An Independent Assessment of the August 13, 2011

Indiana State Fair Collapse IncidentPrepared by

Witt Associates

Presented to theIndiana State Fair Commission

April 12, 2012

Scope

• Status of Preparedness and plans at the ISFC before the Incident, including emergency management and code enforcement

• The events of August 13 leading up to the Collapse and how they compared to plans.

• The events of August 13 in response to the Collapse and how they compared to plans

Methodology

• Reviewed applicable documents• Identified best practices• Interviewed over 100 persons, some multiple times• Assistance of the Indiana Inspector General• Witt Associates does not have subpoena power to compel

interviews under oath• Most agreed to be interviewed, some with legal counsel present• Major Exceptions:

− Mid-America Sound personnel− Sugarland Stage Manager− Limited access to Local 30 personnel

Methodology

• When conducting similar assessments in the past, Witt Associates has found that focusing on areas that offer the greatest potential for improving future public safety performance is the most beneficial for the client.

• This approach can have the effect of emphasizing challenges and negative issues.

• However, Witt Associates also recognizes that there were strengths and successes in the efforts to prepare for the 2011 State Fair; efforts have been made to recognize those when appropriate.

Timeline: Weather Forecasts

• Aug 13th 12:30 PM Storm Prediction Center for Central Indiana issuing advisories

• 4:41 PM NWS Severe Weather Safety Information • 5:57 PM NWS Severe Thunderstorm Watch #777(32 Counties)• 7:04 PM ISFC Public Safety & Logistics Director Ray Allison calls the

NWS and communicates forecast of heavy rain, possible high winds, hail and some lighting

• 8:09 PM Ray Allison communicates forecast of wind gust in excess of 40mph, lightning & the possibility of hail around 9:15

• 8:39 PM NWS Severe Thunderstorm Warning: 60+ mph winds, destructive hail, deadly lightning and very heavy rain.

Timeline: Actions Taken

• 8:00 PM Meeting (attendance, focus of meeting, decision to delay show)

• 8:09 PM ISFC Public Safety Director Ray Allison provides a second weather summary via the auto-notification system; forecast of wind gust in excess of 40mph, lightning & the possibility of hail around 9:15 PM

• 8:10 PM Eric Milby, Lucas Productions speak with Helen Rollens, Sugarland Tour Manager

• 8:15 PM Steve Simmerman, State Fair Board President provides 8:09 PM weather summary to Executive Director Hoye

• 8:15 PM-8:20 PM Mr. Milby and Ms. O’Toole speak with Helen Rollens a second time

• 8:20 PM Executive Director Hoye decides to go along with Act and start show

Timeline: Before Collapse

• 8:20 PM Executive Director Hoye encounter with Capt. Brad Weaver, ISP

• 8:30 PM Mr. Scott Bauer, IATSE is concerned about weather

• 8:30 PM Executive Director Hoye wants guidance from Capt. Weaver and he recommends “…shutting it down”

Timeline: Before Collapse

• 8:39 PM NWS Indianapolis issues a Severe Thunderstorm Warning: 60+ mph winds, destructive hail, deadly lightning and very heavy rain.

• 8:40 PM Executive Director Hoye ask DJ Bob Richards to make announcement

• 8:45 PM Mr. Richards’ makes his announcement

• 8:45 PM Helen Rollins sees lighting and tells Act to hold. Bauer is calling people down from spot light positions

• 8:45 PM Weaver does not agree with DJ Richards announcement; tells Hoye we are calling this and they both walk up to stage to make their own announcement .

• The Structure collapses.

Timeline: Response

• 8:47:02 PM State Trooper on site: “……extrication needed at Grandstand”

• 8:49 PM Indianapolis EMS Cart 2 on site called in to Captain David Kelly in the Joint Operations Center, stating the Grandstand had collapsed;

• 8:54 PM Captain Kelly declares Mass Casualty Incident activating the City’s mass casualty protocols and mobilization of resources

• 9:04 PM EMS reports initial search of the site completed

• 10:05 PM All patients transported to area hospitals

Major Findings

Findings: State of Preparedness

• Although the Indiana State Fair Commission had taken some steps to prepare for an emergency on the Fairgrounds, the overall state of preparedness was not adequate for an event of the size and scope of the Indiana State Fair.

• Developed Emergency Response Plan and Emergency Procedures Guide

• Established Joint Operations Center in 2011 with video from cameras

• Increased Indianapolis Fire Department presence in 2011

• Indianapolis Homeland Security designed and held exercise on July 12, 2011

Findings: State of Preparedness

• Although the Indiana State Fair Commission had taken some steps to prepare for an emergency on the Fairgrounds, the overall state of preparedness was not adequate for an event of the size and scope of the Indiana State Fair. • Emergency response plans and procedures were not fully developed• The plans were not referenced or used on August 13• Multiple agencies were involved in aspects of public safety prior to the

State Fair, although no entity had a clear responsibility for overall public safety

• The plans did not address multi-agency coordination• The State Fair relies on contractors for Grandstand production; they

were not aware of the plans

Findings: State of Preparedness

• Although the Indiana State Fair Commission had taken some steps to prepare for an emergency on the Fairgrounds, the overall state of preparedness was not adequate for an event of the size and scope of the Indiana State Fair. • The ISFC staff were not trained on the Incident Command System (ICS)

• The State Police did have a training plan and schedule to ensure that each employee participated in ICS training; however on August 13, one official on duty had not completed ICS training

• The State Police utilized ICS in response to an event, not for day-to-day operations at the State Fair

Findings: State of Preparedness

• Although the Indiana State Fair Commission had taken some steps to prepare for an emergency on the Fairgrounds, the overall state of preparedness was not adequate for an event of the size and scope of the Indiana State Fair. • Planning for the exercise started 19 months before the State Fair and was

postponed multiple times before held on July 12.• One of the exercise scenarios involved a severe weather incident on the

evening of the Sugarland concert• The participants did not hold a post-exercise discussion to evaluate the

exercise• An After-Action report summarizing lessons learned had not been prepared

when requested on August 19; an Executive Summary was subsequently provided by the City of Indianapolis

• For various reasons, the recommendations from the exercise were not implemented prior to August 13

Findings: State of Preparedness

• The State Fair Commission’s lack of formal protocols regarding decisions to delay, postpone, or cancel the major productions, combined with problematic communications regarding weather forecasts, resulted in an ambiguity of authority and decision-making.

• The ISFC did not use an emergency management protocol to make weather-related decisions

• The ambiguity of authority and lack of a formal protocol created uncertainty and confusion which led to the ISFC’s decision to allow the concert to start at 8:50 PM when the band management said they wanted to play

• The ISFC system to communicate weather forecasts was limited to ISFC staff, and did not include contractors or public safety partners

• Until the chance meeting with Captain Weaver, the ISFC staff’s focus was on the implications of the weather forecast on the timing of the production; the ISFC staff took actions to prepare for an evacuation after Captain Weaver expressed concern.

Findings: Response

• The response to the collapse of the Structure was successful.

• Audience members joined those involved in the production in lifting the structure to free the victims and offer solace.

• Quick thinking and action by individuals facilitated the response.

• All patients requiring hospitalization were transported to the hospitals in under 80 minutes from the time of the collapse.

Findings: Codes

• The type of structure that collapsed was exempt from most aspects of Indiana building code regulation.

• The State Fair Commission had the appropriate certificates from the Division of Building and Fire Safety

• The Division of Building and Fire Safety completed the required inspections.

Findings: Codes

• A survey conducted as a part of this assessment found inconsistent regulation of these types of structures across the country, even as stage productions are becoming more elaborate and complex.

• Indiana had been similar to other states in the regulation and inspection of temporary membrane-covered lattice tower and truss structures

• Regulation of such structures is stronger in larger cities 

Recommendations

Recommendation 1: Planning

1. The Indiana State Fair Commission (ISFC) should develop a comprehensive emergency preparedness plan for year-round operations at the State Fairgrounds, with a specific annex addressing production, public safety, and other operational issues during the 17-day State Fair.

Recommendation 2: Protocols

2. The ISFC should develop formal protocols for delaying, postponing, or canceling major productions. A single ISFC executive official should have the designated authority to make the final decision on the status of a show.

Recommendation 3: Incident Command System

• The ISFC should adopt the Incident Command System (ICS) as the standard command and control management system for all events at the Fairgrounds; for larger events, such as the 17-day State Fair, Witt Associates recommends that a special event planning team be developed to coordinate and manage pre-event, event and post-event operations;

Recommendation 4: Public Safety Position

• The ISFC should develop a position responsible for public safety that reports directly to the Executive Director.

Recommendation 5: Enhance Weather Awareness

• The ISFC should deploy a private weather forecasting service during the State Fair.

Recommendation 6: Mass Casualty Plan

• The Indianapolis Department of Public Safety should develop a specific Mass Casualty Incident Plan for the State Fair.

Recommendation 7: Code Regulation

• The State of Indiana should adopt and implement stringent regulation of the type of structure that collapsed during the State Fair.

Recommendation 8: Strengthen Codes Nationally

• National model building and fire codes should be strengthened to address the increased complexity of such structures.

Actions Taken Since the Collapse Incident

• The Indiana State Fair Commission retained a public safety consulting firm

• More recently the Commission has filled a newly created emergency management officer position

• Commission contract procedures have been modified• The Commission has contracted with a private weather forecasting

service

• SB 273