Fire in a corporate hospital, Kolkata: 93 deaths, several injured
There was a fire incident in the midnight/early morning hours in a 190-bed corporate hospital at Kolkata (West Bengal state) on 09.12.2011 (Friday). As per reports, as of now, 93 persons died, including 3 hospital staff and several others were injured. It is reported that all the deaths were due to suffocation/asphyxiation from poisonous gases like carbon monoxide liberated during the fire. One of the deaths reported is jumping from one of the top floors. The fire started from the area close to the pharmacy located in the basement. The basement originally meant to be a car parking area was modified to house a radiotherapy unit and a pharmacy which is part of central stores. But the area is also used without any authorization to store inflammable materials like, chemicals, spirti cans, wooden furniture, heaps of empty packing boxes, cotton, bandage, oxygen cylinders, etc.
The firefighting equipment in the basement like fire extinguishers, smoke alarms and sprinklers are not functional in the basement at the time of the fire.
Though the fire started at 0130 hr (in another report, it is 0330 hr), fire service was informed only after 40 minutes after attempts by hospital staff to extinguish the fire failed and the fire went out of control.
(A news report for this delay states that when a minor fire occurred a few months earlier, an alert security employee of the hospital informed fire services. But, before they arrived, hospital staff extinguished the fire. However, insisting for inquiry by fire services, as reported, angered the hospital authorities and the security employee was reprimanded and suspended for two weeks. )
The hospital staff informed that as per protocol, person identifying the fire has to inform night administrator who will alert all wings of the hospital and the same was done during this fire incident.
During the initial period of the fire, hospital staff asked the enquiring inpatients to close the doors and sleep. The smoke, carbon monoxide (CO) and other gases liberated during the fire spread to other floors of seven-floor hospital caused suffocation and slow death. CO, a flammable, odorless and tasteless gas is fatal at 3200 ppm after few minutes’ exposure. Carboxyhemoglobin (HbCO) formed by combination of CO with hemoglobin in the blood reduces oxygen carrying capacity and affects the exposed persons with serious consequences. Apart from CO, hot gases inhalation also can create respiratory problems. http://en.wikipedia.org/wiki/Carbon_monoxide_poisoning
Exposed patients, unable to open, banged toughened glass window panes to breath fresh air and find means of escape. It is not clear why they did not open doors of the rooms in which they were staying.
Locals in the nearby areas saw the smoke and had burning lungs. These with kin of inpatients tried to enter the hospital to provide help but were stopped by hospital staff. Traffic on the roads led to late arrival of fire service vehicles. When fire service reached, they found the locked gates and getting hydraulic ladder/lift to cross these closed gates took some more time. They found difficulty in opening the toughened glass panes of the windows. Rescue operations were started in full swing only four hours after the incidents when commando teams with masks and hydraulic lift arrived. Chaos during VIP visits hampered some rescue operations.
At the time of the incident, the staff strength was 130 including 70 nurses and 20 doctors. It is reported that many of these ran for shelter instead of taking part in rescue operations. However, two nurses tried to rescue as many as possible and in the process died due to asphyxiation and heat.
The fire department in their earlier routine inspection objected storage of combustible materials in the basement and hospital authorities promised to clear within three months by November. Though several questioned fire department for not ensuring implementation of their recommendations, it is virtually impossible for any agency when sufficient man power is not allocated. It is easy to say that work and manpower shortage are different and should not be linked. But, the ground reality is that without resources, ineffectiveness creeps in and finally leads to system collapse.
It is reported after the incident that persons from other agencies will be drawn to conduct regular inspection of public institutions like schools, hotels, hospitals, etc . But, this will affect the work in the department when people are taken for the proposed inspections. Unless otherwise dedicated staff is available, the incidents will continue to occur.
The six directors of the hospital were charged with culpable homicide not amounting to murder and with causing death due to negligence.
What can be done?
Following are some of the measures that will help in preventing/mitigating such incidents.
1. A pyramid type safety and fire administration should be established in every town/city.
2. There should be an in-charge for safety and fire for every residential street containing about 10,000 dwelling units or business street containing establishments wherein the total persons employed in various business operations is about 500. These incharges should inspect the areas under their control atleast once in a week for compliance with safety regulations and stop activities in case of violations by issuing a letter with copy marked to their superior and also to local incharges of essential services required to for any dwelling/business like water, power, etc. If the activity continues inspite of notice even after a week, then water, power and other essential services should be stopped immediately by concerned authorities upon receipt of intimation from the safety incharge of the area.
3. There should be a zonal officer for every 100 area incharges. Zonal officer should monitor activities of area incharges, review their reports, conduct meetings with them in small groups and inspect the areas as required. However, he should visit the areas atleast once in a year and send his report to his superiors.
4. If there are more zonal officers, then suitably designated and empowered higher level officials should be appointed to monitor these zonal officers and have defined functions as above.
5. It should be made mandatory to appoint safety and fire officials of required number in every public institution including multistory buildings of all sorts, hospitals, schools, hotels, administrative buildings, bus/rail/air terminals, warehouses, etc. If there are multiple business houses like shopping complexes, then the owner of the building who rented/leased should be held responsible to appoint these officials. These officials should spend atleast half of their working hours to inspect the areas for unsafe conditions and unsafe acts, checking for availability and functioning of specified number of fire detectors/extinguishers/ fire water, and send daily reports to the top man of the institution who should review it on the following day in his meetings with in-charges of various sections, safety and security and ensure necessary remedial measures. The safety officials of individual establishments apart from inspection should also provide training, prepare emergency plan and conduct mock drills every month.
6. A compiled report of these inspections and other safety activities along with actions taken should be sent to the concerned direct area-incharge of the government who should review and take necessary action. Area incharge in turn should compile all these reports in his area along with his inspection reports and send a monthly report to zonal officer to whom he is reporting.
7. All violations found by area incharges, comments/remarks of zonal officers and their superiors should be displayed in the town website for public viewing. The content should be specific to the residence/office/establishment. The website can be designed to enable easier navigation.
8. The safety incharge of the town, call him as town/city safety director or some other designation should be responsible to coordinate with officials of safety, fire, health, transport, administration, etc; prepare an emergency plan for all types of events and ensure conduct of mock drills in all areas/zones, ensure investigation of all incidents and compliance with recommendations, etc. Town/city safety director should prepare an annual report of all safety activities, incidents, etc and publish the report in the town/city website that also contains inspection reports of various officials, details of essential and emergency services, emergency plan, layout of the town extending upto individual house and establishment, list of incidents and details of investigations, recommendations, actions taken, etc.
9. Each of the emergency services of the town should have sufficient number trained personnel; tools like hammers that can be used even at a distance, flood lights, thermal imaging cameras, fire extinguishers, etc; vehicles for moving fire water, fire extinguishers, ladders, hydraulic lifts, generators, communication system, personal protective equipment, etc; ambulances with equipped with necessary equipment and paramedical staff; etc
10. There should be dedicated training centers to train all essential service officials and local communities.
11. Auditing of safety systems in every town/city by reputed agencies, display of audit findings along with action taken report in the website of the town.
Some links on the incident:
http://www.youtube.com/watch?gl=IN&v=3w15rPdyvSE 24x7: News report
http://www.youtube.com/watch?v=GGy2rW6hr04&feature=related TIMES NOW: Eye witness account
http://www.youtube.com/watch?v=FqkdLPip_cA&feature=related AP: News report
http://www.youtube.com/watch?v=sdZElyg9C_M&feature=related newsX: Safety Questions
http://www.youtube.com/watch?v=l6ytgbRr-Ck&feature=related NDTV: Sequence of events
Today (18.12.2011), Chief of Fire Service Department for Government of Andhra Pradesh during his address to a gathering of State Super Specialty Hospitals cautioned and told about
- display of ‘Fire Unsafe Building' board in front of hospitals by Fire Department, for not taking fire safety measures,
- prohibition of generators, transformers, canteens, etc in cellars of high rise hospitals,
- preparation of emergency plan with roll clarity and conduct of monthly mock drills,
- posting a Fire Safety Officer to look after fire prevention arrangements and conduct mock drills once a month.
- a one-day workshop by Greater Hyderabad Municipal Corporation (GHMC) for fire safety officers.
