fire at a dock seriously and allowing all but fifteen of the crew to go play on shore and be potentially unavailable in the case of emergency
d) Developing and practicing any plan for waking and evacuating passengers in the case of a fire while in dock
e) Training the crew on what to do in case of fire or how to operate the extinguishers and hoses.
Or, to put it more baldly, being about as prepared for a dockside fire as a jumbo prawn would be to handle a credit-default swap. The scope of the failure to prepare for or anticipate anything of the sort is breathtaking. The owners knew perfectly well that there was no functional plan in place for dealing with this kind of disaster, and so did the captain–and there was nothing stopping him from taking any steps to remedy the situation. It’s the equivalent of driving a car with half the lug nuts loose and just sort of hoping the damn wheels won’t come off.
The Noronic fire may not have been preventable, but the loss of life associated with it was. Nobody ever did determine what started it, but my money’s on an indifferently butted cigarette tossed into the refuse box in the linen closet, which then spread rapidly throughout a ship lacking in regulation fire-resistant bulkheads, a ship lined with highly inflammable varnished wood, a ship without automatic fire-detection or sprinkler systems, a ship whose fire alarm system was Goldbergian in its unnecessary complexity and multiple stages, and a ship manned by a totally insufficient and untrained skeleton staff. The bellboy O’Neill could possibly have saved the ship had he sounded the alarm before attempting to put the fire out himself–but he didn’t. The story of the Noronic is a litany of “I didn’t,” “I don’t know,” “I cannot say that I have,” and “I can’t see any reason why they would.”
Captain Taylor lost his license for a year; an unknown number of people lost their lives. The steamship company paid out something like $3 million to the families of the victims. Rather horribly, another Canadian passenger ship, the SS Quebec, experienced a similar fire a year later: the Quebec fire was ultimately determined to be the result of arson and started in a linen locker. None of the safety regulations written after Noronic were put in place aboard Quebec, and the crew were just about as useless in trying to fight the fire and evacuate passengers. That was it for Canada Steamship Lines’ passenger cruises on the Great Lakes.
It’s too easy to make fun of the Noronic’s name, which I will now reveal is most likely in reference to Lake Noron, Quebec. It’s too easy to point out that “no we didn’t” and “moronic” overlap quite efficiently, so I will just leave you with First Officer Wood’s deathless turn of phrase:
“I think in cases of emergency, the officer goes where he can be the best help.”
In this case, over the side.
Information in this article is taken from the following sources:
CanadianHistory.suite101.com
www.centrenaufrages.ca, Courage Tales 5, accessed June 16, 2009
GenDisasters.com
Lost Liners
Report of Court of Investigation into the Circumstances Attending the Loss of the S.S. "Noronic" (1949), located at Tales of Tragedy and Triumph: Canadian Shipwrecks, a virtual museum exhibition at Library and Archives Canada
The Walkerville Times
Wiki
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