Islamabad: An inquiry into the fire at the PIMS nursery that killed 14 newborns has concluded that an electrical fault in the supply cable of air conditioner number two was the most probable cause of ignition, while describing the tragedy as the result of “systematic and institutional failures.”
According to the inquiry report, the fire became visible at around 6:38am and dense smoke engulfed the nursery within one to two minutes, leaving an “exceptionally narrow rescue window.”
The emergency was reported to the Capital Emergency Service at 6:54am, creating a 16-minute gap that the committee identified as a major chronological concern, although the emergency service responded within minutes of receiving the confirmed notification.
The committee ruled out arson, multiple ignition points, an external IESCO fault, a pre-fire oxygen leak, and incubators or warmers as the cause.
It identified abnormal localised electrical heating in the AC Unit No. 2 supply cable as the most probable ignition mechanism. However, the precise electrical defect and the duty holder responsible for it could not be conclusively established.
The report held PIMS and its senior management principally responsible for failing to address known fire safety risks. It noted that 15 non-self-evacuating newborns were housed in a nursery designed for 10 patients, with only two doctors and two nurses immediately available.
The nursery also lacked a functional automatic smoke detection and fire alarm system and sprinkler protection, while no adequately documented, approved or rehearsed nursery-specific evacuation plan was found.
The committee further highlighted deficiencies in preventive electrical safety arrangements despite earlier warnings about fire risks.
The inquiry recommended a focused criminal investigation into possible culpable electrical installation or maintenance failures involving AC Unit No. 2, obstruction of emergency routes, non-action despite prior warnings and any proven delay in notifying emergency services. It also recommended scrutiny of Belfort Security Services and engineering contractor BE Engineers.
The committee, however, said frontline doctors, nurses and security personnel who attempted rescue should not be blamed for institutional failures, stressing that responsibility should rest with those who had the knowledge, authority and opportunity to prevent or mitigate the disaster.