Investigation Guidelines

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Follow-Up Activities for Product-Related Injuries

Investigation Guidelines

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Investigation Guideline
Appendix 15
September 2005

MATTRESS AND BEDDING FIRES
I. INTRODUCTION
The purpose of this investigation is to learn more about the characteristics of the mattresses and
bedding that are ignited in fires and the circumstances under which mattress/bedding fires
occur. We are interested in any features or situations that are relevant to understanding the
cause of the fire and how the mattress and bedding behaved in the fire.
Please remember that no guideline can cover all the pertinent factors that may apply to a
particular incident. Include an explanation of any relevant factors in your narrative, even when
these factors have not been specifically mentioned in the guideline.
A. Background Information
Fires in which a mattress or bedding article is the first item to ignite are responsible for a
major portion of the nation’s fire casualties. Mattress fires were of sufficient concern in the
early 1970s to justify the issuance of a mandatory standard intended to address cigarette
ignition (Title 16 CFR 1632). The Standard became effective in 1973. Still, as recently as 2002,
there remained about 220 lives lost in such fires. Another 220 fire deaths were associated with
open flame and other ignition sources. Among the categories of consumer products within the
jurisdiction of the CPSC, mattress and bedding fires were one of the leading causes of civilian
injury in 2002 and second only to upholstered furniture in the number of civilian deaths.
The sleep products industry recently has funded extensive testing on mattresses and bedding.
One of the results of that testing has been a change in focus from prevention of ignition to
limitation of the fuel load, the amount of combustible material present, which is thought to
reduce the most severe effects of a fire. This change has resulted in renewed emphasis on
learning the role of the bedding being used.
A Notice of Proposed Rulemaking was published on January 13, 2005 to address fires ignited
by small open flames. Also on January 13, 2005 an Advance Notice of Proposed Rulemaking
was published to address open flame ignition of bedclothes. We are interested in obtaining
information on all mattress and bedding fires regardless of ignition source since it is thought
that the test criteria being considered may be effective for some cigarette- ignited fires as well.
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B. Product Descriptions
The Standard defines a mattress as ticking that is filled with a resilient material used alone or in
combination with other products intended for sleeping upon. This definition includes, but is not
limited to, adult mattresses, youth mattresses, crib mattresses including portable crib
mattresses, bunk bed mattresses, futons, waterbeds and air mattresses which contain upholstery
material between the ticking and the mattress core, and any detachable mattresses used in any
item of upholstered furniture such as convertible sofa bed mattresses, corner group mattresses,
day bed mattresses, roll away bed mattresses, high risers, and trundle bed mattresses. Mattress
foundations are excluded from the Standard but can be a contributor to open flame hazard. The
term "bedding" includes items such as pillows, sheets, blankets, comforters, bedspreads, etc. A
mattress pad is a thin, flat mat or cushion, and/or ticking filled with resilient material for use on
top of a mattress and must meet the Standard. This definition includes, but is not limited to,
absorbent mattress pads, flat decubitus pads, and convoluted foam pads that are totally enclosed
in ticking.
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The following are common terms used to describe mattress and mattress pad construction:
Ticking – the outermost layer of fabric or related material that encloses the core and
upholstery materials of a mattress or mattress pad. A mattress ticking may consist of
several layers of fabric or related materials quilted together.
Core – the main support system that may be present in a mattress, such as springs, foam,
hair block, water bladder, air bladder, or resilient filling.
Upholstery material – all material, either loose or attached, between the mattress or
mattress pad ticking and the core of a mattress, if a core is present.
Tape edge (edge) – the seam or border edge of a mattress or mattress pad.
Quilted – stitched with thread or by fusion through the ticking and one or more layers of
upholstery material.
Tufted – buttoned or laced through the ticking and upholstery material and/or core, or
having the ticking and upholstery material and/or core drawn together at intervals by any
other method which produces a series of depressions on the surface.
Surface – one side of a mattress or mattress pad which is intended for sleeping upon.

C. Specific Items of Interest
Investigators will need to establish and maintain a strong liaison with local fire departments to
assure timely follow-up investigations. Inspection of products involved will be extremely
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Investigation Guideline
important. Samples will not be collected. However, it is essential that investigators thoroughly
document the construction of the mattress involved if at all possible.
Issues of particular interest include:
• Identification of the major ignition sources in all mattress/bedding fires and the hazard
scenarios involved
• The size and type of mattress construction in which fires are occurring
• When the mattress was manufactured, specifically, before or after the Standard went into
effect (see page 6)
• Ignition sequence, specifically, what item or items ignited first
• The types and role of bedding in these fires; how and to what extent these items
contributed to the ignition of the mattress
The specific involvement of bedding items has been very difficult to establish from past
studies. Thorough identification of the products involved, sequence of ignition, and burning
characteristics will be very important.
Also important is the extent of the flame and smoke damage beyond the room of origin as well
as the victim location in relation to the origin of ignition. Be sure to obtain a copy of the fire
incident report, and any other available reports of the incident (e.g., police).
Include an explanation of any relevant factors in your narrative, even if we have not
specifically mentioned them in the guideline.

D. Headquarters Contacts
David Miller, EPHA, 301-504-7323, ext. 1275, [email protected]
Allyson Tenney, ESME, 301-504-0494, ext. 1289, [email protected]

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II. INSTRUCTIONS FOR COLLECTING SPECIFIC INFORMATION
A. Synopsis
Write a synopsis of the sequence of events that occurred prior to, during, and subsequent to the
fire. Specify the source of the ignition, the products involved, the estimated property loss
(dollar amount), and the nature of all injuries and deaths.
B. Description of the Incident Environment
PRE- INCIDENT: Include

in this portion of the narrative the sequence of events that occurred
prior to the fire (events that led up to the fire). Describe the general activities of the household
that day. Determine if there was any change in the household routine before the fire started.
Specify activity and location of occupants, particularly each victim, and the person responsible
for the fire, at the time of the incident.
INCIDENT : Describe

in the narrative how the fire occurred. Describe the ignition source and
sequence of ignition, as well as the sequence and extent of flame spread, flame damage, and
extent of smoke damage. Describe extent of damage to mattress and all bedding items. Include
a description of other major furnishings in the room that ignited.
POST-INCIDENT:

Describe conditions that may have contributed to the fire ignition or spread
(e.g., crowded or cluttered room, children playing, etc.). Indicate presence/absence of detectors
(smoke, heat, or CO), location of smoke alarm closest to the fire, and whether it operated. If it
did not operate (but was powered and smoke reached it), indicate manufacturer and model
number.
C. Description of Interaction Between Injured Person(s) and Product
Report the nature and extent of injur y and treatment, as well as age, sex, and long term
prognosis for the victim(s). Report the victim’s location when he/she received the injury in
relation to the area of the fire’s origin as well as the activity of the victim(s) at the time of
death or injury. Indicate any competence-reducing factors (e.g., impaired vision, physical
handicaps, medication, narcotics, alcohol, perception of hazard, how victim was clothed, etc.)
that would tend to contribute to the cause of, or hinder escape from, the fire.

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Determine the source of ignition and describe in detail how ignition occurred (e.g., discarded
smoking materials, victim falling asleep with a cigarette, heater left too close to the bed,
children playing with matches, etc.). If the ignition source cannot be determined, indicate if
anyone in the residence had smoked within several hours prior to the fire and where they had
disposed of the cigarette. If a heater was involved, specify how close it was to the item first
ignited.
If the fire resulted from child's play, describe the ignition source involved; e.g., multipurpose or
cigarette lighter, wooden or book matches, etc. Report the age of the person involved in starting
the fire, if appropriate. Determine whether there was an intermediate ignition source (e.g., a
trash can or ashtray containing burning materials).
Report, if known, the amount of time that elapsed between ignition and discovery of the fire,
and the approximate time of day or night that the fire was discovered. Determine if, and how,
the occupants or victims became alerted to the fire (e.g., smoke alarm, visual clues such as
smoke or flames, etc.). Determine what the victim(s) response was upon discovery of the fire, if
incapacitation had not already occurred (e.g., victim(s) tried to fight the fire; victim(s) tried to
carry mattress outside, etc.).
Determine whether the occupant was the homeowner, renter, visitor, etc. Obtain the education
of the head of household, the approximate household income, and approximate home market
value if a single-family residence (including manufactured housing).
D. Description of Product
Mattress
Identify the size (e.g. crib, twin, full, etc.) and type (e.g., innerspring, foam, fiber-stuffed,
futon, etc.) of mattress involved in the fire. Note the approximate age of the mattress, whether
the mattress was obtained new or used, and if obtained used, the length of time the present
owners have had the mattress. The month and year of manufacture (or a date code) should be
on a label. Report the contents of any labels on the mattress or mattress pad that provide
information on the:
• name/location of the manufacturer
• date produced (or possible date codes used)
• materials of construction
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• non-compliance with the mandatory standard (e.g., physician prescribed "one-of-a- kind"
mattresses)
• previous use (e.g., renovated mattresses, purchased second hand)
• care necessary to prevent deterioration of chemical fire retardant treatments
Describe the ticking and surface construction of the mattress (e.g., quilted vs. smooth, etc.).
Note the interior construction of the mattress, from the outer ticking through all layers of
upholstery (filling) materials. It may be necessary to cut a cross section of the mattress, from
the ticking to the inner core. Report the thickness of each layer and a thorough description of
each material [color, texture, type of material (e.g., foam, cotton batting) resiliency, etc.]. Try
to obtain close- up photographs or, at a minimum, provide a diagram illustrating the mattress
construction.
To the extent possible, judge whether the mattress appeared to be of pre- or post-standard
construction. Post-standard mattresses would generally have a layer of polyester fiberfill or
polyurethane foam directly under the ticking (the outermost layer of fabric that encloses the
core and upholstery materials of a mattress). This layer would probably be at least 1/4 inch
thick, but more likely ½ inch. These mattresses may have an aluminum flange at the tape edge.
They may also contain thermoplastic ticking or flame retardant-treated ticking, binding tape,
and tufting cords. While thermoplastics may be difficult to identify on sight, such fabrics and
blends may exhibit some "pilling" (to form small balls resembling pills). Post-standard
mattresses may contain boric acid-treated cotton. If the boric acid was added as a powder,
hands might feel "slippery" (similar to the feel of baby powder) after handling the batting.
Pre-standard mattresses would probably not have any of the above features. In addition, prestandard mattresses would probably be made of cellulosic ticking, binding tape, and tufting
cords that may show signs of wear (but no pilling) because they would be over 30 years old.
Pre-standard mattresses would generally not have a layer of foam under the ticking. They were
often filled with untreated cotton batting or similar materials (no slippery feel).
Determine where the mattress/foundation/bedding appeared to have ignited first, such as on the
top, side or bottom of the mattress, bedding, or foundation. Describe the types of filling that
burned or smoldered; e.g., fiber batting, flexible foam, etc. Also note the type of filling
materials that did not burn or smolder.

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Investigation Guideline
Bedding
This includes such items as mattress pads (which must also comply with the mandatory
standard), sheets, blankets, comforters, bedspreads, pillows, and other bedding. List and
describe each of the bedding items that were on the bed. Indicate the order in which these items
were used, e.g., next to mattress, second layer from mattress, etc. For each bedding item
describe the extent of fire damage. Indicate whether these bedding items actually caught on fire
and flamed, or if they just smoldered, as well as the order in which they ignited, if possible.
Bedding items that are filled with upholstery material can contribute significantly to the open
flame hazard. If possible, determine the sequence of ignition; i.e., what ignited first, second,
etc. If an electric blanket was on the bed, note whether it was turned on or off, and whether it
was plugged into an outlet at the time of the fire.
Product Providing Heat of Ignition
Describe the product that ignited, or may have ignited, the mattress or bedding, for example, a
candle, cigarette lighter, electric blanket, or heater. If there is an investigation guideline for
that product, refer to it to determine the level of detail that is needed.
Other
State whether there were any non-bedding items on the bed and describe their involvement in
the fire.
E. Product Safety Standards
For information on mandatory flammability requirements, see 16 CFR Part 1632, Standard for
the Flammability of Mattresses and Mattress Pads.

III. PHOTOGRAPHS/DIAGRAMS OF INCIDENT SCENE
Obtain close- up color photographs illustrating the interior construction of the mattress and
filled bedding items (pillow, comforter, etc.), from the outer ticking through all layers of
upholstery (filling) materials. If that is not possible, provide a diagram illustrating the
construction. Photographs or diagrams of the mattress/foundation/bedding should be included
to illustrate where ignition first occurred. Photograph all labels present on the mattress and
bedding items.
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Investigation Guideline
A diagram or sketch of the floor plan is important when indicating such things as room of
origin, extent of damage, location of victims, escape routes, or where escape routes were
blocked, detector/alarm locations, etc.

IV. OBTAINING SAMPLES AND DOCUMENTS RELATED TO THE
INVESTIGATION
No sample collection from field investigation is required for this study.
Obtain copies of the fire incident report, casualty report(s), and investigation report, police
report, medical reports, insurance reports, and any other available documentation of the
incident. In cases that involve a death or deaths, procure the coroner’s report and the death
certificate.

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Investigation Guideline
November 2002

MATTRESS AND BEDDING FIRES
DATA RECORD SHEET
Task number _________________________ Incident date ________________________
A. MATTRESS DESCRIPTION:
1. Material directly under surface ticking:
/___/ Polyester fiberfill
/___/ Polyurethane foam
/___/ Cotton batting
/___/ Other _________
/___/ Unknown
2. Pre- or post-standard construction (estimate to the extent possible):
/___/ Pre-standard
/___/ Post-standard
/___/ Other _________
/___/ Unknown
3. Purchased:
/___/ New
/___/ Used. If used, specify how obtained (e.g., garage sale, etc.): ___________
/___/ Unknown
4. Date mattress purchased: __________________ Mattress age: ____________
5. Manufacturer/distributor/brand: _________________________________________
6. Mattress size:
/___/ Crib
/___/ Twin
/___/ Double/full size
/___/ Queen
/___/ King
/___/ Other ______________
/___/ Unknown
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7. Mattress surface type:
/___/ Quilted
/___/ Smooth
/___/ Tufted
/___/ Other __________
/___/ Unknown
8. Type of mattress (i.e. innerspring, foam, futon, etc.) ____________________________
9. Foundation present
/___/ Traditional boxspring
/___/ Bed board (e.g. for bunk beds)
/___/ Other (describe)________________________
/___/ No foundation present
B. BEDDING:
10. Bedding items on the bed at the time of the fire (mark all that apply and specify the type of
filling used, i.e. polyester, cotton batting, down/feathers, etc.):
/___/ Mattress pad – filling ____________________
/___/ Sheet(s)- number_____________
/___/ Blanket(s)-number___________
/___/ Comforter – filling ____________________
/___/ Bedspread – filling ____________________
/___/ Pillow(s) – filling ____________________
/___/ Dust ruffle
/___/ Other ___________
/___/ No bedding items involved
/___/ Unknown
F. FIRE DESCRIPTION
11. Ignition sequence (what ignited first?):
/___/ Mattress
/___/ Bedding ___________
/___/ Other ___________
/___/ Unknown
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12. Ignition source:
/___/ Cigarette
/___/ Lighter; cigarette ___ multipurpose ___ unknown ___
/___/ Match; book ____ box ____ unknown ____
/___/ Candle
/___/ Heater; fuel type ____________ distance from mattress __________
/___/ Other ___________
/___/ Unknown
13. Location of mattress ignition (even if bedding ignited first ):
/___/ Smooth top surface
/___/ Tape edge on top of mattress
/___/ Quilted/tufted depression on top of mattress
/___/ Side of mattress
/___/ Underside of mattress
/___/ Dust cover on box springs/foundation
/___/ Other __________
/___/ Unknown
14. Bedding items damaged by the fire (mark all that apply and specify the type of filling used,
i.e. polyester, cotton batting, down/feathers, etc.):
/___/ Mattress pad – filling ____________________
/___/ Sheet(s)- number_____________
/___/ Blanket(s)-number___________
/___/ Comforter – filling ____________________
/___/ Bedspread – filling ____________________
/___/ Pillow(s) – filling ____________________
/___/ Dust ruffle
/___/ Other ___________
/___/ No bedding items involved
/___/ Unknown

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15. Age of person involved in ignition (if appropriate):
/___/ < 5 years
/___/ 5 -14 years
/___/ 15-24 years
/___/ 25 - 64 years
/___/ 65 -74 years
/___/ 75+years
/___/ Unknown
16. Extent of flame damage:
/___/ Confined to the room of fire origin
/___/ Beyond the room of fire origin
/___/ Unknown
17. Extent of smoke damage:
/___/ Confined to the room of fire origin
/___/ Beyond the room of fire origin
/___/ Unknown

G. FIRE SAFETY DEVICES
18. Fire Safety Devices Present
/___/Smoke Alarm, specify number________
/___/Heat Detector
/___/Sprinkler
/___/CO Detector
/___/Other, specify type: ________________
/___/ None
/___/ Unknown
19. Location of the nearest smoke alarm to point of origin
/___/ In the room of origin
/___/ Outside the room of origin but on the same floor
/___/ Other ____________________
/___/ Unknown
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20. Smoke alarm operated (sounded) during fire?
/___/ Yes
/___/ No, smoke didn’t reach alarm
/___/ No, battery missing or inoperable
/___/ No, other reason_______________
/___/ Unknown
21. Event that caused the occupant to investigate/recognize fire hazard
/___/ Smoke alarm sounded
/___/ Smelled/saw smoke
/___/ Other safety device operated___________________________
/___/ Present at ignition
/___/ Alerted by another person
/___/ Other__________________________________________________

H. VICTIM(S)
22. Total Number of Deaths _______
Enter number for each diagnosis:
/___/ Smoke inhalation only
/___/ Burns only
/___/ Smoke inhalation and burns
/___/ Other ______________
/___/ Unknown
23. Total Number of Injuries _______
Enter number for each diagnosis:
/___/ Smoke inhalation only
/___/ Burns only
/___/ Smoke inhalation and burns
/___/ Other ______________
/___/ Unknown

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