Case Study

On June 13, 1997, at about 6.55 a.m., the bigger of the two transformers installed and maintained by DVB on the ground floor of the Uphaar Cinema building caught fire. At around 7 a.m, an explosion was heard by the security guard, who then discovered smoke in the transformer room. The fire brigade and the Delhi Vidyut Board (DVB) were informed and the fire was brought under control by 7.25 a.m. Inspection of the transformer by the Superintendent of the DVB and his team revealed that three of the low tension cable leads of the transformer had been partially burnt. At around 10.30 a.m., inspectors from DVB and Senior Fitter conducted repairs on the transformer by replacing two aluminum sockets on the B-Phase of the low tension cable leads. The repairs, it appears, were carried out with the help of a die and hammer, and without the use of a crimping machine. DVB completed their repairs between 10:30 a.m. and 11 a.m. The transformer was recharged for the resumption of electric supply by 11.30 a.m. on June 13, 1997

It is alleged that repairs conducted on the transformer in the earlier part of the day were unsatisfactory and resulted in loose connections that caused sparking on the B-Phase of the transformers. This resulted in the loosening of one of the cables of the transformer, which eventually came off and started dangling loose along with the radiator and burnt a hole in the radiator fin. Through this hole, the transformer oil started leaking out which, on account of the heat generated by the loose cable touching against the radiator, ignited the oil at about 4.55 p.m. on 13 June 1997. Since the transformer did not have an oil soak pit, as required under the regulations and the standard practice, the oil that spread out of the enclosure continued leaking and spreading the fire to the adjacent parking lot where cars were parked at a distance of no more than a metre from the door of the transformer. The result was that all the cars parked in the parking area on the ground floor of the cinema hall were ablaze. Smoke started billowing in the northern and southward directions in the parking lot of the cinema complex. The northern bound smoke encountered a gate, which was adjacent to a staircase leading to the cinema auditorium on the first floor. Due to chimney effect, the smoke gushed into the stairwell and eventually entered the cinema auditorium through a door and through the air conditioning ducts. The southward bound smoke similarly traveled aerially through another staircase and into the lower portion of the balcony of the auditorium from the left side. All this happened while numerous of people were seated in the auditorium enjoying the matinee show of ‘BORDER’, a popular Hindi movie with a patriotic theme

Because of smoke and carbon monoxide released by the burning oil and other combustible material, the people in the auditorium started suffocating. The Shift In-charge of the Green Park Complaint Centre of DVB received a telephonic message at the relevant point of time, regarding the fire. It was only then that the AIIMS grid to which the transformer in question was connected was switched off and the flow of energy to the cinema complex stopped. According to the prosecution, the supply of the 11 KV outgoing Green Park Feeder tripped off at 5.05 p.m. thereby discontinuing the supply of energy to the cinema. Inside the auditorium and balcony, there was complete pandemonium. The people in the balcony are said to have rushed towards the exits in pitch darkness as there were neither emergency lights nor any cinema staff to help or guide them. No public announcements regarding the fire was made to those inside the auditorium or the balcony, nor were any fire alarms set off, no matter the management and the employees of the Uphaar Cinema was aware of the fact that a fire had broken out. Even the Projector Operator was not given instructions to stop the film while the fire was raging nor was any patron informed about the situation outside. On the contrary, doors to the middle entrance of the balcony were found to be bolted by the gatekeeper who had left his duty without handing over charge to his reliever. More importantly, the addition of a private 8-seater box had completely closed off the exit on the right side of the balcony, while the addition of a total of 52 extra seats over the years had completely blocked the gangway on the right side of the balcony. Similarly, the gangway on the right of the middle entrance was significantly narrower than required under the regulations. All these obstructions, deviations, violations and deficiencies had resulted in the victims getting trapped in the balcony for at least 10–15 minutes exposing them to lethal carbon monoxide, to which as many as 59 persons eventually succumbed.