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Correspondent

23 August 2024 at 9:59:04 pm

Fatal Negligence

Newborns dying in a fire inside a government hospital is a devastating indictment of a system that is supposed to protect its most vulnerable patients. The Amravati District Women’s Hospital tragedy, where a blaze killed three infants, joins a long list of preventable institutional failures. Thirty-nine babies were inside the three-compartment facility when the fire erupted after a ventilator in the neonatal unit caught fire. Thirty-six were eventually rescued. Parents and eyewitnesses have...

Fatal Negligence

Newborns dying in a fire inside a government hospital is a devastating indictment of a system that is supposed to protect its most vulnerable patients. The Amravati District Women’s Hospital tragedy, where a blaze killed three infants, joins a long list of preventable institutional failures. Thirty-nine babies were inside the three-compartment facility when the fire erupted after a ventilator in the neonatal unit caught fire. Thirty-six were eventually rescued. Parents and eyewitnesses have alleged that the fire alarms did not sound and the automatic sprinklers failed to activate even as the district administration has said the hospital underwent regular fire audits and had applied for this year’s audit. An audit is meaningful only if it establishes that equipment works when lives depend on it. Maharashtra has already witnessed the deadly consequences of fire-safety failures in public hospitals. In 2021, eleven Covid-19 patients died in a fire at the Ahmednagar district hospital even though a fire audit conducted months earlier had recommended a firefighting system. The Amravati tragedy demands more than the familiar ritual of a high-level inquiry, compensation and promises of “strictest action”. The announcement of ex gratia payments cannot compensate parents who have lost a child they had barely begun to know. The investigation must establish not merely what ignited the fire, but why it was allowed to become fatal. Was the ventilator properly maintained? Were electrical and medical devices routinely inspected? Did alarms function? Were sprinklers operational? Was the NICU appropriately located and equipped for evacuation? Were staff trained and drills conducted? And most importantly, who was responsible for ensuring that every safeguard worked? There is another troubling detail: the neonatal unit was reportedly housed on the third floor, rather than at ground level, and questions have arisen over whether the unit was part of the building’s original plan. The state has built an elaborate architecture of laws and child-protection standards which seldom matches the situation on ground. Whether in government hospitals, schools or anganwadis, safety has become a box to be ticked rather than a responsibility to be lived. The most vulnerable children are consequently left dependent not on systems, but on the vigilance and heroism of individual staff members. That is an appalling way to run the childcare infrastructure of one India’s most developed states. A NICU is perhaps the worst possible place for institutional complacency: its patients are immobile, medically dependent and extraordinarily vulnerable to smoke, heat and even brief disruption of life-support equipment. The government must ensure that the Amravati deaths do not become another entry in the grim ledger of hospital tragedies followed by inquiries, outrage and forgetting. The real test will be whether the state can prevent the next newborn from dying in a hospital that was supposed to save him.

Mumbai Ferry Tragedy – A Straw That Needs to be Weighed

Updated: Dec 23, 2024

Mumbai Ferry Tragedy

Mumbai ferry incident on 18th Dec resulting in loss of over 13 lives reminds how imperfect things can get even in fair weather and broad day-light. It is a sad day for Mumbai ferry services which have been operating for over 100 years with a reasonably decent safety record. It is also a sad day for the Indian Navy, with CNS Admiral Dinesh K. Tripathi offering condolences and ordering an enquiry.


CAN OF WORMS

Indian maritime regulators (Directorate General of Shipping and State Maritime boards) should see this as a significant straw and not wait for the camel’s back to break.


MV Herald of Free enterprise (HOF) English channel passenger ferry, sank in a matter of 90 seconds killing 193 persons (passengers/crew) just about 0.7 Km from Zeebrugge berth (Belgium) in 1987. There seems to be a need to revisit and learn lessons from history.


Life saving appliance (Life jackets, Life boats, Life rafts etc) on board ships are designed for a ‘distress’ scenario or foreseeable worst case scenario and not for bizarre incidents such as this. The manner in which the high speed supposedly a Naval MARCOS boat hit the passenger ferry at about 60 km/hr speed (About 30 knots) is almost like a missile for the wooden tender boats. With just few seconds to act it is unlikely that passengers will be level headed in that moment of distress and wear life jackets with their head above their shoulders.


The fact that the boat had passengers in excess of their certified capacity is not something extra-ordinary East of the Suez. This however, does reflect the inadequate monitoring and control measures by Maharashtra Maritime Board, the authority which surveys a boat before a license is issued by Mumbai port trust.


Is it a case of poor accountability and responsibility by Mr Somebody, Mr Everybody, Mr Anybody OR Mr. NOBODY?


Upgrading the Kali Peeli Taxis of Mumbai Harbour

The incident is an eye opener and an opportunity for the age old kali peeli taxi's (wooden boats) of Mumbai harbour, operating for over 100 yrs, to be upgraded to modern fibre glass boats with AIS fitted on them for digital tracking, to match the 21st century Atal Setu trans harbour link bridge over the harbour.


Mumbai, India’s maritime hub, needs to set the trend and align with international standards for other Indian ports to follow.


Further as a matter of safety and good seamanship practice, all passengers travelling in boats which do not have life rafts and/or life boats, should don the life jackets prior boarding and hand-over at destination on or prior disembarking.


Cricket is to be played in Wankhede Stadium not Marine Drive Sea trails are conducted in open sea not in and around port channels where ships and boats are navigating and certainly not in Port limits.


Naval standards of safety are profound given the number of drills they conduct each day, thus giving a Safety talk to Naval personnel is like selling ice to an Eskimo. However, the claim of “double failure” of Engine and Steering is hard to swallow for any mariner.


Some questions that come to the mind of every mariner are:

- Who was at the Helm of the speed boat (experience and qualifications)?

- Why was Emergency STOP not activated if Engines were a problem?

- If steering was not working then how was the craft being manoeuvred in a zig-zag and circular manner prior impact, since this is not possible without a functional rudder?

- Who and how was permission given for sea trials in port limits?


Navy has a lot to answer, since this incident involves a civil craft (Boat) and civilian passengers, thus it will be prudent for Navy and investigators to come out with the facts. Any cover up is unlikely to remain under wraps for long. Thus if SOP’s have been ignored and if heads have to roll, then so be it.


American born safety research scientist William Heinrich would be turning in his grave if his 1931 accident triangle theory is ignored.


(The author is a Shipping and Marine consultant. Member Singapore Shipping Association and empanelled with IMO as a specialist consultant. View personal.)

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