At least 93 people – most of them patients died in the huge fire that broke out in the 
early morning hours in AMRI. The fire began in the basement where a pharmacy and
the godown were located . The area was stacked with highly combustible material such 
as PVC pipes, mattresses, oxygen and LPG cylinders, and even mobil (engine oil). When 
the fire was sparked off, dense smoke started billowing out of the basement and entered 
the upper floors catching many persons unaware in their sleep. 
While most nurses, doctors and other staffers were able to get away, many critically ill 
patients suffocated to death in their hospital beds. With no outlet / openable windows, 
the smoke started circulating in the building, choking the patients and the staff. None of 
the patients who died had any burn injuries. All were choked to death. 
An incensed Chief Minister Mamata Banerjee openly blamed the hospital authorities 
for this “criminal negligence”. Taking a tough stand, she ordered the filing of criminal 
cases against them and ordered their arrest. In the afternoon six directors of the hospital 
group, R.S. Goenka, S.K. Todi, Manish Goenka, Prashant Goenka, Ravi Todi and D.N. 
Agarwal, surrendered at Lalbazar, the city police headquarters. They were booked on 
charges of culpable homicide tantamount to murder under Section 304 of the IPC. 
Ms Banerjee, who holds charge as health minister, also cancelled the hospital’s licence 
and registration. 

What went wrong : 
• The fire broke out at around 0200 am. The hospital staff started fire fighting 
operations on their own without initiating a fire alarm or informing the fire 
brigade. This resulted in loss of initial crucial time. Internal fire hydrants / 
sprinkler system were either nonfunctional OR the staff were not trained to 
operate them in an emergency situation. This resulted in the fire spreading 
rapidly and out of control . 
• The hospital security staff did not allow local residents to enter for rescue work 
after the fire was detected . Few local youths of neighboring slums scaled the 
hospital’s rear boundary wall and jumped into rescue work. Unfortunately, it 
was too late by then. 
• The hospital staff informed fire brigade and Police only when fire was out of 
control and only then all locked doors / gates were opened for rescue 
operations upon their arrival
Fire brigade help also turned up very late and were found entering smoke areas 
without BA sets. Also had no search lights / ladders to initiate any effective 
rescue operation at initial stage. 
• The fire alarm system for the building was found SWITCHED OFF to avoid false 
alarms. This resulted in no fire alarm alert and centralized AC system too did 
not trip automatically. The running of AC in fire situation resulted in spreading 
of smoke in unaffected upper floors causing huge number of casualties. No fire 
/ smoke dampers were found working in the fire situation. 
• External glass Façade made of double glass panes were very difficult to break and 
the building had no operable windows to dissipate smoke which resulted in 
many deaths due to suffocation / asphyxia 
• Emergency lighting too did not work / nor was adequately available resulting in 
total darkness inside the building hampering rescue / firefighting. Nobody 
started rescue operations using internal staircases / lifts ramps due to pitch 
darkness and presence of dense smoke at early crucial stage. The staff was 
untrained and was unaware of any emergency preparedness. 
• The rescue operation was seen being carried out using rope -ladders from outside 
the building reaching to the trapped personnel by breaking the façade glasses. 
Though this saved many valuable lives but the technique used to rescue was 
hilarious / dangerous. Few patients were found jumping on hydraulic platform 
from the window. 
• The basement was converted into pharmacy and godown stacked with highly 
combustible materials. It was learnt that even oxygen cylinders / LPG cylinders 
were found stored in the basement. 
• The Fire Brigade vehicles could not reach closer to the building since the 
approach route was halved due to DG set installation and Gas Bank and 
emergency vehicles could not turn through the narrow passage. 
• It is clear that all significant elements of the system failed - -starting from the 
regulatory oversight of the management to failure of State authorities in 
disaster management ; thus leading to loss of so many precious lives.

Learnings from the incident / Recommendations:
• All statutory and regularity compliance to be strictly implemented by the
management not only to get adequate NOCs but in view to safeguard life of
people.
• Disaster management plan to be prepared and implemented at site providing
clear-cut guidelines to staff and concerned about actions in various emergency
scenarios. The plan to be followed up with training of staff and continual
improvements through on site mock drills.
• Firefighting / life safety systems to be commissioned and to be maintained in a
Ready to Operate condition all the time
• Emergency power: Reliable source of emergency power to be installed in the
building at par with the codes and practices ( Use of MI cables may be made
compulsory ) so that even if main power source is switched off , life safety
systems, lifts, emergency lighting, peripheral lights etc shall be provided with un
interrupted power. This shall ensure rapid and effective emergency response.
• All emergency staircases and lifts should open in enclosed lobby (that can be
pressurized by blowers upon activation of fire alarm) to avoid vertical smoke and
flame travel. At least one emergency staircase shall open directly outside building
at Ground floor for safe evacuation and rescue.
• Openable windows: At least 15% openable windows to be provided that can be
opened easily during emergencies. These windows / doors to be marked with
signage and periodically checked for operability.
• Basement: Proper mechanical ventilation and smoke exhaust system to be
installed in basement to avoid smoke logging. No combustible materials to be
stored in it. Any type of modifications to accommodate storage of consumables /
stationery etc will be forbidden.
• Fire vehicle approach: Approach and peripheral roads to be designed to cater 20
meter turning radius for Fire Tender / Hydraulic Ladders and should be capable
of taking 40 tons load of Fire VehicleS.

Source: NAFO, Laxmikant Khare