Open Letter to Mr. Yuri Luzhkov, Mayor of Moscow

Some Background

I’ve just returned from a two-week trip to Russia and am now sorting through reflections about what I saw and heard, touched and felt.  There was a purpose in my trip.  I’m a professor of management and human resources as well as international business in the College of Business at California State Polytechnic University, Pomona.  For the past five years I’ve been teaching one-quarter course per year on doing business with Russia; however, I had never previously traveled there and felt I should do so to be credible in my instruction.  Aided by university grant funding I, along with my family, took a two week river boat cruise which involved three days each of ground tours and visits at St. Petersburg and Moscow. The Russia course I teach is themed on political risk, which involves the assessment of risk vs. opportunities of direct foreign investment into the country.  Political risk entails political, economic and business issues analysis and management. The main purpose of my trip was to learn about the historical aspects of the country and get a feel for the operational environment.  Even with this background I was determined to not prejudge the situation and to take it all in as it came. I was not attempting nor intending to identify any risks at any level.

Risk Issues Emerge

In the course of the tour we visited a number of historical sites such as churches, monasteries, governmental buildings and venues involving public performances—all normal tourist activity.

One of the more memorable events we took in was the Moscow Circus. The various ice skating events were outstanding and the high wire aerials were awesome. Also, I was surprised to see various “tamed” wild animals in the lobby for the public to view and touch.  The price of admission was well worth it in terms of performance. Actually, getting into the building was a chore because there was only one entry door open where an attendant was taking the tickets.  However, it was upon exiting the building after the performance where an operational risk factor came into my consciousness instantly.

The only exit available to the public was via the doors that we had entered.  The two doorways on the left were locked shut and could not be opened.  Furthermore, the doors opened inward and did not have any emergency evacuation hardware such as “panic bars” and there were no attendants at those doors at the end of the performance.  I believe that the two doorways on the right side were also blocked shut and I saw no other egress locations.  It really dawned on me then just how really dangerously unsafe the building was for exiting especially if a panic situation was in existence. It took a while for the building to empty out, as it had been a packed house of both the locals and tourists.

After that I became more aware of building safety features.  The next day we visited the Armoury within the Kremlin.  Tour groups such as ours entered through a narrow passageway through a Kremlin Wall into the lobby area, which was the entry point to the exhibits upstairs.  The whole area was loaded with visitors and it became apparent that the only way out of the area was through the narrow passageway we had entered.  The only other possible egress point I noted would have been through a doorway at the base of the marble staircase near the entry point.  It was not marked as an exit and there appeared to be no facilitation there for it. Later that evening we attended a superb ballet performance of The Corsair.  There again, I became aware of the hazardous building situation.  The exits as they existed were in Russian language and poorly marked at that.

We all had entered the building through one main door while the doors on either side were not open.  Upon exiting only one side of the door on each of the three doorways were open.  The other side of each of the doors was locked shut and egress was slow into the street.  Again, the doors opened inwardly and I saw no emergency hardware on the doors.

It was during the second half of the performance that I began wondering how I would escape from the building should an emergency arise.  Would it be through the stage area?

Could I be assured that any other emergency exits would be free and clear for egress?  It was a scary thought that detracted me from watching and enjoying the ballet performance fully.

Back on board the cruise boat I compared notes with fellow tourists and we shared our observations and mutual concerns.  In all the public places we visited in St. Petersburg and Moscow there was control at the entry points and lack of rapid egress from those facilities.

Doing Some Research Back Home

Back home I began to research and facts and circumstances of some of the more disastrous situations in US history that had a relationship to the risks/hazards that I had just seen in Russia and that could be valuable lessons learned for Russian authorities (1):

December 30, 1903: Chicago’s Iroquois Theater fire: A standing room only audience estimated at 2,000 people crowded the theater.  At some point during the performance a spotlight overheated and soon fire burst onto the stage area. Panic set in and the audience made a mad dash for the exits.  The cause of death for many came from the terrible smoke and flames; however, most had been trampled and crushed in the rush to leave the hall and 602 people total perished in this disaster.  The investigation discovered the following protective features were missing at the theater:

* Blocked asbestos curtains
* Installed ventilators were not in operation.
* Exits not properly marked.
* Exits blocked with draperies, wood and glass doors.
* No installed fire alarm system.
* No fire protection devises such as extinguishers and standpipes.
* No automatic sprinklers in the stage area, even though it was a municipal requirement.

March 25, 1911:  Triangle Shirtwaist Company fire: Within minutes a volatile fire erupted that resulted in 148 deaths from this ninth story factory.  Fire inspections and precautions were very weak at the time. As word of the fire soon began to pass through the workers jammed into the loft building.  Workers surging through the exits were met with a wall of fire racing up the stairs.  Others moved toward another exit, but were blocked by a locked door.  When they were finally able to force it, they found that it opened inward.  By this time, there were so many people pushing toward the door that the door was jammed shut; people began piling up at this point. A number of young girls faced with the prospect of a horrible death by fire chose to leap to their deaths from windows on the eight and ninth floors.

November 8, 1942: Cocoanut Grove Nightclub: It was a one-story facility built during the Prohibition era of the 1920s and was a popular site, constantly jammed with customers.

The official occupancy was 600; however, on the night of the disaster the estimated attendance was about 1,000. A small fire started in the basement lounge and quickly raced throughout the area.  The crowd surged toward the known exit and it quickly became jammed.  Fire department sources listed nearly 200 people as being found in this area alone.  In all, fire, smoke, heat or the effects of being trampled killed 491 people.

The lessons learned from this fire were as follows:

* Combustible materials must not be used for decorations or in building components.
* Occupancy limit requirements should be strictly enforced.
* Exits need to be kept clear of obstructions and clearly marked.
* Public assembly buildings must have two separate means of egress, remote from each other.
* Exit doors should swing in the direction of egress traffic flow.

May 27, 1977: The Beverly Hills Supper Club, Southgate, Kentucky: The building was built in 1937 and was remodeled in 1970.  The facility was crowded with a concert performance and employees discovered a fire early in the evening. Employees attempted to distinguish the fire themselves and there was 15-minute delay in notifying the fire department.  The first indication to the public that there was a problem was when a large number of people suddenly began leaving.  164 people perished in this fire and the following causes were identified:

* No installed fire protection.
* No fire safety plan.
* Blocked exits
* Crowd in excess of the occupancy load.
* Inadequate exit capacity.
* Combustible wall coverings.
* Toxic smoke generated by burning electrical wire.

Other disasters involving fires and large loss of life include the 1990 Happy Land Social Club and the 1998 Gothenburg Dance Hall Fire in Sweden. Both fires suffered from similar deficiencies as the others cited above.

What Can or Should Be Done?

Based on my recent experiences in public assembly venues in Russia of building safety concerns and recounts of US fire disasters and their causes, I request that you, the Mayor of Moscow, as well as other governmental and private sector officials undertake rapid action on probable deficiencies in building safety through comprehensive audits and inspections.  This can involve short-term, instant fixes such as municipal orders to make sure all exits are fully open for egress at all public assembly venues to more long-term fixes such as reconstruction of exits to make sure they comply with international building safety standards.  Study and recommendations should also extend to heritage buildings.

With risks there are also opportunities.  Some businesses can befit from rework based on new building safety directions and contracts as well as doing the inspections and audits. But the greatest opportunity is the
precluding of loss of life for both the local citizenry as well as tourists. Even if one life is saved as a result of this letter the effort was worth it. Loss of life in these instances could entail massive lawsuits as well as possible criminal sanctions based on gross negligence in knowingly operating an unsafe facility.  I can guarantee you that with the litigious nature of American society loss of American tourist lives would involve heavy duty lawsuits on involving a lawyer’s shark fest that you would never, ever forget.

Adverse publicity from a major disaster involving tourists would linger for quite a while. Tourism appears to be a major source of economic vitality in Moscow as well as St. Petersburg. Your City’s Homepage states that Moscow aspires to become a world-class tourist destination point. This worthy goal should not be damaged by a fact or perception that public assembly facilities are death traps.

May I suggest some required reading for your city’s government.  New Zealand colleague Dr. Patrick J. Caragata has written a very insightful book: Business Early Warning Systems (Butterworths of New Zealand, 1999). There he points out that “management of risk should not be a retrospective issue, but rather one of forecasting the probability of possible future problems and preventing them before they can happen.”  In his book he concludes that there are eight major footsteps to business disasters (I’ll cover the ones that apply here): Poor quality information, weak risk standards, ignoring risk thresholds, ignoring early warning signs and inadequate advance screening (2)

Let’s not wait for a disaster to happen to get the message and make the necessary changes after the fact.   Effective risk assessors as well as public and private officials should always strive to prevent problems rather than solve them after the fact.

I look forward to visiting Moscow again with the feeling that it is indeed a world-class tourist destination point.  Best wishes in your endeavors!

(1)   Much of this section is based on content on The American Fire Service website.

(2)   Also please view http://www.fletcherfcm.com/2001/book.php3 for further information on his book.

Dr. Jerry Rogers may be reached via email at California State Polytechnic
University, Pomona, through his university website at: http://www.csupomona.edu/~pgrogers

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