After the Wells Fire: Beyond Codes and Regulation

When fire spread through the Riverview Individualized Residential Alternative in Wells, NY, four of the nine people with developmental disabilities living there perished. Today, are people with developmental disabilities any safer?


The Grand Jury Report released in December 2009 in response to the Wells fire noted that there are approximately 7,000 such group homes across New York State, and that “a very conservative estimate of the number of structure fires in these facilities is at least one each week.” It concluded:  “There is a grave, and we believe unacceptable, risk that more lives will be lost unless action is taken…to address the systemic shortcomings that affected Riverview and continue to affect every other such residence in our State.” The systemic shortcomings detailed in the report included not just structural issues but human behavior.

The report found that the Wells residence had more fire safety features than many such homes in the state, and met or exceeded all Office of Mental Retardation and Developmental Disabilities residential requirements. State law already requires fire drills four times a year (two of which must be at night) for such residences.

While the Grand Jury’s recommendations called for stricter building code and fire safety standards, it also found that “the practices at Riverview were geared to meet regulatory requirements rather than to meeting the actual needs of the residents who were extraordinarily vulnerable to the risk of death in a structure fire.”

The potential downside of relying on regulation is that it can narrow the focus of all safety issues to compliance, leaving a vacuum of motivation and little understanding of why these things are necessary and desirable. Both thought and action are concentrated on meeting legal requirements. People who are never asked to reflect on the need for meaningful practice may meet only the letter of the law, e.g. performing fire drills in the same way each time, rather than practicing what to do when something unforeseen—a fire—actually happens. Regulation can give a false sense of security. Because they have met a quota of fire drills, people believe they have done a good job and everyone is now safe.

An unintended consequence of a high degree of regulation is that complex safety issues may be addressed by the lowest common denominator of compliance. Home fire safety and fire survival is in fact complicated, as everyone knows who has actually gone through the process of creating and practicing a home fire drill. There are many factors to be considered, and realistic practice can reveal dangerous flaws in an imagined escape plan. How will each member of the household get out of the home if a fire occurred? Does everyone know how to respond? What physical barriers might prevent escape? What physical and mental limitations of each individual might hinder escape? What would be the best route out, for fires in a variety of possible locations? “What if?” is a question that must be continually asked, and which is not readily answered by a regulation. One size simply doesn’t fit all.

Meaningful training is built on models proven to actually change behavior, including the critical factor of motivation. Evaluation is also needed, to know not just that training took place, but that it actually increased knowledge and the probability that people will do what they need to do.

To prevent another tragedy, safety training must change behavior and it must take place at all three levels: residents, staff, and management. If any of these three groups are not involved, meaningful safety training will not take place.

At the Wells fire, three of the residents died after they had almost made it to safety, but went back inside the burning building when the two staff members had to help a resident who had fallen or sat down. The Grand Jury found that “by not practicing full evacuations and evacuations by alternate exits, the residents, who required frequent repetition for learning and who are dependent upon habit, were put at greater risk.” It further noted the “very significant challenge presented in evacuating individuals who do not have self preservation skills,” while also noting that “these circumstances were reasonably foreseeable.”

What kind of training, then, is effective for people with developmental disabilities? In the home safety trainings that Prevention 1st has provided for Finger Lakes Office for People With Developmental Disabilities, the Arc of Monroe, Hillside Children’s Center and others, we have found that, given an opportunity, people with developmental disabilities are interested and engaged in learning about safety. With repetition, they remember important safety lessons.

In our experience people with developmental disabilities have many questions about fire safety, and their questions are very specific and pertinent to their individual situations. They ask plenty of those “What if?” questions. In other words, their questions address the true complexity of fire survival skills described above! Effective training means listening carefully to questions and using them to individualize the training so that it is meaningful to the audience. The person providing fire safety training needs an understanding of and a commitment to the goals of fire safety, as well as the motivation and enthusiasm needed to engage an audience. For this reason, and also because frequent repetition is required to retain learning, we are frequently asked to return to give additional trainings.

Staff and Management
The public report issued by the Office of Fire Prevention and Control concerning the Wells fire found that “fire safety training of new employees has steadily decreased over the years, to approximately 90 minutes.” The Grand Jury Report noted that fire safety at Riverview and other facilities is typically handled by employees who “have little training in fire safety and cannot in any sense be considered professionals in the field.”

The Grand Jury concluded that “the training appears to have been confined to the ‘RACE’ acronym…Rescue or Relocate, Alarm, Confine, Evacuate,” and that some staff members “were unable to elaborate on the acronym beyond the observation that evacuation of residents was the first priority and only after evacuation could efforts to extinguish a fire be taken.” During the Wells fire evacuation, “time was taken to answer the phone call from the alarm operator and to retrieve and discharge a fire extinguisher.” Staff members tried to evacuate residents through the main exit rather than through a side exit nearer the bedrooms which was protected by double fire doors.

At the Wells residence, fire drills conducted on the overnight shift were conducted either: 1) by simulation, with staff estimating the amount of time it would take to get residents up and out; 2) at pre-arranged times of the night and without a full evacuation, or 3) after 5 a.m., when additional staff arrived and could assist the two overnight workers in the evacuation. The result was that the most critical questions of home escape were not addressed: Can everyone get out, under real conditions?

Prevention 1st has found many caregivers are under the impression that regulations require them to perform fire drills monthly, rather than four times a year. This was the belief at the Wells residence. Unfortunately, higher repetition of drills does not necessarily lead to greater safety. Such repetition can lead to resistance, complaisance, and dangerously poor habits, such as going right back inside immediately after evacuating the building when the alarm sounds. When caregivers enforce drills but haven’t internalized the reasons for this practice, they may fail to communicate that it’s important to respond when the alarm sounds, to get outside, and stay out until told that it is safe to return.

The need for sincere support of behavior change by management is obvious. At the Wells residence, random checks of overnight staff by senior supervisors occurred, but “fire drills were generally not conducted as part of these supervisory visits.” It should be emphasized that management’s attitude is critical to the motivation of staff to take the actions that will protect both themselves and the residents in their care. Staff should not simply be threatened with consequences if they fail to comply with regulations. They should be provided with effective training, and they should be thanked, praised and respected for doing things right, even when that means doing things the hard way.


Read the full Grand Jury Report here.
Our thanks to the NYCLU for making this Report accessible.