TO DETERMINE WHAT HAPPENED DURING AND AFTER THE FIRE, THE GENERAL ACCOUNTING OFFICE (GAO) INTERVIEWED 57 INMATES, 16 PRISON STAFF MEMBERS, MEMBERS AND OFFICIALS OF THE BUREAU OF PRISON'S BOARD OF INQUIRY, AND OFFICIALS FROM THE RESPONDING FIRE DEPARTMENT AND THE DANBURY HOSPITAL; SPOKE WITH EXPERTS WHO INVESTIGATED THE FIRE; AND CONFERRED WITH REPRESENTATIVES OF THE NATIONAL FIRE PROTECTION ASSOCIATION REGARDING FIRE SAFETY IN CORRECTIONAL INSTITUTIONS. WITH RESPECT TO THE FIRE ITSELF, THE FOCUS OF THE GAO REVIEW WAS ON LOCATION OF THE FIRE, CORRECTIONAL PERSONNEL ON DUTY, ACTIONS OF INMATES PRIOR TO THE ARRIVAL OF CORRECTIONAL SUPERVISORS, LOCATION AND REACTION OF STAFF WHEN THE FIRE WAS REPORTED, RESPONSES BY CORRECTIONAL SUPERVISORS, EFFORTS TO RELEASE INMATES, ARRIVAL AND UTILIZATION OF THE DANBURY FIRE DEPARTMENT, MEDICAL CARE, AND INJURIES AND DEATHS. CONDITIONS CONTRIBUTING TO THE SEVERITY OF THE FIRE AND ACTIONS TAKEN TO IMPROVE FIRE SAFETY AT DANBURY AND OTHER FEDERAL INSTITUTIONS WERE ADDRESSED. THE GAO REVIEW WAS HINDERED BY THE LACK OF AVAILABLE PHYSICAL EVIDENCE, THE FACT THAT SEVERAL INMATES HAD BEEN TRANSFERRED OR RELEASED, CONFLICTING TESTIMONY, AND CONFUSION CAUSED BY THE FIRE. IT WAS DETERMINED THAT BUILDING MATERIALS WERE IN COMPLIANCE WITH CODES OF THE NATIONAL FIRE PROTECTION ASSOCIATION BUT THAT THE FACILITY DID NOT FULLY COMPLY WITH FIRE SAFETY TRAINING PREPAREDNESS GUIDELINES. THIS AGGRAVATED THE FIRE SITUATION AND HINDERED FIRE SUPPRESSION AND INMATE EVACUATION. WEAKNESSES IN THE FACILITY'S FIRE SAFETY PROGRAM INCLUDED INADEQUATE AND INFREQUENT FIRE SAFETY INSPECTIONS, AN INADEQUATE FIRE PLAN, THE ABSENCE OF RELIABLE EXITS, AND INADEQUATE LIGHTING. SIGNIFICANT FIRE SAFETY IMPROVEMENTS HAVE BEEN MADE AT DANBURY AND ARE PLANNED AT OTHER FEDERAL INSTITUTIONS. LETTERS FROM CONNECTICUT SENATORS AND FROM A DEPARTMENT OF JUSTICE OFFICIAL ABOUT THE FIRE ARE CONTAINED IN APPENDIXES, AS WELL AS A REPORT ON THE DEATH OF ONE INMATE. (DEP)