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# PA senior center More than one problem?

## PA senior center More than one problem?

(OP)
From what I remember, it looked like the fire got into the attic, hence why people walking out were not wet??

by Craig R. McCoy, Staff Writer cmccoy@phillynews.com

The fast-moving November fire that left four dead at the Barclay Friends senior citizens home in West Chester has baffled and alarmed fire-protection experts nationwide.

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How could the flames race so quickly through a modern facility protected by an extensive sprinkler system? And if that system was adequate, why was there little evidence that fleeing residents had been doused by the water that should have rained from every ceiling to suppress the fire?

In the months since, the Inquirer and Daily News have reviewed the original blueprints, calculations sheets, and other records of the sprinkler network. The newspapers asked independent fire-suppression experts to assess the same documents. The papers’ reporting suggests the sprinkler system may have been flawed in its very design.
Among the findings:

•The blueprints and calculation sheets have conflicting figures for the water flow available to douse fires in the complex. While the system’s designer stood by his work in an interview, fire-safety professionals say it is unclear from the records whether sprinklers, as designed, could have delivered enough water to fight the fire.
•The independent experts agree that the designer followed a less stringent standard for the sprinkler network than was required by building codes at the time. The standard the designer used pe
rmitted fewer sprinklers in the facility.
•Handwritten notes on the blueprints show that someone flagged the issue, circling the relaxed standard listed on the document and asking whether it was “not permitted …?”
These questions come on top of a previous charge by the Philadelphia law firm for one of the victims: that water to a large part of the sprinkler system may have been cut off by a closed valve even before the fire.
Investigators led by the U.S. Bureau of Alcohol, Tobacco, Firearms and Explosives have said little thus far about the fire other than noting their belief it began outside on an adjacent patio. An investigative report is expected to be released soon. The report is keenly awaited by fire-safety professionals nationwide

“Whenever you have four fatalities in a sprinklered building, that gets our attention,” said Robert E. Solomon, an engineer with the National Fire Protection Association (NFPA), the organization that drafts the nation’s fire codes.

The last time so many people died in such a fire was in 2009, when four disabled residents of a sprinkler-protected group home in rural New York were killed. In that case, though, three of the victims, confused and unsupervised, actually walked back into the burning building.
‘No water pressure!’

The fire at Barclay Friends began about 10:45 p.m. on a cold and gusty night in the rear of personal-care section of the complex, a wing with 41 residents, four of whom had limited mobility. The five-alarm fire gutted the section. The six other wings, far less damaged, were home to some 100 residents receiving nursing care.
Killed were four tenants in the personal-care section: Theresa Malloy, 85; Mildred E. Gadde, 93; and a married couple, Delores G. Parker, 89, and Thomas F. Parker, 92.

Firefighters, their voices captured on tape in urgent exchanges with dispatchers, repeatedly complained about a lack of water. “There is no water pressure at all at the scene!” one is heard saying.
Aqua, the private water company that serves West Chester, had announced plans a few weeks before the fire to install a larger water main to serve the facility, in part to “improve firefighting capabilities in the area.” The work had yet to begin at the time of the fire.
It seems clear that sprinklers had done little, if anything, to slow the fire before firefighters got there.

Andrew Duffy, a lawyer with the Mongeluzzi firm, which represents the Malloy family, said that when investigators went through the home after the fire, they inspected the large, wheel-like valve that controlled the most extensive portion of the facility’s sprinkler system. It was closed. If it was shut before the fire, no water would have been available to the 365 sprinklers that covered the basement and the first and second floors of the personal-care section.

Duffy said his firm was seeking to determine who, if anyone, might have had access to the valve after the fire to determine if it had been simply turned off post-blaze to shut down the sprinkler system.
Sprinkler systems typically have alerts, such as blinking lights or chirping sounds, to warn when the water has been turned off.

John H. Morley Jr., a licensed sprinkler contractor in Philadelphia, offered a possible explanation for a missed alarm. In his 40 years of testing systems, Morley said, he often finds alarms not in working order. “It is very tricky and complicated to install and fitters don’t have the patience,” he said. As a result, he said, some fitters simply don’t hook up the device or do it in a cursory way.

Morley had an even more ominous observation. In testing sprinkler systems, he said, he occasionally finds the water valve had been left off in error by the last testing crew.
Typos blamed

When the 150-bed Barclay Friends home was built in 1997, its sprinkler system was drafted by Marco Inc., a fire-protection company in nearby Downingtown. The actual design work was subcontracted to Donald Vess, who worked out of North Carolina. At the time, he had more than three decades of experience in his field.
In interviews last month from his current Tennessee office, Vess, now 75, said no one had contacted him as part of the current fire investigation. When asked about potential issues in his plans, he agreed that the documents show discrepancies in two areas.

One concerned the figure documenting the incoming water flow, a measure of the amount of water available to put out fires. The figure is typically supplied to designers by the area water company.

In Vess’ design package, he and his staff put down two different figures for the water flow.
The blueprint for the sprinkler design for the personal-care section lists the water flow as 363 gallons per minute. The blueprint was done by Wendy Vess, Vess’ daughter-in-law.

But elsewhere, in page after page of calculations to determine the appropriate pipe sizes for an adequate system, Donald Vess used a different figure, one nearly double, 663 gallons per minute.

In interviews, the NFPA’s Solomon and expert Kenneth Isman, a fire-protection professor at the University of Maryland, and other experts said the discrepancy concerned them.
“One of the most critical pieces of information that is needed when designing a fire sprinkler system is the strength of the water supply,” Isman said. “The most unusual thing that I found while reviewing your material was the inconsistency in the reporting of the water flow test information.”

He and others said it was important to get the incoming water supply right because the calculation dictates how large the sprinkler pipes should be.

“If you assume the water is stronger than it really is, you’re going to install pipes that are too small,” Isman said. “If the pipes are too small, you’re just not going to get as much water through them and less water is going to be put on the fire.”

For that reason, he said, the borough and Marco “should both have seen that there was conflicting information. … The difference is important.”
Unless the 663 gallons-per-minute figure was verified, Isman said, the “design would be in question.”

While unable to explain the discrepancy two decades later, Vess said he believed he used the right figure for the calculations. “I’m not sure which one is correct, but I would assume it’s the calculation sheets that are correct,” he said. He no longer has records for that job, he said.

For one thing, Vess said, the smaller figure for water flow stuck him as simply too low for a water system for a town as large as West Chester.

“That’s apparently a typo,” he said of the lower figure used by his daughter-in-law in her design drawing
Vess pointed out his plans and calculations were reviewed and approved by Donald J. Kohn, a licensed professional engineer with an office near Allentown. Kohn did not respond to telephone calls and a letter left at his office late last month.

Aqua, the water company in the area, declined to say whether the water flow at the time was 363 or 663 gallons per minute.

Not permitted?

In the sprinkler drawing, there is an odd notation in the very center of the document.

In the blueprint for the personal-care wing of the facility, Marco listed the building code standards it would follow. For the sprinkler system, it listed two — NFPA 13 and the less stringent 13R, which permits the installation of fewer sprinklers
Notably someone circled “13R” on the sketch and wrote next to it “Not permitted in I-1 use group?” The words not permitted are underlined twice. “I-1” was shorthand for Institutional/boarding homes.

Isman, the professor, and Solomon, the NFPA engineer, both agreed that the unknown commentator — whether designer or regulator — got it right in the scribbled note. The relaxed standard was not permitted at that time in personal-care facilities as large as Barclay Friends, they said.

At the same time, the two experts said they were not greatly troubled by the mix of standards. Isman said the long-term regulatory trend has been to permit fewer sprinklers in personal-care facilities, provided residents were mobile enough to flee a fire largely on their own. He noted Vess’ design put more than 150 sprinklers in the attic of the personal-care wing — even though that was not required under the more lenient standard.
Morley, who analyzed the design documents, took a different view, saying the designers should not have deviated in any way from the building code.

He added that the design had “significant errors” that meant any fire at Barclay Friends “would most likely overwhelm the system.”
In examining the plans, Morley also noted that Vess put down an incorrect figure at one point for water density, a measure of the amount of water a sprinkler network will produce over a set area. Again, Vess said it was a typo of no consequence.

Vess said his system, as designed, should have worked well. “It should have protected the structure,” he said.
http://www.philly.com/philly/news/breaking/west-ch...

### RE: PA senior center More than one problem?

(OP)
How could the flames race so quickly through a modern facility protected by an extensive sprinkler system? And if that system was adequate, why was there little evidence that fleeing residents had been doused by the water that should have rained from every ceiling to suppress the fire?

In the months since, the Inquirer and Daily News have reviewed the original blueprints, calculations sheets, and other records of the sprinkler network. The newspapers asked independent fire-suppression experts to assess the same documents. The papers’ reporting suggests the sprinkler system may have been flawed in its very design.
Among the findings:

•The blueprints and calculation sheets have conflicting figures for the water flow available to douse fires in the complex. While the system’s designer stood by his work in an interview, fire-safety professionals say it is unclear from the records whether sprinklers, as designed, could have delivered enough water to fight the fire.
•The independent experts agree that the designer followed a less stringent standard for the sprinkler network than was required by building codes at the time. The standard the designer used pe
rmitted fewer sprinklers in the facility.
•Handwritten notes on the blueprints show that someone flagged the issue, circling the relaxed standard listed on the document and asking whether it was “not permitted …?”
These questions come on top of a previous charge by the Philadelphia law firm for one of the victims: that water to a large part of the sprinkler system may have been cut off by a closed valve even before the fire.
Investigators led by the U.S. Bureau of Alcohol, Tobacco, Firearms and Explosives have said little thus far about the fire other than noting their belief it began outside on an adjacent patio. An investigative report is expected to be released soon. The report is keenly awaited by fire-safety professionals nationwide

“Whenever you have four fatalities in a sprinklered building, that gets our attention,” said Robert E. Solomon, an engineer with the National Fire Protection Association (NFPA), the organization that drafts the nation’s fire codes.

The last time so many people died in such a fire was in 2009, when four disabled residents of a sprinkler-protected group home in rural New York were killed. In that case, though, three of the victims, confused and unsupervised, actually walked back into the burning building.
‘No water pressure!’

The fire at Barclay Friends began about 10:45 p.m. on a cold and gusty night in the rear of personal-care section of the complex, a wing with 41 residents, four of whom had limited mobility. The five-alarm fire gutted the section. The six other wings, far less damaged, were home to some 100 residents receiving nursing care.
Killed were four tenants in the personal-care section: Theresa Malloy, 85; Mildred E. Gadde, 93; and a married couple, Delores G. Parker, 89, and Thomas F. Parker, 92.

Firefighters, their voices captured on tape in urgent exchanges with dispatchers, repeatedly complained about a lack of water. “There is no water pressure at all at the scene!” one is heard saying.
Aqua, the private water company that serves West Chester, had announced plans a few weeks before the fire to install a larger water main to serve the facility, in part to “improve firefighting capabilities in the area.” The work had yet to begin at the time of the fire.
It seems clear that sprinklers had done little, if anything, to slow the fire before firefighters got there.

Andrew Duffy, a lawyer with the Mongeluzzi firm, which represents the Malloy family, said that when investigators went through the home after the fire, they inspected the large, wheel-like valve that controlled the most extensive portion of the facility’s sprinkler system. It was closed. If it was shut before the fire, no water would have been available to the 365 sprinklers that covered the basement and the first and second floors of the personal-care section.

Duffy said his firm was seeking to determine who, if anyone, might have had access to the valve after the fire to determine if it had been simply turned off post-blaze to shut down the sprinkler system.
Sprinkler systems typically have alerts, such as blinking lights or chirping sounds, to warn when the water has been turned off.

John H. Morley Jr., a licensed sprinkler contractor in Philadelphia, offered a possible explanation for a missed alarm. In his 40 years of testing systems, Morley said, he often finds alarms not in working order. “It is very tricky and complicated to install and fitters don’t have the patience,” he said. As a result, he said, some fitters simply don’t hook up the device or do it in a cursory way.

Morley had an even more ominous observation. In testing sprinkler systems, he said, he occasionally finds the water valve had been left off in error by the last testing crew.
Typos blamed

When the 150-bed Barclay Friends home was built in 1997, its sprinkler system was drafted by Marco Inc., a fire-protection company in nearby Downingtown. The actual design work was subcontracted to Donald Vess, who worked out of North Carolina. At the time, he had more than three decades of experience in his field.
In interviews last month from his current Tennessee office, Vess, now 75, said no one had contacted him as part of the current fire investigation. When asked about potential issues in his plans, he agreed that the documents show discrepancies in two areas.

One concerned the figure documenting the incoming water flow, a measure of the amount of water available to put out fires. The figure is typically supplied to designers by the area water company.

In Vess’ design package, he and his staff put down two different figures for the water flow.
The blueprint for the sprinkler design for the personal-care section lists the water flow as 363 gallons per minute. The blueprint was done by Wendy Vess, Vess’ daughter-in-law.

But elsewhere, in page after page of calculations to determine the appropriate pipe sizes for an adequate system, Donald Vess used a different figure, one nearly double, 663 gallons per minute.

In interviews, the NFPA’s Solomon and expert Kenneth Isman, a fire-protection professor at the University of Maryland, and other experts said the discrepancy concerned them.
“One of the most critical pieces of information that is needed when designing a fire sprinkler system is the strength of the water supply,” Isman said. “The most unusual thing that I found while reviewing your material was the inconsistency in the reporting of the water flow test information.”

He and others said it was important to get the incoming water supply right because the calculation dictates how large the sprinkler pipes should be.

“If you assume the water is stronger than it really is, you’re going to install pipes that are too small,” Isman said. “If the pipes are too small, you’re just not going to get as much water through them and less water is going to be put on the fire.”

For that reason, he said, the borough and Marco “should both have seen that there was conflicting information. … The difference is important.”
Unless the 663 gallons-per-minute figure was verified, Isman said, the “design would be in question.”

While unable to explain the discrepancy two decades later, Vess said he believed he used the right figure for the calculations. “I’m not sure which one is correct, but I would assume it’s the calculation sheets that are correct,” he said. He no longer has records for that job, he said.

For one thing, Vess said, the smaller figure for water flow stuck him as simply too low for a water system for a town as large as West Chester.

“That’s apparently a typo,” he said of the lower figure used by his daughter-in-law in her design drawing
Vess pointed out his plans and calculations were reviewed and approved by Donald J. Kohn, a licensed professional engineer with an office near Allentown. Kohn did not respond to telephone calls and a letter left at his office late last month.

Aqua, the water company in the area, declined to say whether the water flow at the time was 363 or 663 gallons per minute.

Not permitted?

In the sprinkler drawing, there is an odd notation in the very center of the document.

In the blueprint for the personal-care wing of the facility, Marco listed the building code standards it would follow. For the sprinkler system, it listed two — NFPA 13 and the less stringent 13R, which permits the installation of fewer sprinklers
Notably someone circled “13R” on the sketch and wrote next to it “Not permitted in I-1 use group?” The words not permitted are underlined twice. “I-1” was shorthand for Institutional/boarding homes.

Isman, the professor, and Solomon, the NFPA engineer, both agreed that the unknown commentator — whether designer or regulator — got it right in the scribbled note. The relaxed standard was not permitted at that time in personal-care facilities as large as Barclay Friends, they said.

At the same time, the two experts said they were not greatly troubled by the mix of standards. Isman said the long-term regulatory trend has been to permit fewer sprinklers in personal-care facilities, provided residents were mobile enough to flee a fire largely on their own. He noted Vess’ design put more than 150 sprinklers in the attic of the personal-care wing — even though that was not required under the more lenient standard.
Morley, who analyzed the design documents, took a different view, saying the designers should not have deviated in any way from the building code.

He added that the design had “significant errors” that meant any fire at Barclay Friends “would most likely overwhelm the system.”
In examining the plans, Morley also noted that Vess put down an incorrect figure at one point for water density, a measure of the amount of water a sprinkler network will produce over a set area. Again, Vess said it was a typo of no consequence.

Vess said his system, as designed, should have worked well. “It should have protected the structure,” he said.
http://www.philly.com/philly/news/breaking/west-ch...

(OP)

### RE: PA senior center More than one problem?

I have no knowledge of this situation other than what is posted here.

It does bring up something that I have noticed an issue in the recent years. Many sprinkler people and architects incorrectly apply NFPA 13 and 13R in multi-family buildings. With NFPA 13R previously titled Multi-Family Less than 4 Stories in Height, many in the industry think this applies to all multi-family buildings of 4 stories. I think many fail to realize the building code takes precedence.

Then, there are many that don't read the nuances. I see many architects call out for NFPA 13R when they do an area increase. This is completely not permitted. The building code is pretty black and white on this. I have had too many battles with architects that just don't read the fully body. Also, you may get a sprinkler guy that, even if architect correctly calls out 13 because of area increase, the sprinkler contractor sells the GC on a 13R system saying the architect is wrong and it is multi-family less than or equal to 4 stories so 13R applies.

Then, heaven forbid if the building can be correctly designed to NFPA 13R, but then the architect or builder decide to eliminate draft stopping because the building has sprinklers. Well, if you do 13R and no draftstopping, then you must protect the concealed combustible spaces per 13.

This is what I love about the work we do. Nothing is just plain cookie cutter. Sprinkler guys have to be familiar with the building code, fire code, NFPA standards and all of the local amendments. There is a lot to keep track of. But, if you are going to do the job correct, this is what you must do. You can't just rely on some one above you getting it right. As the famous saying goes, "Trust be verify."

Travis Mack
MFP Design, LLC
www.mfpdesign.com

### RE: PA senior center More than one problem?

cdafd thanks for bringing this back to life, 4 people were killed in the fire in a fully sprinklered building...so sad.

This fire is very near where I live, I have no knowledge of the cause of the fire, I only know what I have read in the papers and local news reports on the fire. BUT my guess based on 36 years of insurance loss prevention experience and finding closed valves AND valve tamper devices that did not work in my career, is a closed sprinkler control valve was the contributing factor in this fire. As someone who has spent many years trying to prevent this from occurring by inspection and testing of 1000's of valves, by training fire inspectors, maintenance staff, my own company insurance loss prevention staff and being a past member of NFPA 25 committee I find this entire situation so close to home to be very frustrating and heartbreaking.

I find the photo at the end of the article of the OS&Y with the valve tamper cover off very interesting. A few questions come to mind...
1. If this condition occurred before the fire was the fire alarm panel in trouble ( yellow light on)?
2. Did the staff call the sprinkler monitoring company to report the valve closed?
3. Who was the last person to work on the valve tamper switch?
4. Did the occupants ( maintenance staff) call the FD to report the valve closed as required by NFPA 25?
5. As required by NFPA 25 was the sprinkler control valves visually inspected monthly and tested semiannual.
6. Do they have documentation of the required NFPA 25 valve inspections?

I wish the article addressed these questions.

I am waiting and I am sure many lawyers for the ATF to make public the report on the fire hopefully they will address the closed valve and answer some of the questions above.

### RE: PA senior center More than one problem?

(OP)
Hum

Will try to get the investigation report.

Good question when was the osy shut off.

My question did it get into the attic first?

### RE: PA senior center More than one problem?

Cd

From news reports the fire started outside of the building. My guess it went up the side of the building into the overhanging eaves and into the attic, it reportedly had sprinkler protection.

(OP)
OK

### RE: PA senior center More than one problem?

Are worse fears are confirmed, shut sprinkler control valve !!!!!

http://www.philly.com/philly/news/breaking/the-fat...

On the night a fatal fire swept through a West Chester nursing home, water to the sprinkler system was turned off, lawyers for the families of three of the victims say they have been told by an engineer hired by the home.

In addition, the warning system for the sprinklers was giving a false reading that the water was on, according to lawyers with the McEldrew Young and Robert Mongeluzzi law firms.

The lawyers said the revelations came during a December briefing by Dan Arnold, an engineer with Seneca Fire Engineering, an Atlanta firm working for Barclay Friends, a wing of which was gutted by the fast-moving fire Nov. 16.

At the briefing, Arnold informed other engineers and attorneys that investigators for the Bureau of Alcohol, Tobacco, Firearms and Explosives told him that they had determined that the large wheel used to control water to the sprinkler system was in an off position after the fire, according to Ian Bryson, a lawyer with McEldrew Young, and Samuel Dordick, a lawyer with the Mongeluzzi firm. Both attended the briefing.

### RE: PA senior center More than one problem?

How is it that I have this gnawing feeling that arson may be at play here. Sprinkler alarm check valve shut off and by coincidence a fire started.

### RE: PA senior center More than one problem?

Chicopee said
"How is it that I have this gnawing feeling that arson may be at play here. Sprinkler alarm check valve shut off and by coincidence a fire started."

Shut sprinkler control valves as per NFPA is the #1 reason sprinkler systems fail. During my 36 years in the insurance loss prevention side of the business I found closed valves even ones with electronic supervision. This does not surprise me, a closed valve, just saddens me that a simple thing like monthly visual valve inspection could/may have prevented this from occurring. I wonder how times did the 3rd party fire alarm contractor actually closed the valve a few turns to see if the switch worked, or like some I have witnessed just move the switch with their finger because they had 100 valves to test.....

Of all the news reports about this fire I have reviewed arson has not been suggested. At this point the fire started on the outside of the building near where folks smoked gee does that sound like we have been down this path before......

### RE: PA senior center More than one problem?

Shut valves are the worst and most common reason they fail .. Without question.

On a personal note, I responded to an apartment fire at 2:00 once.
No sprinklers as it was built to the minimum permitted to NOT have sprinklers. Another topic.
The fire started in a cheap extension cord with a lamp plugged in.
The fire traveled the carpet, not very large at the time, went thru the window, climbed the side into the attic.
I am unsure if the sprinkler would have operated if present. We will never know.

Once that fire got in the attic, it hauled ass. Remember 13R, no sprinkler up there.
When it reintroduced into the living areas, it was over. The was a curtain rod that I remember in particular because the TV had melted around it. No flames involved.
I was on air for the overhaul it was so hot.
The fire rating of the rooms worked. It super-heated the rooms to flash-over quickly.

No doubt, we can do better.
R/
Matt

### RE: PA senior center More than one problem?

Reading through everything a shut valve seems the most likely.

Even with a "bad" water supply it seems likely there would have been enough water for at least a couple heads and it is surprising how my fires are controlled by just two or three sprinklers. Something like 75% of fires were controlled with two or less heads I think I read once?

Of systems I designed there were two fires that I am aware of and both were controlled with a single sprinkler operating.

The most important part of any designers job is getting the correct water supply for the project because we all know with an erroneous water supply all you got on your pretty drawings is garbage.

I prefer to do my own flow test using my calibrated gauges... I did a flow test a couple years back where the fire chief and I compared gauge readings and his old gauge, it looks like something he took off a ten year old sprinkler riser, read 8 psi lower than what I got on my recently calibrated gauge with papers.

Unless the fire hydrant is on private property I never open and close a hydrant myself. I insist the fire department be there to operate the hydrants and another thing I do is video the flow test.... yes, you read that right I take video and on the audio you can often hear the fire chief and I discussing, and agreeing, on the results that we both saw with our own eyes.

If the city doesn't want to conduct a flow test I will take the results from them as long as date, time and results of the test is in writing to me on city/fire department letterhead.

Travis brings up a good point on what standard to use; NFPA #13 or 13R? To determine the correct standard is not my job it is the job of the building design professional which is the architect or professional engineer. I look at it this way, for me to make that determination I am practicing architecture without a license and that is against the law. It's simple, I want something in writing from the design professional telling me the correct standard because that is the only way I can be absolutely safe. I did this a few years back, got it in writing that it was a 13R system from the architect and it turned out he was wrong... this would have been a huge mess if I had made the determination on my own and it just solidified my belief that selecting the appropriate standard is not my job. Little job went from $25k to over$200k.... boring highways for water and all. Luckily I got a change order.

### RE: PA senior center More than one problem?

Yep valve closed = no protection

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