AN ANALYSIS OF THE MANAGEMENT OF THE KISS NIGHT CLUB FIRE

INCIDENT IN BRAZIL

University of Hertfordshire

Abstract

The Kiss nightclub in the city of Santa Maria, Rio Grande do Sul, Brazil came under fire during

a band performance by Gurizada Fandangueira, when one of the band members ignited a

pyrotechnic device while performing on stage, which ignited the flammable sound proofing foam

on the ceiling. The overcrowded building was in flames in a few minutes, leading to a stampede

of people trying to escape from the singular exit door available. The incident led to the death of

about 245 people and the injury of over 630 people, making it the third-deadliest nightclub fire in

history. The paper looks at the circumstances surrounding the event and the lack of

communication in relation to planning and crowd control.

Key Words

Crowd, Fire, Pyrotechnics, Kiss Nightclub, Emergency Exit, Crowd Control

Introduction

Crowds, or large concentrations of people, occur frequently in modern society. And under

normal circumstances are not problematic. But when saftety protocols are breached, there could

be disaster (Balcik, et al., 2010). This paper seeks to investigate the tragic events that occurred on

Sunday 27th January, 2013 in the Kiss night club located at Santa Maria (Rio Grande do Sul),

Brazil, while one of the country band called Gurizada Fandangueira was performing. The fire

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was caused when a member of the band ignited a pyrotechnic device (similar to a signaling flare)

while performing on stage. The flare then ignited flammable acoustic foam in the ceiling, killing

245 people and injuring at least 630 others. It is the second most-devastating fire disaster in the

history of Brazil—surpassed only by the Niterói circus fire of December 1961, which killed 503

people in Niterói, and the deadliest nightclub fire since the December 2000 fire that killed 309

people in Luoyang, China (Knauss, 2007). It is also the third-deadliest nightclub fire in history,

behind the Luoyang Christmas fire and the Cocoanut Grove fire in 1942 (Wikipedia). Apart from

the fire, lack of exit doors, exit signs and over-crowding contributed to the high death toll. The

inadequate design of building, inappropriate planning stages and crowd management will be

discussed during this analysis.

PRE-EVENT CONTEXT

The Kiss night club was built in the 1950s, but then was used as a warehouse. Then in 2003, it

was used as a small college, but later underwent significant refurbishment into a night club and

remained so until the fire incident in 2013. The first fire license for the club was issued in August

2009 after receipt of a fire safety strategy for the nightclub at commencement of the business.

The last inspection took place in August 2011; which was already expired as at the time of the

fire incident. It stated that the club had two emergency exits, making it 3 exits; one main and two

emergency, and had sufficient extinguishers, licensed for 691 people. But the reality of things

was that as at the night of the event only one exit was available as the others were locked. Also,

although the club owner insists that there were only 600 to 700 people in the club at the time of

the incident, the band’s guitarist told media that there were between 1200 and 1300 people in the

club; which was far higher than the expected population within the building, and the police have

given the same estimate (Dal Ponte, et al., 2015).

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The kiss night club was a ground floor building with a floor area of about 650m 2. The maximum

travel distance to the front door is reported as being 32m, while the only available exit has a

width of 3m. The maximum legal occupancy of the club is reported as being 691 people. The

number of exits depends on occupancy and size of building (> or < 750 m2), no requirements for

remoteness – this building required 2 exits. Exit sizing based on unit width/100 people (5.5

mm/person) i.e., 3.8 m. Travel distance depends on 1 or more exits and sprinkler/no sprinkler) –

in this case 40m (Antonelo, 2013).

The fire was caused by the use of illegal pyrotechnics meant for outdoor events by members of

the Gurizada Fandangueira band. The flare was cheap ($1.25, as against the $35 for the one

meant for indoor) and can reach 4m above according to the Brazilian Association of

Pyrotechnics). It ignited the flammable sound proofing foam on ceiling. The flammable sound

proofing foam covering on the club’s ceiling which has been described as ‘solid gasoline’ foam

acted as an accelerant to the fire. Overcrowding of the club with insufficient fire exits and escape

routes caused the blockage of people which further hindered the emergency exit process.

DURING THE EVENT

The first thing in crowd management is understanding what makes a crowd. That understanding

will help the crowd manager to put in place certain measures once a crowd is attained. A key

model which can be used to explain the ideology behind most crowd disasters is the FIST model

which stands for Force, Information, Space and Time.

In the early morning hours of 27 January 2013, a fire broke out while students from the Federal

University of Santa Maria (UFSM) were holding a freshers' ball. Most of the victims were

between 18 and 30 years old (Wikipedia).

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Brazilian police stated that the fire began when the band Gurizada Fandangueira ignited a

pyrotechnic device (similar to a signaling flare) while performing on stage. [13] The flare then

ignited flammable acoustic foam in the ceiling. According to a survivor, Leonardo Da Rosa, “the

stage that started burning, so people started running, trying to get out of the club, but they

couldn’t, because the smoke spreads very quickly, in a matter of seconds.” This was confirmed

by another 23 years old survivor, Luana Santos Silva, who said that, “We looked up at the ceiling

in front of the stage and it was catching fire. My sister grabbed me and dragged me out on the

ground…The exit was a small door for lots of people to come out by” (Siang, 2013). According

to Still (2000), people typically move according to the principle of ‘least effort’ aiming to

minimize time and cost, avoiding congestion and maximize their speed. As this exit was the only

available exit, it was normal for everyone to rush toward it. Unfortunately, this led to

unimaginable force building up around the door and causing congestion (Natalia, 2018)

According to the authorities, other reasons for the high death toll include the lack of emergency

exits (the only access in and out of the building was the front door) and the fact that the number

of people inside exceeded the maximum capacity by hundreds (CNN, 2013). The space within

the Kiss night club building was overwhelmed by the crowd as it surpassed the expected number

of people, making it impossible for a smooth evacuation of people during the fire (Souza and De

Castro Brombilla, 2014).

Access to information is important in any exit attempt from a distressed building. But in this case

there was no exit sign within the building, neither was clear signs to indicate different

compartments. About 90% of the victims succumbed to smoke inhalation (Shasta, 2013). Many

people died as they either tried to hide in bathrooms or, in panic mistook them for exits. At least

180 bodies were removed from the bathrooms. More than 150 were injured by the crush at the

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front door and the rapidly accumulating smoke within the nightclub. According to Santa Maria,

Fire Department Chief, COL Guido Pedroso de Melo, “People started panicking and ended up

treading on each other…. (Firefighters) had trouble getting inside the KISS nightclub because

there was a barrier of bodies blocking the entrance.” 14 injuries were attributed to severe burns

caused by flames, with eight victims succumbing to their injuries in the days and weeks

following the incident. More than 90 people were hospitalized (Shasta, 2013).

Colonel Guido Pedroso de Melo of the Rio Grande do Sul Fire Department stated that the club's

front door was locked. De Melo told CNN: "This overcrowding made it difficult for people to

leave, and according to the information we have, the security guards at first trapped the victims

inside, because they had not paid their bar bill.” For some minutes the security guards who were

positioned towards the door thought that the fire alarm raised by the people was a false alarm;

and attempt to leave the night club without paying their bar bill, and so tried to stop them from

leaving the building, until they realized that it was real. Unfortunately, attempts by the one of

the band singers and a security guard to extinguish the fire failed when the extinguisher they

used did not work, a witness said (Shasta, 2013).

POST EVENT

After the fire, it was discovered that about 245 were killed, at least 630 people were injured,

while some people however survived (Brooks, 2014). From reports, about 50% of those that died

were students (Souza and De Castro Brombilla, 2014).

Investigation into the incident led to the arrest of two co-owners of the nightclub and two

members of the band for questioning by police (Leonardo, 2013). One of the owners of the

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nightclub tried to commit suicide while still being treated at the hospital; however, one of the

police officers guarding his room noticed the attempt and intervened (Albuquerque et al., 2013)

The state fire department found that the premises did not have enough emergency exits and was

not authorized to use fireworks. The fire department, however, did issue a permit for the club to

operate. The permit stated that the club had two emergency exits. This was another case of false

information contributing to the high fatality of the fire incident. The fact that false information

was used by the club and approved by the fire department resulted in a state investigation of the

authorities responsible for supervising the nightclub, including the city hall and the fire

department itself. It was also reported that the fire extinguishers in the club may have been

artificial or were disabled at the time (Tahiame and Porto, 2013)

On 30 January, the nightclub's owner shifted the blame to "the whole country", as well as to

architects and inspectors who were commissioned with ensuring the building's safety, according

to his lawyer. By that time, the death toll was at least 235. The next day, officials inspected and

closed more than 58 nightlife spots around the country as part of a crackdown on unsafe public

spaces (Wikipedia).

To avoid a future occurrence of such event and improve fire safety, the state of Rio Grande do

Sul published new guidelines (December 2013) based on guidelines already adopted by other

states e.g. Sao Paolo. The guideline addressed the use of fire retardant materials, the use of

sprinklers and smoke control. There were also pressure groups that were calling for fire safety

engineering but had concerns over the state’s ability to adopt technical innovations. Smoke

control for pressurized stairs (NBR 14880: 2014) was later published and became officially valid

for use on 8th February 2014 (Karen, 2013).

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CONCLUSION

In summary of the fire incident that occurred on Sunday 27th January, 2013 in the Kiss night club

located at Santa Maria (Rio Grande do Sul), Brazil, it is evident that there were insufficient risk

analysis of the event and crowd control, absence of essential fire safety systems such as alarms

and lights and there was virtually no means of communication to enable the attendees exit the

building without a security block or stampede which both occurred in this incident. The over-

crowded space and a single exit door made it easy for a stampede to occur leading to more

deaths.

As a recommendation for safety, officials in Brazil will have to strengthen their fire and building

codes, plus vigorous enforcement of those codes, especially occupant loads. One of the most

important code requirements is crowd managers. Every crowded building should have a crowd

manager who should be trained, as well as other employees within the building. The authorities

need to include aggressive enforcement of pyrotechnics, built in fire protection (sprinklers),

crowd managers, public announcements, life safety evaluations. However everyone must become

active in making these clubs safe, and this includes you, the participant. According to John

Barylick, author of Killer Show: The Station Nightclub Fire, America’s Deadliest Rock Concert

said it best: “one of the most important lessons I learned from my experience in this case was

that we all need to be aware that we cannot count on bands, concert promoters, club owners,

bouncers—or even fire officials—to ensure our safety. We need to be our own best fire

marshals. To be safe, go with your gut. If it feels wrong, or dangerous, leave. No show is worth

your life” (James, 2013).

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