Surat Fire Incident 2019 -

Case Study and Learnings

Incident Brief Detail
 On 24 May 2019, a fire occurred at a commercial
complex in Sarthana area of Surat in the Gujarat state of
India

 Twenty-two students died and others were injured in an

academic coaching centre

 Owner of the Institute, Builder and two officials from Fire

Safety Department, was arrested
How fire started
 Fire Started with Short Circuit at Ground Floor

 Then Fire Spread to other floors and Coaching Centre

which was at Terrace !
List of Lapses and Learnings
Lapses in Surat Fire Incident Learnings
Spread of Fire from Ground Floor to Lack of Passive Fire Protection. Passive
Terrace Fire Protection will stop the spread of fire
and smoke
Inflammables are hugely used like Fluxes Interior coatings, internal walls etc are
and Tires as seats spreading the fire fast. Fire Load Must be
calculated and checked on regular
intervals
Fire Tender was 45 minutes away and At least for 2 hour fire fighting capacity
Hydraulic ladder reached in 45 minutes must be available with every commercial
and industrial client.
Ceiling Height was just 5 feet National Building Code 2016 shall be
followed for safety compliance
16 students died due to asphyxiation Smoke is more dangerous than fire.
Smoke Extraction System, Windows and
Maintaining Air Changes per Hour is
critical
List of Lapses and Learnings (Cont.)
Lapses in Surat Fire Incident Learnings
Makeshift Dome was the build on terrace Structure, Wall, Floor and Roof shall be as
where actual tragedy happened per National Building Code-2016 which
guide on fire rating of each.
Short Circuit happened on Air Continuous running loads will have fire
Conditioner Circuit hazard. Thermography and electrical
audits will help client to improve every
time.
3 died as they jumped off the terrace of In adequate exit staircase could have been
the building the reason. Based on each floor occupant
load, travel distance, number of exit must
be calculated in a scientific manner rather
than having one or two staircase.
No Safety Equipment in the building Requirement of Safety Equipment and
Training & Awareness on how to use
might have been saved many life.
Heavy traffic and people taking videos at If not able to extend support, others
incident site should not hamper the rescue team.
List of Lapses and Learnings (Cont.)
Lapses in Surat Fire Incident Learnings
2 Floors was built without permission Adherence to statutory will not only safe
client from legal battle but it is for
Personnel and Property Safety. At end it
has business/commercial benefits.
There was no audit conducted for All high rise buildings and industrial
building. complex must conduct third party audit in
every two year.
Wooden Staircase used. Choice of material of construction and its
thickness matters.
Another Staircase was locked Maintaining the equipment/facility “ready
to use” is very critical which over a
period of time client ignore.
Illegal structure was regularized by the Having NOC or getting the permission to
authorities by accepting the impact fee operate does not mean Premises is Safe
or fool-proof.
List of Lapses and Learnings (Cont.)
Lapses in Surat Fire Incident Learnings
Officials concerned did not conduct a There are loopholes in system and lack of
physical inspection of the building before safety awareness among official sometime
approving the proposal of the builder.
Client declaration was false and Engineer In haste of getting approval, deviations and
Approval was wrong false reporting will be costly to client and
it will be issue of integrity for concern
stakeholders who support client on
wrong grounds.
Couple of months back similar incident Learning from previous or similar incident
happen in the same area in tuition centre is very important to improve safety
where two people died standards of each premises.
Fire Tender did not brought the safety net Emergency Team must equip with right
which could have saved few more lifes equipments, items and tools. Based on
incident it shall be mobilize.
Mr. Ketan Jorawadia, 23 old living near the By keeping self safety in mind, to the
incident site saved at least 10 lifes extent possible support shall be extended
which bring life long impacting result
The End