The newspaper headline tells this story: "3 DEAD AND 40 INJURED IN MOVIE THEATER TRAGEDY."

The fire alarm at the Movieplex Theater was activated by a pull station or for reasons unknown at around 9:45 p.m. on a Friday evening. It could have been someone playing a prank or an upset patron bent on revenge. Authorities are checking all possibilities for an explanation of how such a tragedy occurred. Whatever the reason, the fact remains that three died and 40 were injured.

Here is the account as reported by witnesses to local police and fire officials.

The fire alarm was activated at a pull station within the theater complex. The multiplex theater has 18 screening rooms and can serve up to 9,650 patrons. The alarm occurred during a period of peak holiday attendance; several theaters were full, and a large number of patrons were waiting for the next viewing to begin.

When the alarm was pulled, theatergoers in the viewing rooms began to move out into the waiting area in an orderly fashion. They converged on the congested lobby, where patrons were waiting for the next shows to begin. Reports indicate that there was no organized assistance; theater management refused to comment.

At about the time of the alarm, one of the popcorn machines at a snack bar overheated; the smell of burning popcorn began to fill the lobby area. While not confirmed, it is reported that this odor caused some to panic initially. According to one patron, "People began to push and shove and seemed confused about how to find their way out. Soon, everyone was screaming to get out."

Theater management and employees were quickly overwhelmed; it took police and fire emergency personnel almost 30 minutes to control the situation. Approximately 6,000 patrons were in the theater complex. The investigation is ongoing. It will take some time to complete the inquiry into this tragedy. The complex will be shut down for a minimum of one week to allow for the investigation and repairs.

Officials emphasize that the theater was not overcrowded at the time of the incident. Early reports indicated that they were understaffed because the large crowds were unexpected. The Occupational Safety and Health Administration (OSHA) is also investigating the incident, since an employee of the theater was among the dead. In addition to possible civil action, there may be criminal charges related to the deaths.

You might be asking, "How could this happen?" Does it sound too farfetched? You may be surprised after we examine the situation further.

For many years, large-assembly occupancies were on the decline. With the demise of live theater, circus performances, and the like, large sporting events, typically held in large, open-air stadium or enclosed dome-type structures, became the predominant settings for large-assembly leisure activities. The local assembly occupancy was usually the town cinema.

As recent as 10 to 15 years ago, most movie theaters, even in large urban areas, were relatively small. Most were "twin" theaters; the usual occupant load was between 800 and 1,400 patrons when both theaters were in use. By the mid-1980s, the predominant attitude was that fewer and fewer people would be visiting movie theaters because of the availability of videotape and disk home viewing. In response to this, theater owners began to battle for market share. They began by improving the quality of the sound experience with better recording and sound systems. Some theaters now feature stadium-style seating for better viewing.

As consumers' appetite for variety within one location began to surface, theater owners hit on the idea of the "megaplex," which would make more screens available in the theater. Today, it is not uncommon to find theater complexes with between 15 and 25 screens under one roof; some are even on multiple levels. The capacity of some mega movie theaters, including the waiting areas, is from 8,000 to 12,000 patrons. Some major metropolitan areas may have dozens of these megaplexes.

Movie-viewing trends have been reversed. Many of these complexes are well attended throughout the year, particularly around the holidays and during the summer months. This growing trend may continue as plans for improving the picture quality and instituting new innovations such as the IMAX large screen evolve.

At the same time, however, management policies have gravitated toward lower labor costs, which include hiring fewer employees and implementing automated tellers and online ticket procedures. Although theaters have enjoyed good attendance, profit margins are typically low, and some theaters have been forced to close. To keep costs at a minimum, theater employees usually are high-school or college students and are paid minimum wage.

This may be true also of management positions. Quite often, when movie attendance exceeds expectations, there are too few employees on duty, since the managers try to keep staffing expenses to a minimum. Turnover is also fairly high, making it difficult to maintain a staff well trained in operations. Management is reluctant to invest limited resources in safety training. To be fair, movie theater management has a difficult task of judging what the customer count will be on any given day, which results in over- or understaffing on a regular basis. In an effort to cut expenses, often estimates of how many employees will be needed are on the low side.

Patrons who are often unfamiliar with their surroundings and a limited staff constitute a combination for potential disaster. Few theaters have windows that open to the outside. Often, advertising, banners, and the like partially or completely obstruct exit signs and other directional visuals.

Let's take a closer look at movie theater situation challenges. What are the positives? Often, safety features are built into complexes that are relatively new and must conform to current codes. They include full fire alarm systems, fire sprinklers, and adequate fire extinguishers.

Will fire alarms help save lives? Most definitely. They can provide early warning of danger and occupant notification. Although this early warning is critical, in the past, alarms alone have proven to be of little value in certain situations. At one theater complex where I went to see a movie several times over a three-month period, I found, on each visit, that the main fire alarm panel was in alarm mode and silenced because there was a problem with the system. Would the evacuation alarm have operated if there were an alarm? Many factors affect how people react to fire alarms. The most effective type of alarm is one that provides voice instruction; the least effective is the one that uses bells and flashing strobes. John L. Bryan, in Section 3, Chapter 12 ("Behavioral Response to Fire and Smoke") of the SFPE Handbook, quotes the following from a United Kingdom researcher: "The response to fire alarm bells and sounders tends to be less than optimum. There is usually skepticism as to whether the noise indicated is a fire alarm and, if so, is the alarm merely a system test or drill?" Evacuation notification is supposed to be by recorded or live voice.

Properly designed and installed fire sprinklers are also critical. Adequate fire sprinklers can significantly reduce property damage and even help to contain the fire to the area of origin, as well as provide life safety. Fire extinguishers are available, but employees rarely are trained in their use. OSHA requires that employers determine the employee level of response in an emergency. Keep in mind also that our hypothetical incident at the beginning of this article did not involve an actual fire; it was only a perceived fire.

Insurers must be certain that theater owners and management are in full compliance with these requirements.

Means of egress that will enable patrons to rapidly exit from the facility in an emergency are critical. The most important exit is the main entrance, with which patrons are most familiar. The Life Safety Code? requires that the main exit for a place of assembly be capable of handling a minimum of 50 percent of the building's occupants. The reason for this is simple: Most occupants will seek to exit from the same point through which they entered, because they are familiar with that entrance/exit. This main entrance/exit area, however, is generally cluttered with stanchions, benches, ticket-taking stands, plants, and other obstacles placed there by theater management to facilitate crowd control. In most instances, these obstructions are positioned so that the exit capacity is reduced well below the required 50 percent (it was at one time two-thirds) of building occupants.

The secondary exits are required to have a total combined capacity of two-thirds of the calculated occupant load. This provides a "safety factor": Total exit capacity is in excess of the occupant load. Here, too, you will find that the path of egress in these secondary exits often are partially obstructed by decorations, displays, and even misplaced equipment. In addition, benches, plants, video games, concession areas, and so on, placed in the area for maximum exposure and aesthetics, often interfere with exit travel. On one occasion, I was exiting a theater viewing room through a secondary means of egress when I came on a folding table lying on the steps leading up to the exit doors. Several people had to walk on the folding table to exit the area since the crowd behind would not permit stopping to remove the table.

Direct exit doors from individual theater-viewing areas are another matter entirely. They are not intended for regular use as exits from the building; theater management maintains strict control over these doors to prevent unauthorized entrance into the theater and the potential loss of ticket sales. On a positive note, these secondary exit doors are often alarmed so the staff can monitor them. These areas, however, often also are cluttered with storage and other obstacles, which is in violation.

What is the answer for these modern movie complexes? Better enforcement of codes? Crowd management training? Educating theater management on life safety requirements? Let's go back and revisit our "tragedy" from a different perspective.

This time, the headline would read, "TRAGEDY AVERTED AT MOVIE THEATER."

A normally busy Friday evening at the Crosstown Movieplex was, by all standards, even busier than expected. The warmer weather had brought out more than the usual number of moviegoers seeking an indoor activity, resulting in a nearly full house. According to theater management, a fire alarm pull station was activated around 9:45 p.m. The identity of the person responsible for the alarm is unknown. The alarm occurred when several theaters were ending their shows. The large lobby area was full of patrons waiting for the late showing.

A spokesperson for the complex stated that the alarm was quickly investigated and the situation was immediately controlled. Guests leaving the theaters were able to enter the lobby area, and patrons waiting for the next show were in stanchioned waiting areas when the alarm sounded.

Employees quickly acted to manage the situation, advising patrons to remain calm and directing those who wished to leave to the nearest exits. Everyone was orderly and remained calm during the 10- or 15-minute ordeal.

The area where the pull station was activated was immediately checked. All indications were that it was a prank or an accident. Some patrons reported a burning smell. Management confirmed that it was only the odor of burned popcorn coming from the snack bar area.

The fire department was called to make a routine check of the area. Within 30 to 45 minutes, patrons reentered the theater for the late showing, and business was back to normal.

Does this sound better than the first scenario? In fact, an incident of this type would probably not even make the news unless it was a very slow day for newsworthy events.

What made the difference? Well-trained employees who took action. They averted what could have been a serious, headline-grabbing tragedy.

NFPA 101, Safety to Life from Fire in Buildings and Structures, has recognized the need for providing and maintaining adequate means of egress, training staff members, and ensuring that fire alarm and sprinkler systems are properly maintained. Yet today, many theaters across the country do not provide crowd management training for their employees or adequately maintain the life safety features of their facilities. Why? Because very few regulatory agencies are requiring that theaters comply with these requirements. In addition, there is limited training available. This is based on the local situation I discovered through interviews with business operators. I also worked with a local nightclub to provide crowd management training. The theater checked with an officer at the local authority having jurisdiction, a personal friend of mine, and was advised that the code did require this training, but the code was not being enforced because there were no resources for obtaining the training. Insurers are also lax in demanding that these requirements be enforced. And there is the expense of the training for the theater. (One source for this type of information is www.crowd safecom.)

Yet, the cost of the training is minuscule in comparison with the potential loss of life, the economic impact of interrupting business, litigation, and insurance costs. And, then there's the potential for criminal and civil suits that might result in managers' being imprisoned and charged with punitive damages. One properly handled incident will pay for itself many times over.

One factor officials often overlook when applying life safety to buildings is occupant behavior. The vast majority of code requirements address the building's physical attributes and do not focus on the behavior of the occupants within the structure, although occupant behavior studies were used extensively during the code-development process. According to the second edition of the SFPE Handbook of Fire Protection Engineering, building occupants undergo a psychological process, consisting of the following steps, when confronted with a perceived emergency situation:

• Individuals recognize there is an emergency through cues that alert them to the situation.
• Once the individuals recognize the situation, they attempt to validate the information by ascertaining whether their initial information is correct or not.
• Individuals then define the situation; they try to relate the information to the situation? to determine if they are in immediate danger.
• Individuals evaluate the situation by applying the initial knowledge to a response plan and manner of reacting. Among the influences at work here would be factors such as how threatening the situation is, how others are reacting, and whether there is a reasonable certainty that there is a means for leaving the area.
• Individuals then make a commitment: They use the information they have gathered and evaluated to develop a plan of action.
• The most stressful element of the psychological cycle is reassessment. It involves having to change part or all of the action plan in response to new input or flawed interpretation of the initial input. To put it another way, people investigate conditions, compare them with their experience, and then decide on actions. These actions may have little to do with what is written in codes.

As noted, since occupants will tend to look for the exit with which they are most familiar (the one through which they entered), it cannot be assumed that the secondary exits would be used to the potential specified in the code.

Also, the responding fire units will typically try to use the main building entrance?? the exit most accessible and familiar to occupants? for initiating their operations.

In addition, studies have shown that typically three percent of a building's occupants will have some sort of physical condition that makes it difficult for them to evacuate without help. Depending on the number of people in the theater, 180 to more than 300 patrons may fit this category.

Complicating the issue are common assumptions concerning the movement patterns of occupants during an emergency. These assumptions, according to the SFPE Handbook, are the following:

• Everyone starts to evacuate at the same instant.
• Occupant flow will not be interrupted by the individual's decisions.
• All or most of the people involved do not have disabilities that would significantly impede their ability to keep up with the group.

There are efficiency and delay elements in the evacuation process. Typical examples of efficiency elements would be delays caused by egress management activities of those directing the evacuation, time delays caused by stopping and restarting flows, delays instituted by the individuals themselves, and an inefficient balance in the use of exit facilities (some emergency routes are overtaxed while others are underused).

Moreover, the start of the evacuation may be delayed by the time it takes to make the decision to evacuate, the time used to investigate (search for additional information about the incident), the time used for other activities that do not fully contribute to effective evacuation, and the time involved in determining the appropriate exit route.

One method for evaluating crowd movement is metering. It involves three fundamental characteristics: speed, density, and width. It is expressed as flow = speed 2 density 2 width.

Speed is the flow of people past a specific point; density refers to the number of occupants per square meter or square foot; width refers to the width of the point being observed (SFPE Handbook of Fire Protection).

How do we improve life safety for occupants of megaplex theaters and other large places of assembly? The Life Safety Code? requires that "every Class A place of assembly (those that can accommodate 1,000 or more occupants) must provide trained crowd managers at a ratio of one for every 250 occupants. Therefore, a facility that can accommodate 2,000 occupants would be required to have eight trained staff on duty during operation; 40 such trained persons should be on duty if the facility can hold 10,000 occupants.

The crowd managers and crowd manager supervisors are NOT intended to handle crowd-control duties; they are to manage crowds based on a variety of factors and situations.

The Code's chapter on "Operating Features" states: "The training program in crowd management should develop a clear appreciation of factors of space, energy, time, and information, as well as specific crowd management techniques such as metering." It is also required that "employees or attendants of assembly occupancies shall be trained and drilled in the duties they are to perform in case of fire, panic, or other emergency to effect orderly exiting." In addition to crowd management duties, the employees are required to "be instructed in the proper use of portable fire extinguishers and other manual fire suppression equipment where provided."

Prior to the presentation, theaters are also required to make an announcement on the locations of exits or project an image that notifies occupants of the locations of exits to be used in case of a fire or other emergency. This is rarely done, and occupants do not know how to evacuate quickly and orderly.

Investigations of incidents such as the Beverly Hills Supper Club, in Kentucky, and the Summerland Leisure Center on the Isle of Man yielded valuable information on employee response. In both situations, employees thought they could control the fire and did not want to cause "unnecessary" disruption and alarm. This delayed the alarm activation. Employees trained to handle these situations are better able to make the right decision the first time. Theater owners must take a more active role to ensure that their facilities are maintained, including alarm systems, means of egress, and detection systems. They must also ensure that they are meeting all of the Operating Features requirements, including certified crowd manager training and establishing training programs to educate their employees on life safety requirements. Specific emphasis on the areas outlined in the Operating Features section of the Life Safety Code? should be addressed. Include any unusual circumstances or conditions.

Regular facility inspections will help to ensure that these objectives are met. Required recorded or live announcements to audiences on exit locations must be provided. One simple solution is to announce exit procedures in the slide show before the movie.

These requirements may sound simple, but it is necessary to look more closely at what is needed to implement the above requirements. Some knowledge of training techniques and how people learn is important. Those responsible for providing emergency response should develop a written plan and use it as a guide. The basic elements in the plan would be the same. Include also the unique characteristics of each facility. The planning and development needed to achieve an effective training program are too extensive to review and discuss in detail here. There are very good publications, including the SFPE Handbook, second edition, and Introduction to Employee Fire & Life Safety, that offer assistance in this area.

Individual and small chain theater owners may find it more cost-effective to contract this task to others. Larger theater operators may wish to use consultants to develop an in-house program that can be easily duplicated. Providing videos, workbooks, reference materials, and so on to individual theater managers will make it possible to address overall needs and information.

Each location should be encouraged to "customize" this program based on local conditions and requirements. In addition, OSHA requires a written plan for workplaces with more than 10 employees. Theaters with fewer than 10 employees may find it convenient to use a "canned" program, available from vendors or insurance carriers. The document should be customized to meet unique conditions.

Also, theaters must be made aware that having a written plan on a shelf doesn't satisfy the requirement. Employees must be able to demonstrate knowledge of the information contained in the document. Local code enforcement officials must develop specific plans to ensure that these large-assembly occupancies are inspected regularly. Budgetary and staffing shortages may make this difficult. One solution would be to use fire suppression personnel to conduct exit checks and report unsafe conditions to code enforcement personnel.

Many jurisdictions levy fines for false alarms; the fines were instituted because of the inconvenience caused by these "false" alarms. There should also be a policy for levying fines for impaired building life safety features, which is much more critical. In most areas, the only threat to the building management is being written up and being given a considerable length of time to comply. In most situations, it is easy to put off correcting conditions until the last minute. A threat of immediate closure would go a long way to gain compliance.

Those responsible for code enforcement must also be on the lookout for unsafe alterations to buildings. In one privately owned theater, the owners had added a concession stand by building a partition into one of the larger theaters. Although the stand was only about 200 square feet in size, this combustible addition in a modified fire resistive building created a serious hazard. To provide soundproofing to prevent activities in the snack bar area from disrupting the theater patrons, a barrier of six-inch foam insulation was placed on the theater side of the wall. Only cloth curtains covered (and hid) the panels and partition walls. Without any fire barrier, there would be rapid spread over the wall's surface, and the thick smoke from burning plastic insulation would quickly reduce visibility for those exiting and cause them to quickly succumb to products of combustion.

Insurance companies that write coverage on these businesses must demand strict enforcement of the Life Safety Code? requirements. This should be backed up by visits of qualified loss control personnel capable of evaluating adequacy of compliance and who are also a good source of information with regard to meeting code requirements.

The occurrence of a serious incident involving a large movie complex is not an IF question but a WHEN question. Theater owners and management must work with their local fire department to develop preincident plans so that full cooperation can be cultivated through a thorough understanding of the role each is to play. I recommend that the following information pertaining to preplans be incorporated in fire department preplans.

Ticket sales figures will give an idea of how many patrons are in the theater.

If you were responding to an incident, you would want to know the following: How many occupants are in wheelchairs? Is the crowd made up predominantly of youths or adults? Have you worked with the theater to make sure its management knows the type of information you would like to have available in an emergency? You would take a different approach to the incident if you knew the following: management has a written plan to address emergencies in the theater, management has conducted the drills listed in the emergency plan, a plan was in place to maintain the means of egress and inspect emergency equipment, and competent em-ployees have been trained in the use of fire extinguishers on incipient fires.

How complete is your response plan? If you knew that the theater's written plan directs employees to evacuate only and not take any firefighting steps, would your response plan use secondary egress doors as the main access point if the main exit is being used for egress or if it cannot be used? Do you know the locations of the secondary exit doors? Should your plan involve positioning personnel to assist at each of the secondary exits?

Do you know how to access the main alarm panel and PA system?

Detailed drawings of the theater's layout showing exits, alarm equipment, sprinkler controls, etc. can be very helpful. With proper planning, training, maintenance of life safety features, and an understanding of crowd behavior, you can prevent a major disaster. However, it will take much greater effort on the part of all those involved to ensure that theaters are safely operated and incidents properly managed.

SFPE Handbook of Fire Protection Engineering, Second Edition: Section 3, Chapter 12: "Behavioral Response to Fire and Smoke," John L. Bryan; Chapter 13: "Movement of People," Jake Pauls; Chapter 14: "Emergency Movement," Harold E. "Bud" Nelson and Hamish A. MacLennan.

Introduction to Employee Fire & Life Safety, Guy R. Colonna, P.E., editor, National Fire Protection Association, 2001.

DAVID R. BLOSSOM is a loss control consultant with Atlantic Mutual Companies/Atlantic Risk Services, Inc. He has attained the designations of Associate in Loss Control Management, Certified Fire Protection Specialist, and Certified Fire Inspector 1. He currently is vice president of the Central Florida chapter of the American Society of Safety Engineers (ASSE) and is a member of the City of Orlando Fire and Building Code Appeals Board and the Orange County (FL) Fire and Life Safety Code Board of Adjustments and Appeals.

Information on the E-2 nightclub fire in Chicago that occurred on February 17, 2003, was limited at press time. However, preliminary facts indicate that the second floor of the building had only one usable means of egress. Based on this fact, the maximum allowable occupant load for the second floor would have to be fewer than 50.

The "crowd managers" seemed to act in a manner inconsistent with the methods of handling crowds outlined in the Life Safety Code?. There is no initial information to indicate that certified crowd managers were present in the facility at the time of the incident.

There is somewhat of a challenge in that crowd managers would not be necessary if the occupant load was consistent with the allowable number of patrons. If the entire building had an occupant load of fewer than 1,000, there would be no requirement to provide trained crowd managers. Preliminary press reports indicate that between 500 and 1,500 people were in the building at the time. At 1,000, four trained crowd managers would be required to be on duty; an additional two would be required if there were 1,500 people.

There is one certainty: If large places of assembly continue to operate without having personnel properly trained in crowd management and with inadequate exits, these incidents will continue to occur. Of the many factors that contribute to such incidents, common conditions emerge? large crowds, inadequate training, and improper operations or occupancy.

The tragedy that occurred on February 20 in West Warwick, Rhode Island, at The Station nightclub claimed the lives of 99 people. Although this facility did not have to comply with the requirements for Class A places of assembly, there are some strong concerns. It was reported that the majority of the patrons attempted to use the main entrance for exiting the facility. This is consistent with studies that have shown people will use the most familiar route when exiting.

The Life Safety Code? prohibits the use of indoor pyrotechnics unless the local authority approves every display. Of great concern is that, apparently, there are a number of incidents in which these materials are used without approval.

The Department of Labor/OSHA likely will become involved with these incidents because employees were killed or injured.