By Hadley Barndollar
masslive.com
BOSTON — The inspection process for fire sprinklers in Massachusetts relies on a haphazard honor system that can fail the very people it’s meant to protect.
A MassLive investigation following the July fatal fire at Gabriel House — a Fall River assisted living facility where 10 people were killed by a five-alarm blaze — revealed a chain of problems with the state’s oversight of sprinkler systems in buildings:
- Inspections of sprinkler systems depend on an honor code, where fire departments rely on building owners to maintain these critical safety components. This reality extends beyond Massachusetts and is codified in the standards published by the National Fire Protection Association, which are adopted across the country.
- At Gabriel House, a sprinkler failed to activate in a second-story room where the fire started, sources with knowledge of the investigation have told MassLive. A mandated, five-year internal inspection of the sprinkler system was overdue, and several lawsuits claim the system also contained parts that were recalled decades ago.
- There is no centralized tracking of fire code violations in the state, and enforcement is arduous due to strained fire department staffing.
- Meaningful changes to fire safety regulations often only follow tragedy, experts said, such as the fire at Gabriel House, the deadliest in the state in over 40 years. “Fire safety regulations are written in blood,” said Chris Nelson, senior fire protection engineer in the Boston Fire Department’s Fire Prevention Division. “Someone has died because of an incident, and the code is written because someone died.”
- Nearly every fire department in Massachusetts reports being understaffed, undermining public trust and expectations that they can ensure fire safety in buildings across their communities.
These are daunting realities laid bare by the fire that struck Gabriel House on the night of July 13. Under scrutiny by an ongoing state investigation and numerous lawsuits is whether owner Dennis Etzkorn and the fire safety company with which he contracted, Fire Systems Inc., were negligent regarding the building’s sprinkler system.
In the days after the fire, Fall River Fire Chief Jeffrey Bacon was quick — and honest — to speak about weaknesses of the honor system that local fire safety inspections hinge on. The legal responsibility lies with building owners to have their sprinkler systems inspected, maintained and repaired if necessary.
In most cases, fire departments are simply following up to ensure there are no blatant fire code violations, officials said. And enforcement is a scattershot approach entirely dependent on manpower, resources and overall knowledge.
In Massachusetts, there isn’t a central mechanism — such as a statewide database — for pursuing and tracking noncompliant building owners and code violations across municipalities. Instead, violations are maintained by individual fire departments or in housing courts around the state.
Fire codes and standards are written by the National Fire Protection Association (NFPA), the Quincy-based industry nonprofit that publishes more than 300 best practices adopted by states and municipalities across the country. NFPA 25 is the minimum standard governing sprinkler inspections and testing, and it’s the law in Massachusetts.
“All of the codes and standards put the responsibility on the owner,” said Shawn Mahoney, a senior engineer at the National Fire Protection Association. “If you’re going to have a building and going to bring occupants into it, it’s the owner’s responsibility to make sure it’s a safe place for everybody.”
Therein lies an inherent tension — while liability may be on individual property owners, the public expects accountability from fire departments to ensure buildings in their cities and towns are safe to patronize, assemble and live in.
But the system isn’t set up to ensure they can — an unsettling reality in a state where fire department staffing woes are widespread.
Meanwhile, lurking in the background is a broader push to weaken fire safety codes and prevent additional regulations from being enacted. Fire officials contend codes are “under attack” across the country due to anti-regulatory attitudes and the influence of lobbying powers.
Because of that, stronger fire safety laws only happen when people perish in egregious events, they said.
The Cocoanut Grove (1942) and Station Nightclub (2003) fires are infamous in the U.S. for leading to widespread fire safety code reforms for public assembly buildings, such as multiple exits and exit doors that open out rather than in.
This time, state leaders and lawmakers have proclaimed the double-digit deaths at Gabriel House must lead to significant changes.
‘It’s OK until it’s not OK’
Municipal fire inspectors typically rely on building owners to contract with licensed third-party vendors to inspect and maintain their fire safety equipment, including sprinklers.
That documentation is then supposed to be relayed to local fire departments during their annual building inspection process. Some departments require contractors to upload reports directly online, while for others, it’s less clear how they obtain and organize confirmation of inspections and testing.
“That’s where things can get a little difficult,” Mahoney, of the NFPA, said.
Fire safety contractors working on sprinkler systems must be licensed by the state of Massachusetts — both companies and the individuals who work for them. If they aren’t properly licensed, the state can issue cease-and-desist orders that could result in civil or criminal penalties if violated.
During a press conference in July, Bacon, Fall River’s fire chief, said “no fire department in the country” is staffed to the level that they could verify and conduct all inspections themselves.
“We just don’t have the resources to do that,” Bacon said. “We need to rely on the licensed professionals to do those, to do their inspections. And we’re just following up to make sure those are done.”
In Fall River, the fire department’s annual inspection form is a one-page checklist, according to records obtained by MassLive. Department records show three different individuals inspected — and passed — Gabriel House over the last six years. There is a check-off line for sprinklers where inspectors historically marked “FSI,” short for Fire Systems Inc., the contractor, and noted the date they reportedly did their inspection.
A survey of firefighter unions conducted after the Gabriel House fire found that nearly all Massachusetts fire departments fail to meet national standards for staffing fire trucks.
The survey didn’t include fire prevention and inspection staffing, but Mahoney noted that when budget cuts hit fire departments, fire prevention resources are usually slashed first — “before they take people off trucks.”
Bacon said the fire prevention staff in Fall River is “less than half” of what it was when he started with the department 23 years ago.
“Over the course of my career, many of those positions were reassigned back to [fire] suppression due to manpower shortages,” he said. “This presents a significant challenge for chiefs of departments like Fall River because fire prevention plays a critical role in life safety.”
There are six inspectors in Fall River — in addition to the city fire marshal and captain of fire prevention — who handle plan reviews, inspections of high-risk facilities, fire drills at schools, complaint investigations and more.
Fire officials across the state, including those in Boston and Springfield, told MassLive they don’t inspect sprinkler systems themselves, but instead review the documentation provided by contractors who conduct the inspections and testing for building owners.
The protocol sets the stage for things to fall through the cracks, particularly when they aren’t obvious to the naked eye, according to Nelson, of the Boston Fire Department.
He described a situation where the sheer amount of buildings (and the older building stock in New England ), combined with understaffing, makes the endeavor to catch all deficiencies virtually impossible.
“I could walk into most buildings in the country and find something wrong,” Nelson said. “It’s on the honor system because there are millions of buildings in the state of Massachusetts, and the squeaky wheel gets the grease. The small mistakes slip through the cracks where it’s OK until it’s not OK.”
At Gabriel House, Etzkorn previously said he had the sprinkler system visually inspected annually as required, and he regularly passed inspections by the Fall River Fire Department, according to department records. However, he was missing the comprehensive fire-year inspection of his sprinkler system, which ensures that internal parts are functioning, MassLive previously reported.
Etzkorn has said the sprinklers were found to be in working order just five days before the July 13 fire. But that same day, Fire Systems Inc. also alerted Etzkorn to his ongoing failure to obtain the five-year inspection, sources told MassLive.
Bacon said he wasn’t sure municipal fire inspectors would pick up on a missing five-year inspection tag.
“That’s definitely something between the building owner and the sprinkler contractor,” he said.
Data from 2017 to 2021 show the most common reasons for sprinkler failure or ineffectiveness were that the system was either shut off prior to a fire or the water discharge didn’t reach the flames, according to the National Fire Protection Association. Lack of maintenance accounted for less than 10% of failures.
Several lawsuits claim the sprinklers at Gabriel House also had components that were recalled decades before the fire and ultimately never replaced.
An ongoing investigation led by the Bristol County District Attorney’s Office and the state Department of Fire Services, which will determine Gabriel House’s compliance with life safety requirements, has yet to conclude. But officials have determined the fire started accidentally in a second-floor resident’s room, caused by either an electrical or mechanical failure of an oxygen concentrator or the improper use/disposal of smoking materials.
Private attorneys who have filed at least seven lawsuits were on site this week, granted access to the building’s interior for the first time to conduct their own investigations.
Etzkorn, through a spokesperson, did not provide additional comment for this story.
Another example that highlights the cracks in the fire inspection system recently came to light in nearby New Bedford. The New Bedford Light reported that the city’s fire department had not inspected Whaler’s Cove, the city’s lone assisted living facility, for at least 18 years.
The reason, given by local fire officials, was that assisted living facilities are regulated by the state’s Executive Office of Aging and Independence and thus not the fire department’s responsibility.
The state office, however, said it doesn’t conduct fire safety inspections itself and instead defers to local fire departments.
How sprinkler violations are enforced — if they are
When problems are discovered, Massachusetts’ fire code clearly states that enforcement of violations is left up to local fire departments. This has led to a piecemeal approach across the state, as staffing and resources vary drastically from major city departments to all-volunteer staff in small towns.
“It’s local,” said Robert Duval, Northeast regional director for the National Fire Protection Association. “Unfortunately, it can be different in each town or city depending on the jurisdiction. A violation in Springfield, Worcester or Boston, it’s going to be a lot different than way out in the boondocks somewhere.”
Most fire departments are “up against it” in terms of inspections and enforcing violations, Duval said.
“They do the best they can and they do the high-priority stuff (high-occupancy buildings) first,” he said. “It is a challenge around the country.”
The Department of Fire Services can step in, most often when a fire results in a fatality. DFS inspectors, in addition to specific industries and activities under their purview, are also available to help municipalities with code interpretation, inspections and citations.
Sprinkler violations are usually “honest mistakes” rather than willful negligence, most often attributable to “old buildings that get changed over the years or change hands,” Nelson said.
Before it became an assisted living facility in the late 1990s, the Gabriel House building was a motel, for example, built in 1964.
If fire code issues aren’t addressed, local departments and the Department of Fire Services can pursue non-criminal citations filed through housing courts, and criminal charges if warranted.
Non-criminal penalties for violating the fire code are established by state statute, but enforcement is left to the “authority having jurisdiction,” which is most often the local fire department.
According to state law, a person can be fined between $100 and $1,000 for violating a fire code.
The law explicitly states that any person who “wantonly or recklessly violates the state building code or state fire code” and causes serious bodily injury or death to any person can be fined up to $25,000 and face a potential state prison sentence of up to five years.
Capt. Richard Martin, fire marshal for the city of Springfield, said in his experience, building owners “get compliant pretty quickly” when they’re notified of a problem, because they understand liability issues associated with having a sprinkler system violation.
“When a deficiency appears on my desk, it’s normally fixed within 48 hours,” he said.
Like others, Martin said one of the mounting challenges for fire departments is that fire codes are always several years behind new technology. Solar panels and battery storage are examples of developments that fire codes haven’t caught up with, officials said.
In Springfield, there are more than 35,000 structures and roughly seven fire inspectors in the field at any given time. Some sprinkler systems in the city date back to 1929.
“We try to do our best in all cases of high life-hazard facilities, like medical facilities, large apartment buildings, A2 occupancies (places of assembly with food and drink),” Martin said.
Unique in Boston is an entire legal unit within its fire department dedicated to enforcement — they follow up on code violations in the field and take building owners to court if necessary. This is in addition to a staff of fire inspectors.
A Boston property owner typically has 15 days to fix an issue and schedule a new inspection; if they fail to do so, the violation will be escalated to a criminal complaint.
Capt. Robert Kelly, of the Boston Fire Prevention Legal Unit, acknowledged that those resources are far beyond what most communities in the state have. And yet, Boston, too, always seems to be playing catch-up.
“A lot of times things fall through the cracks,” he said. “We’re constantly finding things that haven’t been maintained, and we fix them as we find them. A lot of times (building owners) will work with you, but sometimes they won’t.”
The Boston Fire Department depends on sprinkler system affidavits when it comes to issuing certificates of occupancy, Kelly said.
“That means (building owners) hire an outside third party to sign an affidavit, stamp it with their engineering stamp, saying that they installed the system, that it works like this, and it works as designed,” he said. “We send an inspector out there to make sure that everything’s in place, but we don’t actually do the testing ourselves. That basically falls in line with what most departments do.
“I mean, should Boston have our own sprinkler guy? You know, in my opinion, we probably should. But we rely solely on third-party affidavits,” Kelly said.
Attacks on fire safety codes
A national movement pushing back against fire safety standards has been transpiring in the background for years, with a particular focus on sprinkler requirements in certain residential dwellings.
While fire officials tend to advocate for additional standards and regulations, the homebuilding industry is often pulling the levers to do the opposite — as evidenced by the 48 states across the country that don’t follow a hotly-debated residential sprinkler standard.
Current NFPA codes and standards require sprinklers in new one- and two-family homes and townhouses, as do recent editions of the International Residential Code. However, only two states in the U.S. currently follow this — California and Maryland, as well as the District of Columbia.
In 2016, an investigation by ProPublica and The Post and Courier revealed the homebuilding industry had, at that point, spent millions of dollars in state capitals to block fire sprinkler mandates in new homes.
“Fire sprinklers in single-family homes are illogical for the expense, as homes are already designed with many points of egress and smoke detectors can alert homeowners to fires before they spread,” according to the National Association of Home Builders.
The association claims “emotional arguments” are used when mandates are pushed in state legislatures.
A bill before the Massachusetts Senate this session would allow municipalities to “opt-in” to a one- and two-unit residential dwelling sprinkler requirement solely for new construction. The same effort stalled in the last six legislative sessions, according to the state’s website.
In Massachusetts, the homebuilding industry has historically lobbied against residential fire sprinkler proposals, arguing they raise the cost of housing and that efforts should instead focus on ensuring working fire alarms in all buildings.
According to the Department of Fire Services, more than 70% of all fire-related injuries and deaths in Massachusetts take place at home, yet residential occupancies are the least likely to be protected by fire sprinklers.
“People take safety for granted and don’t understand what actually goes on behind the scenes,” Mahoney said. “Codes and standards are under attack and they have been under attack for a while. They are there for a reason and things are happening in (state) legislatures where people are undermining the process.”
Because of the competing interests that result in stalemates, fire officials say calamities like the deaths at Gabriel House are often the only force that spurs change.
“Things generally don’t get fixed until there’s a tragedy,” said Kelly, of the Boston Fire Department. “It’s always about money. They’re always looking at the budgets. And we can only work with the tools they give us.”
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