accident report of van that resulted in death of 16 children and their teacher in gujrat, pakistan

7/30/2019 Accident report of van that resulted in death of 16 children and their teacher in Gujrat, Pakistan

1/7

18, H-9, Islamabad. TELEFAX No. 9257470 PH: 9257821-24, E-mail: [email protected]

HYDROCARBON DEVELOPMENT INSTITUTE OF PAKISTAN

(CNG OPERATIONS)

INSPECTION REPORT

(Prepared as Third Party Inspectorunder the rule 10 of CNG Rules 1992)

REPORT NO: HDIP-CNG-INSP(ACC)/09/2013 INSPECTION DATE: May 25, 2013

DATED: May 26, 2013 REGISTRATIONNUMBER OF VEHICLE:

SGG 9076 (Mitsubishi Van)

TYPE OF

INSPECTION:

Preliminary Accident Report PLACE OFACCIDENT:

Sargodha-Mandi Bahaudin RoadRoad, Near Kot Gakha,

Mangowal, Gujrat

Directives of Director General, Hydrocarbon Development Institute of Pakistan

SUMMARY OF INSPECTION

The HDIP inspection wings engineer, Mr. Asim Riaz visited the subject site

on at 1730 hrs on May 25, 2013, to enquire the possible causes of accident

which took place at 0700 hrs on May 25, 2013.

Based on the inspection of the site, statement of the witnesses, Police

FIR, and review/examination of the wreckage of the vehicle, the report is

given as under:

1. Accident Details:

HDIP Inspecting officer recorded the verbal statements of passengersof the subject van, Mahnoor and Pakeeza daughters of Khurram Shahzad

Butt and eye witness motorcyclist Muhammad Ahsan. According to their

statements the brief summary of the accident is as under:

The accident occurred at about 0700 hrs, on May 25, 2013 atSargodha-Mandi Bahaudin Road, Near Kot Ghakka (Butt colony),

Mangowal, Gujrat.

There were twenty-one (21) children and female teacher in the van atthe time of accident. The teacher was sitting next to the sliding door inthe van.

According to the children the vehicle went out of order frequently inpast days.

The driver Muhammad Irfan was a smoker and according to childrenhe was smoking at the time of accident.

The petrol tank of the vehicle was not working. The petrol was insidethe passenger compartment in a Can from where it supplied fuel to

the engine through the plastic pipe.


2/7


Prior to the accident, the vehicle was refueled by Overseas Oil TradingCo.(Pvt.) Ltd retail outlet site at Kot ghakka, Sargodha-Mandi

Bahaudin Road, Gujrat.

There was another can filled with petrol inside the passengercompartment which driver was carrying for the generator.

Petrol Cans were placed adjacent to the engine behind the front seat ofthe van.

About a minute before the accident, as soon as the driver convertedfrom CNG to petrol the children complained to the driver that they are

smelling odour of petrol in the vehicle.

More than four children complained about the odour. Daud in thefront row, Hasnat Hafeez sitting in the middle and Mahnoor

sitting in the back row all complained about the petrol smell. Thedriver turned a deaf ear to the complaint. Just after that fire

broke out from the front of the vehicle where Cans were placed

and within seconds it spread all over the vehicle and it was

engulfed in flames.

The driver showed cowardice and ran from the site of accident. He didnot even try to open the door of the van.

The children sitting in the front row beside the driver opened the frontdoor and escaped. The children sitting in the rear row escaped bybreaking the rear window of the vehicle.

Black smoke filled the passenger compartment due to which childrenwere suffocated.

The teacher sitting next to the sliding door tried to open the door frominside but the door was out of order and could only be opened from

outside the van. The back door of van was also out of order and could

not be opened from inside or outside.

All the witnesses reported that the burning teacher saved 3 kids bypushing them out of the window after she failed to open the door. She

did not try to save her life but preferred saving the children till she

was burnt to death.

About a dozen people gathered around the vehicle soon after theaccident. The eye witness Mr. Muhammad Ahsan said that flames

were so severe that the vehicle could not be reached. People tried to

extinguish the fire by throwing sand, water and a milkman emptied all

his milk Cans by throwing it on fire but to no avail.


3/7


Sixteen (16) children and the female teacher were burnt alive anddied at the spot.

The brother of eye-witness passengers Mahnoor and Pakeeza was alsoburnt alive in the van. Three of their cousins were also dead. The

Grandfather of the children had a heart attack after he saw the deadbodies of children and died in the hospital.

The fire brigade and rescue 1122 arrived 30 minutes after theaccident.

The injured/burnt children were evacuated to CMH Kharian formedical treatment.

2. Police Report:

The First Investigation Report (FIR) No. 18535 was registered againstdriver of the van at Konjah Police Station, Gujrat on May 25, 2013.

According to FIR, there was additional petrol Can in the passengercompartment of the vehicle which caught fire due to negligence and

carelessness of driver.

The fire was extinguished by the volunteers. Six (6) children were rescued and shifted to CMH Kharian hospital.

3. Observations & Findings:

The site of the accident was a two-way road. The road was straightwithout any slope, narrowing or evident deficiency compared to other

sections. According to witnesses the road condition was dry and

visibility was good at the time of accident.

The Mitsubishi van was Dual Fuel vehicle converted to CNG and couldbe operated either on petrol or CNG. However, because of the non-

availability of the CNG in those days, the van was running on petrolwith very unsafe fuel system.

Both the plastic petrol Cans placed and pipes inside the passengercompartment were burnt and consumed by the fire.

The charred body parts of the children were found in thewreckage during inspection of the vehicle which showed the

extreme temperature of the inferno created by the instant

inflaming of two petrol Cans. It represents to us embodiment of

pain and suffering the innocent children and their teacher went

through when they were burnt alive in the van.


4/7


The vehicle had two sliding doors in the passenger compartment. Theright side sliding door behind the driver seat was permanently closed.

The vehicle battery was placed inside the passenger compartment at

the foot-rest of the aforementioned door.

CNG cylinders were installed under the passenger seats. The cylinderdid not detach from fastening although it was not properly installed.

The cylinders were almost empty at the time of accident. There was noevidence in the wreckage that the fire ignited or augmented due to

CNG as even the plastic part of three ways cylinder valves were intact.

Two CNG vehicle cylinders were installed in the Mitsubishi van. Thespecification of the cylinders are given as under:

SerialNo.

Manufacturer

Cylinder

SerialNumber

Date ofManufacturing

ManufacturingStandard

Water LiterCapacity

1 DNA 686483 04/2010 DNA 49

2 DNA 683092 04/2010 DNA 50

None of the CNG cylinders exploded in the accident. The petrol tanks of most of the public service vans are rusted as

drivers run the vehicle only on CNG due to price differential i.e. CNG

is half the price of petrol. Due to gas load management the drivers are

forced to run the vehicle on petrol. For this reason most of the public

service vans have made alterations and are running the vehicles with

petrol stored in un-capped plastic Cans placed in passenger

compartment which is illegal and extremely dangerous. The fuel from

Can to the engine is supplied through ordinary plastic pipes.

This improvisation is done in order to save expenses as replacing thepetrol tanks costs roughly 20 times more than this unsafe inexpensive

alternative, which was the case with this van.

In addition, the vehicle was carrying an extra lose Can of petrol insidethe passenger compartment for a generator.

As the driver shifted from CNG to petrol, the petrol spilled on floor ofthe vehicle due to leakage in the plastic pipes or jolting of the vehicle

due to missing which lead to spilling of petrol. The odour of petrol was

smelled by the children in front, middle and back row which implied

that petrol must have spilled over just before the accident.

Most probably the fire ignited in the van due to contact of petrol withhot surfaces of engine as the Cans were placed near the engine.


5/7


However, short circuiting of wiring and throwing of the burning

cigarette on petrol by the driver may also have caused fire.

The vehicle was immediately engulfed by flames as the petrol hadalready spilled over on floor of the vehicle.

The sliding door of van could not be opened from inside which is thecase with many public service vehicles.

The CNG cylinders remained inside the burning vehicle for half anhour. The burning has made the cylinders unfit for further use as the

cylinders were heat treated (i.e. surface annealing). The Konjah Police

station should be advised to hand over the CNG cylinders to HDIP.

The fitness certificate of the vehicle was not renewed.4. Conclusion:

By reviewing the site of the accident, statement of the witnesses,

Police FIR, and review/examination of the wreckage of the vehicle, it is

concluded that:

The accident was caused by negligence and

carelessness of the driver Muhammad Irfan, sub-

standard petrol supply system and poor road-

worthiness of the vehicle i.e. the vehicle battery

and petrol Cans/pipes were inside the passenger

compartment. The side and back doors of the

vehicle were out of order.

5. Recommendations:

1. All those responsible for this tragedy of horrendous magnitude mustbe accounted for; which in this case fall in three categories.

a. Category one comprises of subjects of law, i.e. the driver, ownerof the vehicle and the petrol OOTCL pump which illegally sold

inflammable material (petrol) in the lose container. All of them

should be punished.

b. Category two consists of law enforcers, i.e. motor vehicleexaminer, traffic police, district administration, the regulator i.e.

Oil & Gas Regulatory Authority (OGRA), concerned

Ministries/departments responsible for inspections,

documentations and periodic and spot checks of all transport

licensed to come on the road. That can be done only by someone

who really has a say in system.


6/7


c. Category three is of those who are above law; who createenvironments for criminal acts and neglects of categories

mentioned above. The rusting of the petrol tank of public service

vehicle and carriage of additional petrol Can for generator that

caught fire was the result of prevailing energy crisis created by

mismanagement, incompetence, corruption, irrational tariff

structure, poor regulatory framework and governance. Energy

crisis is not only responsible for economic recession but is also

accountable for accidents like this van. To blame those who

created the energy crisis for burning alive of the children may

sound too philosophical, but it remains the bitter fact.

The FIR of police may be extended to all those responsible in the above

three categories and responsibility should be fixed on the individuals

responsible for such a tragic accident.

2. Number of accidents have occurred in the past due to lack ofmaintenance, tempering and alteration of petrol systems in the public

service vehicles. Therefore, it is strongly recommended that either the

public service vehicles should run on dedicated fuel only (either petrol

or CNG) or strict measures should be taken to immediately stop the

practice using petrol Cans placed in passenger compartment of public

service vehicle. It may be noted that the use of CNG in public service

vehicle promotes economic activity and should be encouraged.

Whereas CNG in the private vehicles should be discouraged due to

shortage of gas.

3.The Konjah Police station should be advised to hand over the CNGcylinders installed in the van to HDIP.

4.The female teacher kept rescuing the children till death. She shouldbe given Civil Gallantry Award for her extraordinary valor as her

physical safety has been perilously exposed to danger during rescue.

Inspecting Officer:

Asim Riaz(Senior Research Engineer)


7/7

18 H-9 Islamabad TELEFAX No 9257470 PH: 9257821-24 E-mail: hdipcng@apollo net pk

accident report of van that resulted in death of 16 children and their teacher in gujrat, pakistan

Documents