More light on Godhra fire

Published : Feb 11, 2005 00:00 IST

An inside view. The Hazards Centre report too has concluded that the origin of the fire was within the coach. -

An inside view. The Hazards Centre report too has concluded that the origin of the fire was within the coach. -

A technical analysis of the burnt coach of the Sabarmati Express rules out the possibility of the fire being ignited by inflammable liquid thrown from outside.

THE Bharatiya Janata Party (BJP) has held that the Justice U.C. Banerjee Committee report is politically motivated and that Railway Minister Lalu Prasad timed its release with an eye on the Bihar elections. But the same charge cannot be levelled against the technical report on the burning of Coach S-6 of the Sabarmati Express that led to the death of 58 passengers, which too coincidentally was released on the same day as the Banerjee report. The report is the result of an independent investigation by the Hazards Centre, a Delhi-based non-governmental organisation.

Like the Banerjee report, the Hazards Centre report too has concluded that the origin of the fire was within the coach, resulting perhaps from an accident. Based on a scientific analysis of available evidence and depositions of survivors, it has built a most plausible and logically consistent scenario of the incident. Specifically, it says that the fire is extremely unlikely to have started on the floor of the passage or the floor outside the toilets following the throwing of some inflammable liquid from outside.

It must be pointed out that the Hazards Centre undertook the investigation almost 32 months after the incident. "The study," the report says, "was initiated because of the increasing concern over the manner in which previous investigations had been conducted and the absence of an explanation consistent with the facts as recorded."

The investigating team comprised professionals from engineering disciplines relevant to the issue: A.K. Roy of Hazards Centre, a chemical engineer with expertise in hazards and safety; Dinesh Mohan, professor of biomedical engineering at the Indian Institute of Technology, Delhi, with expertise in human tolerance to injuries; Sunil Kale, professor of mechanical engineering at IIT, Delhi, with expertise in thermodynamics and fluidisation; and, S.N. Chakravarty, a Mumbai-based consultant mechanical engineer to the Railways for 10 years, with expertise in railway coaches.

Although two and a half years had lapsed when the team examined the burnt 72-seater coach at Godhra, it had access to video footage of the coach taken two months after the incident. According to the report, the essential features of the damage to the coach had not changed. Besides the video footage and actual examination of the coach, the team analysed the documents of previous investigations, including depositions of survivors and post-mortem reports. It visited railway workshops at Matunga, Mumbai, and Jagadhri near Delhi.

But crucial to the investigation was the fortuitous discovery of a burnt coach (16526 GSCN) kept at Jagadhri that was remarkably similar to the Sabarmati Express coach. This coach had apparently caught fire while under maintenance in the washing line at Delhi Junction on November 21, 2003. The team also looked at six other coaches burnt at different locations in order to understand how railway coaches burn and how the flames spread and also to compare damage patterns. Of these, one was parked at Gandhinagar and five at Jagadhri.

Dinesh Mohan said: "To understand what must have really happened, a detailed modelling of the actual inhabited coach and computer simulation is needed. In its absence, the chance discovery of this Delhi coach became central to our conclusions."

While the actual cause of the fire in the Delhi coach is apparently not known, what is known is that the fire was initiated between the first and second compartments of the coach and did not involve any inflammable liquid thrown on to the coach floor from outside. The seats burnt first and it took about 15-20 minutes for the fire and smoke to spread throughout the coach from the time the smoke was first noticed.

Given the striking similarity of heat marks and patterns on the outside between the Godhra and Delhi coaches, the investigators concluded that in the case of the Godhra coach too the fire probably originated in the region between the last two cabins - cabins 8 and 9 - and started by burning the lower berth first. "The resultant dense and high temperature smoke spread to the top of the carriage and then moved along the ceiling and between the ceiling and the roof though the length of the coach. The radiative and convective heat generated eventually resulted in a `flash-over' when the fire engulfed the entire coach towards the top," says the report.

"This kind of scenario is well documented in house fires caused by say a cigarette or some such source," says Dinesh Mohan. "Flammable objects like clothes smoulder for some time before a flash-over and a consequent conflagration results. This is likely to have happened in the Godhra case too where material stowed away under a berth may have been smouldering for some time before the plywood, a flammable substance, underneath the berth caught fire and then the latex foam of the berth, the most flammable substance inside, causing intense heat and smoke."

Clothes and other materials stored under the seats by passengers could have been set afire by cigarettes or bidis, burning match-sticks and, worse still, cooking stoves with fuel. For materials such as cloth, plastics and paper to smoulder and set fire to the plywood, it would take about 10-20 minutes, the report points out. The foam in the seats can be completely on fire in about 10 minutes. The total combustible mass per berth is about 10 kg while the average luggage carried by a passenger would have been about 10 kg, much of which would be combustible. Heavy smoke too would have been noticed only 10-20 minutes after the initiation of the fire and smouldering of the material below the seats and the plywood, and not immediately, the report notes.

"The important difference between the Godhra coach and the Delhi coach is the absence of flammable substances in the latter. Even then the heat due to smouldering was sufficient to cause a flash-over. Here the conflagration would have occurred much more easily. There would have been enough material to burn the seat plywood and foam," he points out. "In the area around the toilets, the vinyl floor, the laminated walls and the wall paint are all made of fire retardant material. So the fire could not have sustained for long in this area," Dinesh Mohan says. Also, if the fire was started by an inflammable fluid on the floor, the flames would have been noticed right away in a carriage that was packed to nearly double its capacity, precluding the possibility of a long smouldering source.

TWO features in the Godhra coach are indicative of the all-engulfing fire having originated from above rather than from below. The heat was greatest in the upper portion of the compartment. At the rear-end of the coach, the aluminium water tank above the luggage compartment next to seats 68-70 displayed a large hole towards the inner side. The vestibule near this end had burnt patches on the upper side while the lower portion of the rubber seal remained intact.

The latex foam, the most flammable material in the coach, is, however, protected by plywood below and vinyl fabric cover (rexine) on top. While rexine is fire retardant, plywood is the next most flammable material. The latex foam creates enormous clouds of hot, dense, asphyxiating black smoke and this itself would act as a source of ignition for other materials by raising their temperature to flashpoint. Besides dense smoke, all these would together have produced highly toxic hydrogen cyanide, isocyanates and carbon monoxide.

If the fire originated between cabins 8 and 9 (Seat no 72), only the passengers in these cabins would have had a chance to escape from the rear exit. All the passengers in cabins 1 to 7 and even some from 8 would have been forced to move towards the front end because of the dense asphyxiating smoke in the region between cabins 8 and 9. The depositions of 41 survivors to the police - which, unfortunately, are neither systematic nor complete - also partly substantiate this as only few seem to have escaped from the rear door.

Interestingly, although 22 passengers had claimed that some inflammable substance was flung from outside, 16 of them could not say where they were seated or the number of their reserved berth. It is known that a well over a hundred kar sevaks were travelling unreserved in the coach.

It emerges from the study that most people must have gathered in the region of seats, say 1 to 50, in trying to escape. Since the process of escape would have taken a long time, these passengers must have been subjected to fumes emanating from the roof and upper levels of the compartment and radiative heat as the ceiling heated. No one could have remained in the region between seats 48 and 64 because of intense heat and smoke. Most of the survivors would have been those in the region of seats, say 1 to 40, who managed to get out through the front door or through windows (there is evidence of window grills having been broken). Only 21 per cent of the survivors had minor burns and physical injuries, mostly confined to the lower limbs, sustained while trying to escape and jumping down from the compartment, a height of 1.5 m. It is the bunch farthest away from the exit and closer to the fire (say, between cabins 5 and 6) that would have felt the full impact of the fumes. While some may have managed to break their way through the windows, many would have collapsed inside to be consumed by the engulfing flames. This scenario seems to provide a reasonable explanation as to why a group of people in the centre of the coach were found completely charred.

The important thing to note, Dinesh Mohan says, is that none of the survivors saw fire inside. Either they escaped before the conflagration or fell unconscious. "There is no gradation of injuries," points out Dinesh Mohan. Available data on 56 injured victims are revealing. A majority (68 per cent) had reported breathing trouble. They had soot marks largely on the face, head and upper body, indicating that soot-laden smoke was only in the upper portion. Burn patients were only 12 per cent and most of them had superficial burns. Of these, 83 per cent had facial and head burns and 58 per cent had upper limb burns.

The report has also highlighted the unsystematic nature of investigations by the Gujarat state machinery. " The procedures followed by the Forensic Science Laboratory in collecting and analysing samples leave much to be desired," notes the report. In the police recording of statements, "no procedure has been followed and many of the statements are repetitive as if they have been dictated. Thus vital clues have been missed and a scientific analysis of the probable cause of the fire has been subverted."

More damaging is the finding that the post-mortem reports are unscientific and unreliable as 26 of the 27 reports are identical. Moreover, these were carried out in the yard without adequate equipment and the average time taken (38 minutes) is too little to obtain details of injuries and preserve tissues, which would have given clues to the cause of death.

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