Thursday, March 31, 2011

Provo Tabernacle Fire Officially Caused By Human Error; 300-Watt Lamp Placed Too Close To Wooden Speaker Enclosure

On March 31st, 2011, the Provo Fire Department released a 135-page report on the December 17th, 2010 fire at the Provo Tabernacle, and they concluded that an energized 300-watt lamp placed too close to a wooden speaker enclosure was the primary cause. But the report noted other sources of human error, to include failure to recognize unsafe lighting conditions and lack of urgency to report signs of a fire. Primary media stories include the Deseret News, the Salt Lake Tribune, and KSL Channel 5; however, the shorter Provo Daily Herald story identifies both the company and the technician who installed the lamp. You can also read a shorter 14-page executive summary of the Fire Department's report HERE.

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A grass-roots campaign to get the Provo Tabernacle rebuilt is still active:

The Primary Cause: A series of lights had been placed inside the Tabernacle on December 15th, 2010 just before a December 16th rehearsal of composer Lex de Azevedo's "Gloria" by 200 singers and musicians, accompanied by a BYU film crew. The 300-watt lamp triggering the blaze had been installed by technician Jeremy Ostler of Trax Lighting and AV on a truss in the attic too close to a wooden speaker box, despite the fact that original lighting plans did not originally call for it. Ostler allegedly added the truss because he felt it was necessary to adequately illuminate the performers. The packaging for the lamp used in the fixture of origin, a Sylvania model 300BR40/FL clearly states: “Do not allow paper or other flammable or heat sensitive materials within 12 inches of the glass bulb during operation,'” according to the report. From the 14-page executive summary comes this description (after the jump):

On Wednesday December 15th, 2010 Trax Lighting and AV arrived at the Tabernacle to begin to set up for the production. They were somewhat familiar with the structure because they attended the “tech shoot” in November and were shown around by the building coordinator, Robert Rasmussen... According to the producer Tyler Weston and the lighting technician, Jeremy Ostler, the original plan did not include a suspended lighting truss. Jeremy Ostler stated that he added the suspended truss because he did not feel that he could adequately illuminate the performers without the suspended truss. At some point on the decision was made to suspend the lighting truss. Mr. Ostler made access into the attic to suspend the lighting truss. It is unclear how he accessed the attic. He first stated that Bob Rasmussen had let him in; however, he later stated that he used the keys on his key ring until one of them opened the door, and finally he stated that the door was not secured. Mr. Rasmussen disputes that he allowed access or that the door was unlocked.

Mr. Ostler brought two 6 foot sections of triangular aluminum truss, a yellow 10 gauge extension cord, and a nylon rope into the attic to suspend the truss. Mr. Ostler states that he set aside the two east incandescent light fixtures and placed the triangular trusses over the 2 x 8 wooden boxes and attached the chains to the trusses. When asked about the status of the lamps in those fixtures Ostler stated that the fixtures were not connected to any wiring. He later stated that they were attached with an electrical tether using wire nuts. Mr. Ostler never indicated that he removed the lamps from the fixtures he removed to suspend the lighting truss. Mr. Ostler stated that he placed the light fixtures onto the plywood deck. Mr. Ostler stated that there were no lamps in the fixtures although he does not say how he reached that conclusion. He also stated, in a subsequent interview that the fixtures were “light as a feather” so there would not have been lamps in them. Mr. Rasmussen, as well as Pete Crane and David Knecht all state that there were lamps in all of the eight incandescent lamps and all were functioning except for the northeast fixture that had a burned out bulb. It should be noted that the eight incandescent light fixtures were not energized on December 15.

On Thursday, December 16th, 2010 Mr. Ostler returned to the Tabernacle to complete the lighting set up. He suspended the lighting truss, set up his dimmer racks, and used one of his dimmer boxes to connect into the Tabernacles eight fixture incandescent dimmable lights. He stated that the lighting truss was suspended by mid-afternoon. It should be noted here that all of the production lighting was powered by a small trailer mounted generator located in the south side of the west parking lot. According to Mr. Ostler, the only house power used by Trax Lighting was the power drawn from an attic outlet used to power the chain crawlers.

Other Contributing Factors:

-- Failure to recognize initial signs of a problem: A camera operator told investigators he smelled smoke as early as 9:30 p.m., but he and another camera operator attributed it to the hot lights.

-- Failure to react correctly to the internal alarm: At 1:10 A.M., a security guard heard an audible alarm that he took to be an intruder alarm. When he reached the alarm control panel, he did not recognize it as a fire alarm control panel. So he failed to either see or follow the first instruction (on the panel), which states, "What to Do: Evacuate the building and notify the fire department”.

-- Excessive false alerts of the alarm system caused uncertainty and apathy: The fire alarm system was having problems, most recently failing an inspection and testing on December 2nd, 2010. The most frequent location of false alarms reported were in the northwest turret and the attic, where the fire originated.

In summary, a repeatedly malfunctioning alarm system caused a loss of vigilance attributed to skepticism and apathy. Initial reports of a smoke smell were dismissed, and the first internal alarm blown off as an alarm malfunction as a result. This was compounded by an overeager technician who sought to provide the most professional lighting display possible, and who deviated spontaneously from the lighting plan on the fly out of a desire for maximum professionalism. He did not take the warning instructions for deployment of the lamp seriously enough.

Official LDS Church Reaction: Church officials said they still have not yet decided whether to rebuild the tabernacle. “The Provo Tabernacle was a meaningful part of Church history and the Provo community. The recent fire is a tragedy for all who loved the building and its link to our pioneer past. Church leaders continue to evaluate and explore options for the building and we will make those plans known as soon as they are available,” said church spokesman Scott Trotter.

The LDS Church's reluctance to make a commitment one way or the other is understandable at this point, but their reluctance may inhibit fund-raising efforts launched by a Facebook group organized to rebuild the Provo Tabernacle.

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