ILO Report on the Fire at Kader Industrial Co. Ltd Factory (Buddha Monthon Nakhon Pathom Province, Thailand Monday, 10 May 1993) by David Gold, 4 June 1993

1. There was a major industrial fire with a significant loss of life which took place in the Kader Industrial (Thailand) Co. Ltd. Factory located in Nakhon Pathom Province, Thailand on the afternoon of Monday, 10 May 1993. The factory was located approximately 30 kilometers from the centre of Bangkok.

2. Kader Industrial (Thailand) Co. Ltd. is a company owned in-part by foreign interests. The company, along with two sister companies occupied four large buildings and several smaller associated buildings.

3. There have been several fires at this location prior to the 10 May 1993 fire, one on 16 August 1989 and the more recent being 13 February 1993.

• The fire in August 1989 destroyed three buildings and all associated machinery and equipment. Its cause was attributed to polyester fabric (used in the manufacture of dolls) igniting in a spinning machine. The manufacturing license was revoked by the authorities shortly after this fire. A new manufacturing license was applied for and granted.
• A small fire erupted late at night in a storage area on 13 February 1993. The cause of this fire which burned polyester and cotton has not yet been released. There were no reported injuries or deaths attributed to the 13 February fire. Within a few days after the 13 February fire, a labour inspector visited the factory and issued a warning containing five points. The warning addressed the need to appoint safety officers, the need for the provision of safety equipment, the provision of safety equipment for a goods lift to transport material from the first to the upper floors, health examination of workers and the need to provide an emergency plan.

4. It is reported that buildings numbers 1-4 were four story buildings constructed with an unprotected steel structure. (Unprotected means that the steel was not insulated against heat and looses its strength at high temperatures such as those generated in a structural fire.) The floor of the four buildings were prefabricated concrete. The fire completely destroyed three of the four large buildings.

5. Two stairways serviced the upper floors of each building. These stairways were the only means of access and egress to the upper floors with the exception of a goods lift and the connecting structures to other buildings. The width of each stairway was 1.5 metres. Buildings 1-3 were joined at each upper floor by a connecting structure and building 3 was connected to building 4 with a bridge at the level of the second floor.

6. Building number 1 was a four story building and is where the fire reportedly started on the first floor. According to the acting general manager, the first floor was used by the die cutting and sewing section. The second floor was a warehouse for finished products. The third floor was used by the finishing section and the fourth floor was used by the sewing section.

7. The Kader Industrial (Thailand) Co. Ltd. Factory reportedly manufactured soft stuffed toy animals in building number 1 and plastic dolls in building number 2.

8. It is understood from the acting general manager that in building number 1, normally thirty-six workers were engaged in activities on the first floor, ten on the second floor, five hundred on the third floor and six hundred workers on the fourth floor. It is reported that most of the deaths occurred to workers on the fourth floor.

9. It has been estimated that the fire broke out at approximately 4:00 p.m. The Police Fire Brigade received initial notification of the fire at 4:21 pm and the first fire apparatus arrived at the scene 19 minutes later. At this point building number 1 was in a partial state of collapse.

10. Although the official cause of the fire has not yet been released there are several possibilities that are currently being investigated. Initially, there was suspicions that the ignition source may have been of electrical origin. A second theory suggested arson. Currently, police are exploring the possibility that a carelessly discarded cigarette may have been the ignition source and a worker has been arrested by the police.

11. It seems clear at this time that the lack of an adequate number of clear, unobstructed means of egress to a safe area outside of the building contributed to the substantial number of deaths.

12. One hundred and eighty-eight deaths have been reported as associated with the fire, workers having died from contact with fire byproducts (such as heat and smoke) (approximately 80%) or from trauma due to being crushed. Additionally, several hundred workers are hospitalized, many with back injuries and bone fractures as a result of jumping from the upper stories of the building.

13. The fire has raised a great deal of concern nationally with the Prime Minister taking a strong position concerning the prevention of such disasters.

14. To date, the ILO study team has reviewed relevant press articles in both Thai and English languages, consulted with representatives of the management of Kader Industrial (Thailand) Co. Ltd., consulted with several divisions of the Ministry of the Interior's Department of Labour Protection, the Department of Public Works, the Thailand National Police Department's Police Fire Brigade, and the Ministry of Industry. Consultations were also held with the Employers' Confederation of Thailand and several Thai workers' organizations.

15. It was the objective of the ILO study team to develop an understanding of what occurred with a view to proposing solutions-oriented, locally implementable protective measures for enterprise-level action. It was clearly not within the scope or the purview of the study team to seek nor establish fault or blame for the unfortunate events.

16. The study team attempted to explore the possibility of developing a strategy for assisting the government to develop a wide-spread industrial fire prevention approach, concentrating on assuring, in its initial phase, emergency action planning at the enterprise level, evacuation alarms, adequate means of egress for workers to areas of safety and personnel trained in assisting the evacuation process.

17. The life loss at the Kader Industrial (Thailand) Co. Ltd. Factory centres around several distinct areas which should be taken into account by the management of all enterprises:

• The structural design of buildings and their ability to withstand fire until occupants can be evacuated to safety needs to be examined. This should be taken into account during the design and approval stage and periodically reviewed as buildings, processes and occupancies are modified.
• Although there was an alarm system, it is reported that the alarm did not function on the day of the fire. The ability to warn occupants of danger and the need to evacuate should be reviewed and reinforced.
• There should always be an adequate number of fire exits based on occupancies. These exits must always be unobstructed, well lighted and lead to safe areas outside of a building.
• Even after the February fire when a labour officer requested the submission of an emergency plan, no emergency plan was submitted by the enterprise. An up-to-date emergency plan should be developed and put into effect for all workplaces.
• Workers should be trained as to where emergency exits are located and appropriate actions to take if a fire alarm is sounded or if they detect a fire.

18. During consultations held thus far, several ideas have emerged regarding how the ILO may be of assistance and are being explored. These include the following:

• The organization of a one day workshop for officials from departments representing several ministries to explore ways of preventing and mitigating the effect of industrial fires
• The organization of a fully tripartite meeting to generate a list of implementable steps and an action plan for increasing plant level action for fire prevention and the preparation for in-plant emergencies
• Assistance to the National Institute for the Improvement of Working Conditions and Environment for strengthening the training of in-plant safety officers as concerns fire emergencies.
• Assistance to the government in the development of a promotional video on the evacuation of workers during a workplace fire.

19. The study team included Mr. Teuvo Uusitalo, Associate Expert, Mrs. Chinda Saengcharnchai, Administrative and Finance Officer and myself.

20. The study team should like to express its appreciation to the Ministry of Labour's Department of Interior's Department of Labour Protection and Welfare, the Public Works Department, the Thailand National Police Department's Fire Brigade, the Ministry of Industry, the Employers' Confederation of Thailand, the Thai Trade Union Congress, the National Free Labour Union, and the National Labour Congress.