Abstract
Biorepositories may be affected by a number of emergencies ranging from bad publicity to natural disasters, and biorepositories should have plans for handling such situations. The emergency management process includes all phases from mitigation to recovery. Fire is one disaster that may cause extensive damage to both physical structures and humans. In this article, we analyze events related to a fire in a storage facility for mechanical freezers. The analysis covers both the pre-crisis stage, the fire itself, and the post-crisis stage. Even the best intended planning cannot stop a crisis from happening. However, an open-minded analysis of the crisis with focus on learning and quality improvement can improve an organization's ability to handle the next emergency situation.
Introduction
• Mitigation: Activities that prevent or reduce the chances of an emergency. • Preparedness: Planning how to respond in case of an emergency. • Response: Actions taken at the emergency stage to save lives, minimize property damage, and enhance the beginning of recovery. • Recovery: Activity that returns infrastructural systems to minimum operating standards and guides long-term efforts to return life to normal or improved levels after an emergency.
Fire represents one type of emergency situation that may develop into a major disaster causing extensive harm to both humans and physical structures. In this article, we analyze events related to a fire in a biorepository storage facility situated in a public hospital in Norway. Our intention is to show that even the best intended planning cannot stop a crisis from happening, and that an open-minded analysis of the crisis with focus on learning and quality improvement—and not blame attribution—should be the goal.
The Crisis
A crisis can be divided into three stages; (i) the pre-crisis (mitigation and preparedness), (ii) the acute crisis (response), and (iii) the post-crisis (recovery). 3 A recent review of emergency planning publications found that many focused mainly on the emergency response, while fewer addressed risk analysis and mitigation. 4 We believe optimal organizational learning from an emergency requires both a proper understanding of the process leading up to the crisis in question and a systematic review of the crisis itself. In the present article we will accordingly describe relevant events prior to the fire (the pre-crisis stage), the fire itself (the acute crisis), and the events that took place the first month after the fire (post-crisis).
The pre-crisis stage: Establishing a storage facility for mechanical freezers
Ulleval University Hospital (now merged into Oslo University Hospital) was a large general public hospital with 10,000 employees. In 2002 the hospital targeted biobanking as a key element in its research strategy, and a dedicated biobank department was established in 2004. Having appropriate storage facilities for biological material was deemed essential, and in 2005, planning was begun for a dedicated facility for mechanical freezers (-80°C). The facility was considered a pilot for further storage facilities and was to be located in the basement of one of the hospital's buildings mainly used for outpatient clinics and patient wards. The project group established included both end-user representatives and external technical consultants. The group was co-chaired by a project manager from Facilities Management and the hospital's biobank coordinator. In the first stage of the planning process, a basis document outlining general functional and technical requirements was prepared. The best practice-document published by the ISBER in 2005
5
was among the background documents used for this. Three overall guiding principles for biobank activities were identified;
• Collection, storage, and retrieval of human biological material must be in accordance with relevant local legislation, including health and safety regulations. • The risk of damage to employees, third parties, buildings, and other physical structures must be reduced to an acceptable level. This must be documented by formal risk analysis. • The integrity of the biological material, with respect to the intended usage, must be ensured during the entire (pre-defined) storage time. This was to be documented by formal risk analysis.
Following approval by the hospital's chief executive officer, a more detailed planning phase started early in 2006. In accordance with hospital guidelines for facility planning, both end users (researchers) and staff involved in facilities operation were formally engaged in the planning process. As part of this, written documentation on all technical solutions suggested was sent for a final review by relevant stakeholders within the hospital.
A formal risk analysis was undertaken as part of the detailed planning phase. Fire was among risk factors identified with a potential for major damage. The project got in touch with the local fire department, and they stated that all efforts would be focused on saving human life, and that no attempts would be made to rescue biological material in case of fire. In line with this, the project group focused on risk reduction (mitigation), effective fire detection, and extinguishing systems (preparedness). Risk reduction included a general effort to limit the amount of flammable material to be used or stored in the facility. As one identified potential cause for fire was failure of the power supply unit of individual mechanical freezers, risk reduction efforts required all freezers to be stored in the facility to undergo an annual preventive maintenance check-up. With respect to fire suppression systems, three types were considered:
• A water extinguishing system: This was rejected since immersion in water could cause a large number of mechanical freezers to fail simultaneously. • A foam extinguishing system (consisting of water, air, and foam-making agent): This was rejected since immersion in water could cause a large number of mechanical freezers to fail simultaneously. • A gas extinguishing system (reduction of the oxygen concentration): This was considered best with respect to electrical equipment. However, certain gases (such as carbon dioxide) in enclosed spaces present a risk of suffocation.
Following safety considerations, it was decided to use a gaseous mixture of argon and nitrogen whereby the oxygen concentration in the facility is reduced to 12%, thereby causing fires to extinguish in less than 1 minute. This can be achieved in a controlled manner when the room in question has a controlled “air-space”. Based on room volume calculations, a pre-defined amount of gas is released into the room. The gas is nontoxic, and humans can breathe while evacuating. Since the gas mixture creates minimal fog, escape routes remain visible. In our case, gas was to be released after detection by two independent detectors (see Control and monitoring system and electronic communication).
After organizational approval, building construction ensued for a dedicated storage area of 100 m2 holding up to 28 mechanical freezers. Technical infrastructure equipment (e.g., bottles for extinguishing gas, back-up power supply, and control and monitoring system) was housed in two adjoining separate rooms. A dedicated control and monitoring system for the storage facility was installed. This system was linked to a separate alarm system being used by the technical staff responsible for maintenance of the mechanical freezers. This staff had an around-the-clock call of duty for moving biological material from failing mechanical freezers in the facility to dedicated back-up freezers. The facility was officially opened in May 2007. Almost 2 1/2 years of work and USD 2 million had been spent on planning and construction of the facility itself (excluding the mechanical freezers).
The crisis stage: Fire!
On November 7, 2007 a fire alarm sounded at 16:06 hours in the building where the storage facility is located. At 16:08, a fire alarm in the corridor outside the storage facility was manually activated by an incidental by-passer hearing alarm bells inside the storage facility and noticing smoke sieving through the doors. In line with written notification on the doors to the storage area, the individual did not attempt to enter the premises. Following activation of the manual fire alarm, both on-duty technical staff and the municipal fire department were automatically alarmed. In addition, all outpatient clinics and wards were automatically warned and the pre-established procedure for patient evacuation was initiated. The fire brigade arrived the building at 16:14, just 6 minutes after being notified. Guided by staff from facilities management, the fire brigade then entered the storage area itself. Some smoke and a smell of burnt plastic were noted, but no ongoing-fire was detected. There was no visible damage to either structural building elements or technical equipment, and no humans had been injured. Parallel in time to this, the on-duty staff responsible for maintenance of the mechanical freezers had arrived at the scene, having been electronically notified of failure of a particular freezer. The side panel of the freezer in question was opened, and a damaged power supply unit was observed. Inspection of the electrical control panel housed in one of the two separate technical rooms showed that the automatic electrical fuse belonging to this freezer had blown. As the fire had been stopped and the electrical power had been terminated, there was no risk for immediate recurrence of fire in the power supply unit. The fire department accordingly left the premises at 17:00 and hospital staff were allowed to enter the premises on their own. The biological material within the damaged freezer was then moved to an empty back-up freezer. Staff from facilities management established an on-site manual fire guard post and requested a follow-up meeting with involved parties the following morning.
The post-crisis stage: Analysis and follow-up
After-action report
A meeting involving all relevant stakeholders within the hospital was held on the morning of November 8. It was decided to prepare an official after-action report 6 in order to (i) investigate the cause of the fire and to (ii) analyze the event and the observed responses in order to enhance organizational learning and to suggest possible actions to be taken for further quality improvement. A detailed time-log of all events was obtained from the control and monitoring system. In addition, verbal accounts were gathered from key personnel involved directly in the event.
Cause of fire
With respect to the cause of fire, investigations of the failed mechanical freezer showed that wires on top of two transformers in the power supply unit had burnt. There was no indication of dust or foreign material causing this. Such a failure had been identified in the risk analysis undertaken in the planning phase of the facility (see Pre-crisis stage). The investigators concluded that the risk analysis had been sound, and that no further preventive action could be undertaken to avoid another incident like this.
Control and monitoring system and electronic communication
The electronic log showed that fire pre-warning signals were registered independently by two detectors (ionization and aspirating) 2 seconds apart. These warnings were confirmed by the same two detectors 5 seconds later, and the extinguishing gas was consecutively released another 7 seconds later. The gas was accordingly released 14 seconds after the first pre-warning registration. This was in accordance with pre-defined action commands programmed into the control and monitoring system. The system had also forwarded relevant information to the freezer maintenance staff in an appropriate manner. The investigators concluded that the established electronic communication protocols were adequate, and that no further action should be taken.
Refill of the gas extinguishing system
During the post-crisis stage, it was discovered that the hospital did not have a contract on refill of the gas extinguishing system. Furthermore, all representatives from the small company originally providing the gas were away on a business trip, and there were no alternative suppliers. This caused approximately 48 hours to elapse before the extinguishing system was refilled. In the interval, an on-site manual fire guard post had to be maintained. The investigators concluded that the planning had not been optimal, and recommended that facilities management should establish a contract on refill of the gaseous extinguishing system within a specified number of hours. In addition, two manual carbon dioxide fire extinguishers were mounted on the walls on the outside of the storage facility.
Human action and communication
Verbal accounts, from hospital staff present when the local fire brigade arrived, indicated that the fire brigade had intended to use water to extinguish what they believed was a possible ongoing fire within the storage facility. This action was only halted by verbal interference from the hospital staff explaining that a dedicated nontoxic gaseous extinguishing system had been activated. Without this interference, 27 mechanical freezers might have been massively exposed to water, and thereby possibly failing. The hospital had no back-up solution to handle such a scenario. The investigators concluded that, although relevant knowledge on the facility had been dispersed to relevant hospital staff who then had acted appropriately at the crisis stage, personnel from relevant external organizations (such as the fire brigade) had not been properly informed. In order to ensure communication of relevant information to everybody intending to enter the storage facility, large signs were mounted on the doors leading directly to the storage facility stating that (i) a nontoxic gaseous extinguishing system was present, and that (ii) only carbon dioxide was to be used as a supplementary extinguishing method.
Discussion
The very nature of “emergencies” is that they are low probability events, and that they may not adhere to pre-defined contingency plans written by the particular organization being affected. Investing resources in preparing detailed plans outlining every foreseeable alternative may accordingly not be the optimal approach. Drafting generic plans defining lines of authority, roles and responsibilities and means of coordination may be more appropriate. 7 Eriksson and McConnell have stated that successful pre-crisis planning does not in itself guarantee successful crisis response and that successful crisis management may be achieved despite weak pre-crisis planning. 8 McConnell and Drennan have taken such reasoning even further by claiming that some contingency plans are not likely to provide blueprints for coordination and action in times of crisis because they are out of touch with the realities of crisis, and that the plans are merely symbolic—a form of reassurance to the organization. 7
However, considering that some risks are more plausible than others in a given context, we believe that a mixture of detailed and generic plans is the best approach. Very unlikely events (e.g., a major earthquake in Norway) can be omitted from the detailed planning process, while more plausible events (e.g., a fire) should be considered in more detail. In our case, pre-crisis planning was done both because it was required formally by hospital guidelines for facilities management, and also because the organization was strongly motivated to establish a storage facility in accordance with best-practice guidelines. Formal risk analysis, measures for risk reduction, and proper routines for crisis management were part of the planning process. All internal stakeholders were formally engaged in the process, and operating procedures were established in order to ensure that all groups were aware of their roles and responsibilities. Such a way of working is recommended for emergency planning. 9 With respect to fire as a possible emergency, quite detailed plans were made. These covered prevention, detection, extinguishing, and post-crisis damage control aspects.
Emergency management can be deemed successful if (i) pre-defined processes have been adhered to, (ii) decisions made have minimized loss of life/damage, (iii) daily order has been restored, and (iv) the management process has gained general support. However, establishing criteria for such an evaluation is not easy. Issues such as which crisis stages to include, time span to be evaluated (short, intermediate, or long), and whether focus should be on individual, intra-organizational, and/or inter-organizational aspects can make an evaluation difficult. There might even be cases where overall crisis management was deemed successful precisely because pre-defined rules were breached and improvised decision making was given top priority. A good example is the handling of the explosion on board Apollo 13. 10
In our case, the after-action report had two overall goals, discovering the cause of the fire and gaining knowledge on the pre-crisis, crisis, and post-crisis stages in order to improve hospital routines. With respect to the cause of fire, it was quickly discovered that this resulted from a failure in the power supply unit in a mechanical freezer. The risk had been identified in the pre-crisis stage and measures to prevent, detect, and limit the damage had been introduced. Our after-action investigation found that all pre-defined procedures with respect to automatic routines for the crisis stage had worked according to plan. However, we found a fault in the hospital's operating procedures regarding refill of the gas extinguishing system. Despite extensive engagement of stakeholders, this aspect had not been brought out in the pre-crisis stage. We believe a more systematic use of scenario methodology 11 in the pre-crisis stage could have prevented this weakness. The basic questions of “what, where, when, and who” when walking through an emergency scenario are very useful. In our case, we had not really considered “what needs to be done, and by whom after the extinguishing gas has been released?”
That the human factor is crucial in an emergency response was clearly demonstrated in our case. Proper communication of known relevant facts from prepared hospital staff to the local fire brigade during the crisis stage prevented the storage facility from being flooded by water. However, both the presence of qualified staff at the scene and their actual knowledge were results of pre-defined organizational guidelines.
Conclusion
We believe pre-crisis risk analysis and planning to be essential for biorepositories. In addition to formal procedures, real involvement of all stakeholders with an active use of scenario methodology and practical crisis training can enhance an organization's ability to handle emergencies.
Footnotes
Author Disclosure Statement
No competing financial interests exist.