HYDROCARBON DEVELOPMENT INSTITUTE OF PAKISTAN

(CNG OPERATIONS)

INSPECTION REPORT

(Prepared as Third Party Inspector under the rule 10 of CNG Rules 1992)
REPORT NO: DATED: TYPE OF INSPECTION:
HDIP-CNG-INSP(ACC)/09/2013

INSPECTION DATE:
REGISTRATION NUMBER OF VEHICLE:

May 25, 2013 SGG 9076 (Mitsubishi Van) Sargodha-Mandi Bahaudin Road Road, Near Kot Gakha, Mangowal, Gujrat

May 26, 2013 Preliminary Accident Report

PLACE OF ACCIDENT:

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 passengers of 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 at Sargodha-Mandi Bahaudin Road, Near Kot Ghakka (Butt colony), Mangowal, Gujrat. There were twenty-one (21) children and female teacher in the van at the time of accident. The teacher was sitting next to the sliding door in the van. According to the children the vehicle went out of order frequently in past days. The driver Muhammad Irfan was a smoker and according to children he was smoking at the time of accident. The petrol tank of the vehicle was not working. The petrol was inside the passenger compartment in a Can from where it supplied fuel to the engine through the plastic pipe.

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

 Prior to the accident, the vehicle was refueled by Overseas Oil Trading Co.(Pvt.) Ltd retail outlet site at Kot ghakka, Sargodha-Mandi Bahaudin Road, Gujrat. There was another can filled with petrol inside the passenger compartment which driver was carrying for the generator. Petrol Cans were placed adjacent to the engine behind the front seat of the van. About a minute before the accident, as soon as the driver converted from 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 the front row, Hasnat Hafeez sitting in the middle and Mahnoor sitting in the back row all complained about the petrol smell. The driver 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 did not even try to open the door of the van. The children sitting in the front row beside the driver opened the front door and escaped. The children sitting in the rear row escaped by breaking the rear window of the vehicle. Black smoke filled the passenger compartment due to which children were suffocated. The teacher sitting next to the sliding door tried to open the door from inside 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 by pushing 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 the accident. 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.

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

 Sixteen (16) children and the female teacher were burnt alive and died at the spot. The brother of eye-witness passengers Mahnoor and Pakeeza was also burnt alive in the van. Three of their cousins were also dead. The Grandfather of the children had a heart attack after he saw the dead bodies of children and died in the hospital. The fire brigade and rescue 1122 arrived 30 minutes after the accident. The injured/burnt children were evacuated to CMH Kharian for medical treatment. 2. Police Report: The First Investigation Report (FIR) No. 18535 was registered against driver of the van at Konjah Police Station, Gujrat on May 25, 2013. According to FIR, there was additional petrol Can in the passenger compartment 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 straight without 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 could be operated either on petrol or CNG. However, because of the nonavailability of the CNG in those days, the van was running on petrol with very unsafe fuel system. Both the plastic petrol Cans placed and pipes inside the passenger compartment were burnt and consumed by the fire. The charred body parts of the children were found in the wreckage 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.

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

 The vehicle had two sliding doors in the passenger compartment. The right 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 cylinder did not detach from fastening although it was not properly installed. The cylinders were almost empty at the time of accident. There was no evidence 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. The specification of the cylinders are given as under: Serial No. 1 2 Cylinder Serial Number 686483 683092 Date of Manufacturing Manufacturing Standard 04/2010 04/2010 DNA DNA Water Liter Capacity 49 50

Manufacturer DNA DNA

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 the petrol 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 inside the passenger compartment for a generator. As the driver shifted from CNG to petrol, the petrol spilled on floor of the 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 with hot surfaces of engine as the Cans were placed near the engine.

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

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 had already spilled over on floor of the vehicle. The sliding door of van could not be opened from inside which is the case with many public service vehicles. The CNG cylinders remained inside the burning vehicle for half an hour. 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, substandard petrol supply system and poor roadworthiness 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 must be accounted for; which in this case fall in three categories. a. Category one comprises of subjects of law, i.e. the driver, owner of 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 vehicle examiner, 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.

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

c. Category three is of those who are above law; who create environments 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 of maintenance, 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 CNG cylinders installed in the van to HDIP. 4. The female teacher kept rescuing the children till death. She should be 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)

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

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