into the

of the

January 2005

Hazards Centre

New Delhi

This report is the outcome of an independent investigation by the Hazards Centre into the burning of the S-6 coach of the Sabarmati Express in February 2002. It gives observations and conclusions about:

• The Coach – the pattern of fire marks on comparable coaches and what they indicate.
• The Fire – what may be deduced about the manner in which the fire was initiated and spread.
• The Depositions – an analysis what 41 passengers in the coach had to say to the police.
• The Mortalities – an analysis of 27 post mortem reports and the procedures followed therein.
• The Injuries – an analysis of 56 injury reports and what is the correlation with the spread of the fire.

Based on the above, the investigating team has come to the following main conclusions:

1. The fire probably originated in the region between the last two cabins (8 & 9) and it is highly unlikely that it could have started on the floor of the passage or the floor outside the toilets by throwing of inflammable fluid.
2. The resultant dense and high temperature smoke spread along the ceiling of the carriage and eventually resulted in a flash over when the fire engulfed the entire coach from the top.
3. In the above circumstances, people must have gathered trying to escape and been subjected to dense and toxic fumes and radiative heat, resulting in asphyxiation and death.
4. Systematic recording of the evidence and scientific investigation of the case has been marked by its absence. Specific procedures need to be developed for mapping the damage and interviewing the witnesses.
5. Procedures for scientifically collecting and analysing samples also need to be pursued in line with modern approaches in forensics and medical investigation.
6. Serious thought needs to be given to the design of doors and exits and emergency escape designs for Indian carriages, considering the high passenger load per compartment.

--0--

The 9166 Sabarmati Express was on its way to Vadodara in the early morning of 27 February 2002. It was running almost five hours late at 07.47 hours, when a chain pulling was reported just as it began pulling out of Godhra station with reports of an altercation and stone throwing at the station. The vacuum was apparently set right and the train moved out again but stopped a few minutes later again slightly ahead of A Cabin. There was reportedly a longer period of stone throwing at the train and then the S-6 coach caught fire. Before the tragic event could be brought under control, 58 persons had perished on the spot.

Almost 32 months later, the Hazards Centre has undertaken an investigation into the probable causes of the fire. The study was initiated because of increasing concern over the manner in which previous investigations had been conducted and the absence of an explanation consistent with the facts as recorded. Hence, the Centre set up a multi-disciplinary group consisting of the following persons:

• A K Roy, M Tech in Chemical Engineering, with expertise in hazards and safety, Hazards Centre, Delhi
• Professor Dinesh Mohan, PhD in Biomedical Engineering, with expertise in human tolerance to injuries, Indian Institute of Technology, Delhi
• Professor Sunil Kale, PhD in Mechanical Engineering, with expertise in thermodynamics and fluidisation, Indian Institute of Technology, Delhi
• S N Chakravarty, Mechanical Engineering, with expertise in coaching section of the Railways for 10 years, Consultant, Mumbai

Several other individuals from different fields, as well as the Railway authorities, also assisted the group as and when necessary. Their cooperation is gratefully acknowledged.

On different occasions the group members analysed the documents available from previous investigations, visited the railway workshops at Matunga and Jagadhri, viewed video footage of the Sabarmati Express S-6 coach, and observed the burnt coach at Godhra. Other coaches, not belonging to the Sabarmati Express and which have caught fire at other places and times, and now lying at Gandhinagar and Jagadhri, were also examined to learn more about the broader processes and results when such coaches burn. After several consultations this final report has been prepared for wider public discussion and debate.

January 2005

Hazards Centre

92 H, Pratap Market

Munirka

New Delhi 110067

91-11-26187806, 26714244

haz_cen@vsnl.net

The burnt Coach-6 at Godhra was physically observed 2½ years after the incident. Hence, clearly allowance has to be made for the passage of time and the changes that may have been brought about by exposure to weather, investigating teams, and curious onlookers. However, the Hazard Centre’s team was fortunate enough to be able to view video footage of the coach taken two months after the burning incident, and the visual evidence suggests that the essential features of damage to the coach remain the same. The photographs (video stills) of the Godhra Coach-6 included in Annexure 1 are taken from this video footage.

The observations of six other coaches (burnt at other locations) presently parked at Gandhinagar (one) and Jagadhri (five) were also very useful for comparing the fire patterns across coaches in order to understand the manner in which the flames spread. The team discovered that one coach kept at Jagadhri was very similar to the burnt coach at Godhra. This coach (16526 GSCN – hereafter referred to as the Delhi coach) caught fire while under maintenance in the washing line of Delhi Junction Station on 21 November 2003. Comparative pictures of the two coaches (Godhra coach S-6 and Delhi coach) are given in Annexure I.

1. The heat marks are clearly visible on the sides of both the Delhi and Godhra coaches where the paint has got scorched and peeled or vaporised off. The heat marks on the left and right side of both the coaches are roughly similar and more severe on the upper half of the coaches. The patterns are also very similar, indicating that the heat was greater at one end of the coach in both cases. It should be noted that the Delhi coach was painted blue while the Godhra coach had a red coat. In the case of the Delhi coach it is also known that no materials were thrown from outside.
2. The crinkling of the steel body and the roof is also similar and has taken place in the middle section but more towards the end where the scorch marks are more pronounced. This crinkling took place as the coach expanded with increasing temperature and the sheet metal folded to take up the structural expansion from one end.
3. The pattern of heat marks on the outside of the coaches is clearly correlated to the conflagration inside. In both the coaches almost half the plywood floor has crumbled in one half where the fire presumably originated, although the under-floor remains intact. The vinyl and foam berths and sunmica partitions have been completely destroyed in this half and the steel is mangled. On the other half of the coaches the various components are better preserved, particularly for the Delhi coach.
4. The seat and window details in both the coaches are also remarkably similar. The reinforced fibre shutters and glass panes as well as the aluminium frames have vanished on the side the fire originated. As the distance from the centre of the fire increases, the aluminium frames and reinforced fibre shutters slowly begin to reappear, as do scorched remains of the seats.
5. The damage to the ceilings indicates that in those regions where the highest temperatures obtained, the asbestos ceiling has crumbled, the fan blades have got warped and the underlying synthetic wool insulation has fallen down because of the melting of the bitumen paint, even behind the intact portions of asbestos.
6. In the Godhra coach, two important features stand out towards the eastern end, where the floor has also crumpled under the intense heat. Firstly, the aluminium water tank above the luggage compartment next to seats 68-70 displays a large hole towards the inner side indicating that the heat was greatest in the upper portion of this end of the compartment. Secondly, the vestibule near this end also shows burnt patches on the upper side while the lower portion of the rubber seal remains intact.

1. Given that, for the Delhi coach, there was no evidence of anyone throwing inflammable fluid on to the coach, the heat marks on the outside must have been caused by the heat inside. Any inflammable fluid thrown from the outside could not have produced such heat marks on the top end of the carriages unless the coach was on fire throughout its length inside.
2. It was reported for the Delhi coach that the fire was initiated, without the use of any inflammable fluid on the floor inside, between the first and second cabins and the seats burnt first. It took about 15-20 minutes for the fire and smoke to spread throughout the coach from the time the smoke was first noticed.
3. Therefore, in the case of the Godhra coach (where the damage is strikingly similar to the Delhi coach), it is possible that the fire originated in the region between the last two cabins 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 through 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.
4. Hence, in the Godhra coach, it is highly unlikely that the fire could have started on the floor of the passage or the floor outside the toilets. Inflammable plywood and foam in three tiers of seats would not be available for the fire to burn in this area. If the fire was started by an inflammable fluid on the floor, the flames would have been noticed right away in a very crowded carriage, precluding the possibility of a long smouldering source.
5. Systematic recording of the evidence is highly desirable in all cases of burning of coaches to preserve and collate the evidence as soon as possible. A damage-mapping matrix is provided in Annexure II for the recording of data. This matrix clearly demonstrates the pattern of the fire in the Delhi coach and is amenable to analytical exercises for the purposes of understanding the source and course of the fire.
6. The procedures followed by the Forensic Science Laboratory in collecting and analysing samples leave much to be desired since simple activities like mapping, locating samples along a grid, developing an inventory of inflammable substances, and doing detailed spectroscopic analysis have not been pursued.

--0--

The similarities between the fire patterns in the Godhra and Delhi coaches are striking, as is the fact that both were stationary at the time the smoke and fire were noticed. However, the major difference is that, in the first case, the coach was more than full with passengers while, in the second case, the coach had no passengers as it was in the washing line. Hence, apart from the inflammable materials in the structure of the coach it is also necessary to consider the other materials that may possibly be accompanying passengers. A list of materials and their combustibility is given in Annexure III.

1. In the coach the most flammable material is the latex foam in the seat. This is, however, protected by a plywood base and a vinyl cover. The next most flammable material is the plywood base itself and if this is exposed to a source of ignition it will rapidly catch fire and, in turn, set the foam on fire too. The plywood can be set on fire by clothes and other materials stored by passengers below the seat. These materials can be set on fire by cigarettes, matchsticks or cigarette lighters that are still burning. If there is any cooking equipment with fuel stored below the seat, this can worsen matters (see Annexure III for burning properties of these materials).
2. The latex foam creates enormous clouds of hot, dense, asphyxiating, black smoke and this itself becomes the source of ignition for other materials as the temperature rises to flash point. The total combustible mass per berth is 10 kg. If this drops to the floor while it is burning, it will also ignite other berths, partitions, panels, and the vinyl flooring. Other materials in the coach that will melt and vaporise are the vinyl fabric cover (rexine) of the seat, laminated plastic partitions (sunmica) and vinyl flooring (linoleum). All these materials will jointly produce hydrogen cyanide, isocyanates, carbon monoxide and dense smoke.
3. The luggage carried by each passenger in a coach varies between 5-10 kg, and almost all luggage will carry clothes that are highly flammable. Any smouldering or lighted particle can set the luggage on fire, if it remains in contact long enough to raise the temperature for flammable materials to catch fire. For materials like cloth, plastics, paper, etc. to smoulder and set the plywood on fire it can take 10-20 minutes. Then the foam in the seat can be completely on fire within 5-10 minutes.
4. The depositions of the passengers suggest that very few escaped from the 9^th cabin side. The damage in the Godhra coach is similar to the Delhi coach. In the Delhi coach the fire is said to have originated on the 9^th cabin side. These two pieces of evidence suggest that the fire must have originated on the 9^th cabin side for the Godhra coach too. For the initial fire to have enough material to burn the seat plywood and foam on fire, and spread quickly, the fire would have to originate under the seats belonging to the partition between the 8^th and 9^th cabin.
5. If the fire originated around the 8^th and 9^th cabin, then the passengers in these cabins would have a chance to escape from the 9^th cabin end and all the passengers in cabins 1-7 and some of those in 8 would move toward cabin 1 to escape. This is also suggested by the testimony of the witnesses.

1. To scientifically establish and understand the process of combustion, a dual strategy of experimental and computer simulations needs to be adopted. For the experimental part, instruments for measurement of temperature, gas sampling, and videography will have to be attached to a coach shell. Successive experiments will have to be conducted to set fire to differently furnished cabins and record the processes that follow.
2. By using coach geometry, materials and their properties, the fire can be simulated on a computer model for different scenarios. The results could be used for deciding location of fire detectors and safety interventions.
3. The available evidence for the Godhra coach strongly suggests that the fire initiated in the luggage below the seat in the 8^th or 9^th cabin and then spread through radiative and convective heating from the overhead smoke.
4. It is possible that the material below the seat smouldered and the plywood smouldered for 10-20 minutes or more before the smoke was noticed. Heavy smoke is not likely to have appeared immediately after the initiation of the fire.

--0--

The statements made by several passengers and railway, police, and fire brigade employees to the police and the High Level Committee are available on record and provide some important insights into the incident. After careful screening it was found that there were 41 passengers, some bona fide and others not so, whose statements had some bearing on the pattern of the fire. Of these, about half could provide some idea of which seat they were occupying at the time of the incident. Their statements are summarised in Annexure IV.

Based on the statements given by those 19 passengers who could recall their position or exit mode, we have made an attempt to map the possible escape routes from the burning coach. The interpretation has been based both on what the passengers stated as well as an observation of which window bars were broken and the area of intense heat in which the floor was burnt. This map has been provided in Annexure V.

1. Of the 11 passengers who made statements in this regard, only 1 said that the fire began towards the engine (front) end of the coach. The rest were unanimous that the fire began from the guard (rear) end.
2. The limited information available from 4 statements suggests that the time taken for the fire and smoke to spread could vary between 10 to 20 minutes. All these statements have been made by passengers who were further away from the origin of the fire.
3. 14 passengers have testified to stone pelting on the coach and 5 of them were sure that the stones had come from the South (or platform) side.
4. 23 passengers said that some inflammable substance was flung into the coach. 10 of these even specified that this was in the form of a burning rag or "mashal" or petrol and acid thrown from outside. All these 10 passengers were in the 5^th or 6^th cabin from the front but did not mention their specific seat.
5. 4 passengers said some liquid was thrown into the lavatory. Of these, 3 belonged to one family who were located in the 1^st cabin. 4 passengers noticed some liquid on the floor and all of them were in the 5^th cabin.
6. 17 passengers said they had escaped out of the door and they all specified that this was towards the yard (North) side. 13 other passengers escaped out of windows, again presumably towards the yard side because of alleged stone-throwing on the other side.
7. The mapping exercise indicates that all those passengers who were towards the passage side up to the 6^th cabin and probably noticed the smoke first escaped out of the door on the yard side of the front end of the coach. Only 1 person escaped from the other door on the same side because he was sitting on berth 72 closest to the door. 3 others of one family in the 1^st cabin said they had forced their way out from the space between the connecting vestibules in the front. 2 windows from which some of the bars were broken appear to have been the exit route for 6 other passengers. The bar joints can be broken from the inside by a few sharp blows with something heavy.

1. Those passengers with easy access to the door appear to have made their way quickly through it as soon as the first signs of smoke began appearing.
2. Others who were further away from the door and closer to the origin of the fire had to break their way out through the windows.
3. Apparently stone pelting from the South meant that people hesitated to make an exit from that side.
4. The huge majority (16/23) of those who said that inflammable substances were thrown from outside could not specify which seat they were in or what was their reserved berth. Of the remaining 7, only 3 were located near where the fire began near the 9^th cabin. Of the other 4, 3 also belonged to the family that said they saw liquid being poured into the lavatory and were at the opposite end in the 1^st cabin, while the 4^th was in the 2^nd cabin. Hence, the evidence points to the fact that the fire could not have been ignited by pouring petrol on the floor and setting it ablaze.
5. Recording of statements from passengers by the police has been totally unsystematic and shoddy. No method has been followed in the procedure, 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 causes of the fire has been subverted. A detailed and systematic procedure for recording of evidence must be laid down and all police personnel trained in adopting these procedures.

--0--

A total of 27 post mortem reports have been made available to us. The salient data from these reports is summarised in the Annexure VI. Out of 27 reports, 26 are for those who died on 27 February 2002 and one for an individual who died on 3 April 2002. Summary facts for 26 post mortem reports of 27^th February 2002 are given below.

1. All post mortems except one were conducted in the railway yard.
2. 8 doctors performed the post mortems.
3. The reported time taken for the post mortems ranged between 20 to 75 minutes with an average of 38 minutes.
4. All the 8 doctors record almost exactly the same details for injuries with all body parts charred/roasted/burnt including internal organs and contents.
5. For all cases, the diagnosis is that the burn injuries were "ante mortem".
6. For all cases, the cause of death is recorded as "shock due to burns".
7. The estimated age of all victims ranges from 4 to 45 years. Only 3 persons were estimated to be less than 10 years old. The average age is 31 years, comprising 12 females, 14 males and 1 unknown.
8. Out of 17 post mortem reports, the identity of only 5 persons is known.
9. In 11 cases some details of the colour of clothes are recorded.

1. The post mortem reports can be considered unscientific and unreliable for the following reasons:

1. 26 were conducted in the yard without adequate equipment and support needed for a scientific post mortem.
2. Time taken (average 38 minutes) for the post mortem is far too little for obtaining details of injuries, preserving relevant tissues, etc.
3. It is not possible that 26 bodies will have almost identical injuries.

2. In most cases it is recorded that almost all body tissues, including internal ones, were roasted/charred/burnt. For example, it is recorded that the particles found in the small and large intestines were "roasted". This is not possible unless the skin covering the abdomen and the intestines is itself completely burnt first in order to char or burn the contents. This is unlikely in all cases. If the burns are so deep and extensive some of the bodies would not have any structural form. This could also be true for many other internal body tissues recorded as roasted or charred. The fact that some of the bodies still had clothes whose colour could be recorded shows that the post mortem reports indicating all body parts to be charred/roasted/burnt are likely to be untrue.
3. In all cases the burns are recorded to be "ante mortem" and death caused by "shock due to burns". There is no indication how all the doctors have arrived at this conclusion. Sophisticated methods are now available to determine cause of death by examining various body organs. In this case, at least the lungs should have been preserved to examine the contents of the tissues. Scientific examination of lung tissues available could have disclosed what chemicals were present whether the presence of such chemicals could have produced asphyxia. Similarly, examination of blood vessel and brain tissues may have given clues whether death was due to inhalation of poisonous fumes and/or asphyxiation or burns. None of this has been done.
4. It is well known among forensic scientists that even in house fires the victims very often become unconscious from inhaling fumes before they get burnt. It is surprising that this possibility was not considered by the doctors conducting the autopsies. In this case, the fire would have released isocyanates, hydrogen cyanide and carbon monoxide (Annexure III). With the presence of these gases people can fall unconscious and die within minutes depending on the concentration of gases.
5. It appears that those passengers, who were located at the rear end of the crowd and were from cabins 5-8 waiting to escape from the seat 1 end, never got a chance. They probably fell unconscious and/or died from asphyxia before the fire burnt them completely. This may be why all the passengers who died are reported to have been charred completely.

--0--

A total of 56 injured victim reports are available with us. The salient data from these reports is given in Annexure VII. Out of 56 reports, 48 (86%) were examined on the 27^th of February and 8 (14%) on the 28^th February 2004. Summary facts for the 56 injury cases are given below:

1. A majority of patients (68%) reported trouble in breathing due to smoke and heat inhalation. Almost half of these victims had no other problems except breathing trouble. Soot marks were largely on the face, head and upper body, at times on the hands. This indicates that soot laden smoke was only on the upper half of the carriage in the region where these victims spent their time before escaping.
2. Burn patients comprised only 12% of the patients treated. Of all the burn patients, 83% had facial and head burns and 58% had upper limb burns. Only 3-4 patients had more than superficial burns. This indicates that:

1. Among these survivors, it is unlikely that any of them faced the full impact of the heat generated by the carriage fire. They probably managed to escape while the fumes were still in the upper regions of the compartment.
2. The fumes and the heat were localised in the upper half of the compartment where they were gathered before escaping.

3. Only 21 percent of the survivors comprising this sample suffered physical injuries. Only 2 injuries include fractures of the hand. Most of the injuries were to lower limbs and could have been sustained while escaping and falling from the compartment. The height of the compartment floor from the ground was more than 1.5 m. A fall from this height hands first can fracture an ulna. Falling head first from this height can produce serious head injury, especially among older people. If someone jumps feet first, fractured ankles, sprains, and bruises to knees etc. are very likely. Very few injuries to the upper body parts are recorded, indicating that they might not have been subjected to violence from others.

1. The fire initiated from the 8^th or 9^th cabin (seat 72 side) after smouldering for a while. The initiation is unlikely to have been noticed by any one and therefore it is unlikely that any burning material was thrown from outside as they would have then taken action before it smouldered.
2. It is unlikely that there was any fire on the floor as long as these survivors were in the compartment. If the evidence given by some passengers from the 5^th–6^th cabin that some inflammable substance was flung into the coach and that there was fuel on the floor is correct then this fuel would have caught fire and burnt the lower parts of passengers’ bodies. Since this is not true for a vast majority of the cases, it is unlikely that there was any inflammable fluid on the floor in any significant quantity.
3. When the fire started and gave out a great deal of smoke, the occupants in the region of seats 64-72 (approximately) would have been taken by surprise and moved away. Most of them would have tried to escape from the exits on the seat 72 side. The occupants on seats 1-64 (approximately) side would have tended to move toward seat 1 to escape.
4. In the above circumstances, 150 or more people must have gathered between seats 1 and 50 or so trying to escape. These passengers must have been subjected to dense and toxic fumes emanating from the roof and upper levels of the compartment and radiative heat as the ceiling heated. At this time it is unlikely that there was anyone left between seats 48-64 where the smoke and fire would have been intense.
5. Most of the survivors are likely to be those who were in the region of the seats 1-40 and managed to get ahead. These survivors are those who sustained the injuries mentioned above as they escaped the debilitating effect of the fumes.
6. Serious thought needs to be given to the design of doors and exits and emergency escape designs for Indian carriages, considering the high passenger load per compartment. Specific attention may be paid to the possibility of vestibuling all coaches and enlarging the passage way.

1. It is most probable that the fire originated in the region between the last two cabins (8 & 9) and started by burning the lower berth first. It is highly unlikely that the fire could have started on the floor of the passage or the floor outside the toilets by throwing of inflammable fluid.
2. The evidence regarding the initiation of fires suggests that materials like clothes, wood, etc., smoulder for 10-20 minutes at least before a major fire starts.
3. The resultant dense and high temperature smoke spread along the ceiling of the carriage and eventually resulted in a flash over when the fire engulfed the entire coach from the top.
4. The initiation is unlikely to have been noticed until the dense asphyxiating smoke emerged from the burning latex foam. The evidence from the Delhi coach suggests that after the first dense smoke is detected, it takes about 20-30 minutes for the whole coach to be on fire and full of smoke.
5. The nearest occupants in the last cabins (8 & 9) would have been taken by surprise and tried to escape from the exits on the seat 72 side. The occupants on seats in the other cabins would have tended to move toward seat 1 to escape.
6. In the above circumstances, 150 or more people must have gathered trying to escape, and been subjected to dense and toxic fumes emanating from the roof and upper levels of the compartment and radiative heat as the ceiling heated.
7. Since it would take a long time for the people to exit, a group of people from the last few cabins is likely to have been asphyxiated by toxic fumes full of soot and fallen unconscious to be burnt by the fire.
8. Passengers with access to doors and broken windows appear to have escaped as soon as the first signs of smoke began appearing. Apparently stone pelting from the South meant that people hesitated to make an exit from that side.
9. Such passengers logically show signs of soot, breathing difficulties, burns, and injuries in the upper body. Other injuries could be caused by falling from a height.
10. Systematic recording of the evidence and scientific investigation of the case has been marked by its absence. Specific procedures need to be developed for mapping the damage and interviewing the witnesses.
11. Procedures for scientifically collecting and analysing samples also need to be pursued in line with modern approaches in forensics and medical investigation.
12. A dual strategy of experimental and computer simulations needs to be adopted to understand the process of combustion. The results could be used for deciding location of fire detectors and safety interventions.
13. Serious thought needs to be given to the design of doors and exits and emergency escape designs for Indian carriages, considering the high passenger load per compartment.

---xxx---