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This document is a compilation of case studies on industrial accidents from various industries in India. It includes 31 case studies summarized by safety officers from the Directorate of Industrial Safety & Health. The case studies describe how different accidents occurred, the factors that contributed to the accidents, and recommendations to prevent similar accidents in the future. The goal is to help industry professionals learn from past mistakes and improve safety practices.
This document is a compilation of case studies on industrial accidents from various industries in India. It includes 31 case studies summarized by safety officers from the Directorate of Industrial Safety & Health. The case studies describe how different accidents occurred, the factors that contributed to the accidents, and recommendations to prevent similar accidents in the future. The goal is to help industry professionals learn from past mistakes and improve safety practices.
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This document is a compilation of case studies on industrial accidents from various industries in India. It includes 31 case studies summarized by safety officers from the Directorate of Industrial Safety & Health. The case studies describe how different accidents occurred, the factors that contributed to the accidents, and recommendations to prevent similar accidents in the future. The goal is to help industry professionals learn from past mistakes and improve safety practices.
Авторское право:
Attribution Non-Commercial (BY-NC)
Доступные форматы
Скачайте в формате PDF, TXT или читайте онлайн в Scribd
OFFICE OF THE ADDITIONAL DIRECTOR, INDUSTRIAL SAFETY & HEALTH,
PUNE
CASE STUDIES ON INDUSTRIAL ACCIDENTS
COMPILED BY OFFICE OF THE ADDITIONAL DIRECTOR INDUSTRIAL SAFETY AND HEALTH, PUNE
Preface We know that many stories of accidents, near-misses, and accidents waiting to happen go untold. According to Henrichs Theory of Accidents, for every one reportable accident there are 29 non-reportable accidents and 300 first aid cases. On analysis for the causes of accidents, he further states that cause are- 88 % accident due to unsafe act, 8 % accidents due to unsafe working conditions, 2 % each due to physical deficiency and natural disaster. Thus, unsafe act and unsafe working conditions are the main causes of the industrial accidents. As much as the next years promise to be exciting for the industry, they also pose a great challenge to the industry to maintain workplace safety and health. We must address this perception and change the reality. While workers are at work place, it is important that they do not risk life and limb. It is crucial that these workers go home safely after work. This compilation of case studies on fatalities and serious accidents in the industries is initiated and put together by the Office of The Additional Directorate Industrial Safety & Health, Pune. This booklet depicts how the accidents occurred and provides valuable learning points on how they may have been prevented. This booklet of case studies offers insights to all in the industry on how these tragic accidents occurred, so that we may glean important, lifesaving lessons from the experience. In learning from our past mistakes, we can and must prevent these mishaps from happening again. Together with your help, we can transform the factory into safe and healthy workplaces for our workers. Some human errors appear to be completely random. However, most errors are not random but are system induced or systemic errors caused by the unsafe system of work. The book will use case studies to demonstrate how and why they have occurred and what could have been done to reduce their likelihood of occurrence or the severity of their consequences. However, the objective of the book is not simply to reproduce case studies of systemic errors that have led to serious accidents. Rather, it is intended to identify common features in the accidents and the way they are investigated, so that lessons may be learned to prevent similar accidents in the future. There is another aspect of blame, which needs to be considered. In the immediate aftermath of a serious accident there is a natural tendency, especially by the management, quickly to suggest a cause by quite often the words it is believed the accident was a result of workers error are heard. The accident investigation does not accept human error as inevitable but goes on to reveal the underlying reasons. Organizations of the industries should look too closely at the system faults which caused the accidents. Further accidents of a similar nature will occur because the underlying causes have not been corrected. Apart from the human cost of future accidents in terms of loss of life, injury and trauma, the long term cost to the organization in loss of production, customers and reputation will far exceed the cost of correcting a faulty system. It is crucial both to the prevention of major accidents with multiple fatalities which make the headlines, as well as to the host of minor accidents leading to injury and disability, which rarely make the headlines, but still cause untold human suffering. Accidents could occur due to various reasons. It is not possible to cover case studies on all the types of causes. However efforts have been made to cover cases studies based on commonly used machines, processes, activities. They cover a variety of issues, ranging from accidents at Engineering Industries to chemical industries. The cases studies include accidents on the power press machines- Mechanical, Electro pneumatic, Hydraulic, machines like-pressure die casting machine, bagasse bale braking machines, lathe machines, etc. The case studies are based on the causes like non provisions of guards, lack of maintenance, unsafe system of maintenance work, unsafe material handling, unsafe working at height, unsafe working in confined space, unsafe method of pneumatic testing of coils of heat exchangers. It also covers the incidences like collapse of cement silos, sliding gate, boiler chimney, explosion of the reaction vessel, curing oven etc. The book comprises a wide range of case studies from various industries in order to show how systemic errors have in the past led to catastrophic accidents. The use of these case studies also enables the more technical subject matter in the book to be better understood. In order to change the future, the lessons of history need to be brought to bear on the present. This is why the book draws so heavily on what has happened in the past in the hope that some of the terrible accidents referred to in the case studies may never be repeated. The case studies in this booklet are presented in a typical manner. It provides you the information about how the accident occurred, what were the observations made by the investigating officer, what went wrong and also suggests the remedial measures. Through a series of case studies and the lessons drawn from them, you will: * Probe the methods of failure by which most industrial accidents occur, * Investigate common components of accidents, * Explore a common-sense strategy for systematic industrial operations, * Determine the purpose of operating limits and the safe operating envelope, * Review how alert, well-trained operators are developed, * Examine the importance of investigating abnormal events, * Realize the worth of continuing training, * Analyze a case study in implementing the systematic approach. The intention is that the reader can use the book to select an appropriate accident analysis methodology to suit their analysis needs, and then use the practical guidance and case study examples provided to see how the method works and then apply the method effectively. These factual cases studies are investigated by the officers of Directorate of Industrial Safety & Health. The success of this booklet will rely on every safety professional if they study each case thoroughly and take effort to prevent the accidents and not to create another case study in future. I express my sincere gratitude to the officers and staff of my office who directly or indirectly helped in compiling this book. Thank you!
M.N.Gadappa Additional Director Industrial Safety & Health, Pune
INDEX SR.NO. A CASE STUDY ON
COMPILED BY PAGE NO 1. Electro pneumatic Power Press Machine Shri.R.P.Khadamkar 01 2. Mechanical Power Press Machine Shri.A.B.Pawar 03 3. Hydraulic Power Press Machine Shri.V.M.Yadav 05 4. Power Press Machine- Unsafe system of work during maintenance work Shri.R.P.Khadamkar 07 5. Pressure Die Casting Machine Shri.R.D.Kichamabare 10 6. Rotary Vacuum Dryer Shri.J.B.Kumbhar 12 7. Bagasse bale breaking machine Shri.R.D.Kichamabare 14 8. Lathe Machine-Non use of tight fitting clothing Shri.R.P.Khadamkar 16 9. Lathe Machine-Unsafe system of work during maintenance work Shri.S.G.Giri 18 10. Material Handling-Use of improper lifting mechanism Shri.N.A.Deshmukh 20 11. Unsafe Material Handling Shri.S.G.Phadatare 23 12. Unsafe Material Handling in a Sugar Factory Shri.R.B.Lakhe 25 13. Working at height-Falling through fragile roof Shri.S.G.Giri 27 14. Falling from a Platform without Railing Shri.Y.P.Patange 29 15. Working in Confined Space-In a vessel at a Chemical industry Shri.J.B.Kumbhar 31 16. Working in Confined Space-In a tank at a Engineering Industry Shri.R.P.Khadamkar 33 17. Working in Confined Space -In a tank at Edible oil Industry Shri.R.D.Kichamabare 36 18. Falling in quenching tank containing hot water Shri.T.M.Kambale 38 19. Heat Exchanger-Unsafe system of work during pneumatic testing Shri.R.P.Khadamkar 41 20. Extrusion Machine-Use of a kerosene burner near the trough containing a highly flammable solvent-toluene Shri.A.B.Pawar 45 21. Explosion of the condenser coil Shri.P.V.Adkar 47 22. Chemical Industry-Unsafe system of work while handling Di Methyl di Sulphide. Shri.V.M.Yadav 48 23. Explosion of the Reaction Vessel Shri.P.V.Adkar 51 24. Minor Fire causing tragedy Shri.P.V.Adkar 53 25. Explosion in the curing oven Shri.P.V.Adkar 55 26. Collapse of cement silo at Ready Mix Concrete plant Shri.V.M.Yadav 56 27. Collapse of sliding gate of the shed of the factory Shri.R.P.Khadamkar 60 28. Prevention of fall of Boiler Chimney Shri.P.V.Adkar 63 29. Driving Fork Lift Shri.N.A.Deshmukh 65 30. Explosion due to Ammonia gas leakage in a cold room.
Shri.V.M.Yadav 66 31. Chlorine Gas Leakage-Successful Disaster Management
Shri.V.A.More 69 A Case Study On 1 1.SERIOUS ACCIDENT OCCURRED WHILE WORKING ON ELECTROPNEUMATIC POWER PRESS MACHINE Compiled By R.P.Khadamkar Deputy Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ A serious accident had occurred to a worker while working on the Power Press Machine in the factory premises.
ABOUT THE ACCIDENT: The factory is involved in the manufacturing of the various press components required for the automobile industries. The manufacturing process for the job Piller Side Wall involves various operations on C.R. sheets like-drawing, trimming, restriking, piercing etc. The drawing operation is carried out on the 400 T power press. The said power press was having loading side, from where the job was loaded for drawing operation and unloading side from where the job prepared, was taken out. On each side of the machine i.e, loading and unloading side, there was a push button station. Thus there were total two no. of push button stations. Each push button station was having two push buttons. When all push buttons were pressed, the stroke of the power press machine was getting operated. The injured worker was employed through the contractor as Power Press Operators. On the day of incidence, the injured worker along with a co-worker was entrusted with the work on 400 T Power Press machine in the factory premises for carrying out the drawing operation of the job Piller Side Wall. Accordingly they started the said machine. For carrying out the said job, the work involved was as under. The co-worker was working on loading side of the machine and the injured worker was working on unloading side of the machine. The co-worker was loading the job on the die of the machine through the opening in the punch and die of the machine by hands from loading side. Then both of them were operating the push buttons of the respective stations provided to them. With this the punch was coming down and the job was getting pressed between punch and die of the machine and punch was going back to T.D.C. (Top Dead Centre). After drawing operation, the injured worker was removing the job by hands from the die of the machine and keeping near the machine. They prepared about 700 no. of jobs in the above said manner. While the injured worker was removing the next prepared job from the die of the machine, the punch of the machine suddenly came down, while his right hand was still on the die. As a result, his right hand was caught and crushed between the punch and die of the machine. The accident resulted in the amputation of his right hand at level of mid forearm.
OBSERVATIONS: It was a Power Press Machine of capacity 400T. The main motor is of 3 phase, 440V, 60 H.P., 1440 RPM. The upper die fixed to ram forms the punch and the bottom die is fixed to the table i.e. bed. The size of punch and the die top was about 1600 mm x 930 mm. The maximum POWER PRESS M/C
distance between the punch and die was about 400 mm, when the punch was at TDC. The distance of the die top from the ground level was about 820 mm. The front and rear opening of the machine was of size of about 2840 mm x 1050 mm. The left side and right side opening of the machine was of size about 800 mm x 1400 mm. On each side of the machine i.e. loading and unloading side, a push button station was provided. Each push button station was having two push buttons. The loading side and unloading side and right, left side openings of the machine are not found provided with a photo sensitive guard or any other guard for preventing access to the punch and die, while the machine is in motion. For carrying out the drawing operation of job on the power press machine, a job is to be kept on the die of the machine from the loading side through the rear opening with hands. When the stroke of the machine operates, the punch comes down and the job gets pressed between the punch and die of the machine. As a result, drawing operation of the job takes place. Thus due to design, location, function, reciprocating action of the punch, the portion between punch and die is dangerous zone and constitutes the dangerous part of the machine, when the punch is descending.
WHAT WENT WRONG: 2
The accident had occurred, while the injured worker was removing the next prepared job from the die of the machine. The punch of the machine suddenly came down, while his right hand was still on the die. As a result, his right hand was caught and crushed between the punch and die of the machine. He was seriously injured. Thus, there was access to the dangerous parts of the machine, while the machine was in motion. The above said dangerous part of the machine ought to have been securely fenced by providing an interlocking photo sensitive safeguard to prevent access for any part of body to it from all sides of the machine, while the machine is in motion and also the safeguard for securely fencing of the above said dangerous part ought to have been constantly maintained to prevent access to the dangerous part, for each worker working on the machine. But the front opening (unloading side), the rear opening (loading side) and side openings of the machine were not provided with any safeguard for preventing access to the above said dangerous part of the machine, while the machine was in motion.
REMEDIAL MEASURES: i) The dangerous zone between punch and die of power press machine shall be securely fenced from all sides by interlocking safeguard and prevent access of any part of body and the safeguard shall constantly maintained and kept in position while the punch is in motion.
DANGEROUS ZONE DANGEROUS ZONE ACCESSIBLE FROM REAR SIDE A Case Study On 3 2.SERIOUS ACCIDENT OCCURRED WHILE WORKING ON MECHANICAL POWER PRESS M/C Compiled By A.B.Pawar Deputy Director Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------ A serious accident had occurred to a worker while working on the Power Press Machine in the factory premises.
ABOUT INCIDENCE: The factory is involved in the manufacturing of the various press components required for automobiles. The manufacturing process involved various operations on s.s. sheet like, blanking, forming, etc. The injured worker was employed as a helper. On the day of incidence, he was entrusted with the work on 150 T Power Press Machine for carrying out the forming operation. Accordingly he started the said 150T Power Press M/C. For carrying out the said job, the work involved was as under. He was keeping the piece of s.s. sheet on the die of the machine through the front opening of the power press machine by his right hand. Then he was operating the stroke of the machine by pressing the foot pedal switch provided at the front side of the machine. With this the punch was coming down and the s.s. sheet was getting pressed between punch and die of the machine and punch was going back to T.D.C. (Top Dead Centre). He was taking out the prepared job by his left hand through the front opening. Then he was again keeping another s.s. sheet for next job and the process was repeated. While he was keeping next job on the die of the machine through the front opening, the foot pedal switch got pressed by his foot, unknowingly and the stroke of the machine got operated. With this the punch of the machine came down and his right hand was caught and crushed between the punch and die of the machine. He was seriously injured. The accident has resulted in the amputation of the two phalanges of the fore finger and middle finger and part of the first phalange of the ring finger of his right hand.
OBSERVATIONS:
I It was 150T mechanical Power Press machine. The punch was fixed to ram and the die was fixed to the bottom table. The size of table was about 600 mm length x 730 mm breadth. The die was cylindrical having size of about 200 mm dia x 140 mm height. The maximum distance between the punch and die was about 120 mm, when the punch was at TDC. The machine is provided with the foot pedal switch at height 170 mm from the ground level. For carrying out the operation for job on the power press machine, a job was to be kept on POWER PRESS M/C DANGEROUS ZONE
For carrying out the operation for job on the power press machine, a job was to be kept on the die of the machine through the front opening with hands. When operator presses the foot pedal switch, the stroke of the machine operates. As a result the punch comes down and the job gets pressed between the punch and the die of the machine, to form the required shape and size. Then the punch goes up to the T.D.C. (Top Dead Centre) and the prepared job is removed from the die of the machine through the front opening by hands. Thus due to design, location, function, reciprocating action of the punch, the portion between punch and die is the dangerous zone and constitutes the dangerous part of the machine, when the punch is descending.
WHAT WENT WRONG?
4 The accident had occurred, while the said worker was keeping the next job on die of the machine by right hand. The stroke of the machine got operated, while his right hand was between the punch and the die of the machine. Thus there was access to the dangerous part of the machine, while the machine was in motion. The above said dangerous part of the machine ought to have been securely fenced by providing interlocking safeguard of substantial construction to prevent access for any part of body to it, while the machine is in motion. But the above said dangerous part of the machine was not securely fenced by providing with any safeguard to prevent access to it, while the machine was in motion.
REMEDIAL MEASURES: The dangerous zone between punch and die of power press machine shall be securely fenced by interlocking safeguard and prevent access of any part of body and the safeguard shall constantly maintained and kept in position while the punch is in motion.
NO SECURE FENCING TO DANGEROUS PART A Case Study On 5 3.SERIOUS ACCIDENT OCCURRED WHILE WORKING ON HYDRAULIC POWER PRESS M/C Compiled By V.M. Yadav Deputy Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ A serious accident occurred to a worker, while working on the hydraulic power press machine in the factory premises.
HISTORY: The factory was involved in the manufacturing of wheels required for cars, heavy motor vehicles. In the plant there were rim line, disc line and assembly line. The rims were manufactured on the rim line and the discs were manufactured on the disc line. The rims were fed one by one to the inlet conveyor of the hydraulic power press machine in the assembly line. The discs were kept on the rim at the inlet conveyor manually. Then the rim with disc was fed to the hydraulic power press machine by inlet roller conveyor. The hydraulic power press machine was operated to press rim and disc together to form a wheel.
ABOUT THE ACCIDENT: The injured worker was employed through the contractor and was working as an Operator. On the day of incidence, the injured worker along with other worker was entrusted with the work on assembly line for manufacturing of wheels.
Accordingly they started the 30 T Hydraulic Power Press Machine in the assembly line. The Hydraulic Power Press Machine was having parts like-a ram, a fixture, die tool, control system etc. A fixture was fixed to the ram provided at the bottom to form a punch, while a tool was fixed at the top to form a die. The punch was hydraulically operated. An inlet conveyor was provided at the left side for feeding rim and disc to the press machine. An outlet conveyor was provided at the right side of the press machine. For carrying out the said job, the work involved was as under. A rim from the rim line was fed to the inlet conveyor of the press machine. The injured worker was keeping a disc received from the disc line, on the rim manually. Then other worker was operating the machine from control panel to push rim along with disc on the fixture inside the hydraulic power press machine. Then he was operating the press machine from the control panel. With this the rim along with the disc was moving upwards by the ram of the machine and the rim and disc were getting pressed in between the tool (die) and the ram (punch) to form the wheel. The ram along with wheel was moving downwards again. The wheel was then fed to the next station for welding operation, by outlet conveyor. The process was being repeated for the next job again. They prepared about 300 such jobs in the above said manner. For next job, the rim along with disc was pushed on the fixture inside the hydraulic power press machine. But, the injured worker felt that the disc was not properly located on the rim. So, he put his right hand on the disc through the front opening of the machine to check and to confirm it. By that time the other worker, who was unaware about this, operated the hydraulic power press machine from the control panel. With this, the ram (punch) along with the rim DANGEROUS ZONE HYDRAULIC POWER PRESS MACHINE
power press machine from the control panel. With this, the ram (punch) along with the rim and the disc moved upward and the right hand of the worker was caught and crushed between the die tool and the job (disc on the rim). The accident resulted into the amputation of two phalanges of first finger and amputation of the middle finger, ring finger and little finger of his right hand completely.
OBSERVATIONS: It was 30 T Hydraulic Press machine. The tool of size 400 mm diameter fixed to the upper portion formed the die and the fixture fixed to the ram formed the punch. The rim together with the disc formed the job wheel. The size of the wheel was about 400 mm diameter x 160 mm height. The height of the fixture fitted to the ram was about 1300 mm from the floor level. The height of the disc of the wheel from the floor was about 1460 mm. The distance between the wheel top (disc) and the upper die tool was about 150 mm. The size of the front opening was about 550 mm x 700 mm. The ram was operated by the hydraulic pressure of about 100 bars. For carrying out the said operation on the 30 T hydraulic power press machine, a rim and disc were to be kept on the fixture fixed to the ram of the machine. The worker had to check whether the disc is located properly on the rim. When the auto cycle was started, the punch along with the rim and disc moved up and the job (the rim and disc) got pressed between the punch and die tool to form a wheel. Thus due to design, location, function, reciprocating action of the punch, the portion between punch (ram) and die (tool) was dangerous zone and constituted the dangerous parts of the machine, when the machine was in motion. 6 WHAT WENT WRONG:
The accident to the worker, while he was checking alignment of the disc on the rim by keeping his right hand inside the job wheel and tool die of the machine. Thus there was access to the dangerous part of the machine, while the machine was in motion. The above said dangerous part of the machine ought to have been securely fenced by providing interlocking safeguard of substantial construction to prevent access for any part of body to it, while the machine was in motion. But the above said dangerous part of the machine was not securely fenced by providing with safeguard to prevent access to it.
REMEDIAL MEASURES SUGGESTED: The dangerous parts of hydraulic power press machine shall be securely fenced by an interlocking safeguard to prevent access for any part of body to it, while the machine is in motion.
NO PHOTOSENSITIVE GUARD A Case Study On 7 4.A FATAL ACCIDENT WHILE REMOVING CLUTCH ASSEMBLY OF POWER PRESS M/C DURING MAINTENECE Compiled By R.P.Khadamkar Deputy Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------
A fatal accident had occurred due to unsafe system of work, lack of training, lack of instructions, while carrying out maintenance of the 150 T Power Press Machine in the factory.
CONSTRUCTION OF CLUTCH:
The manufacturing process in a factory involved use of an electro pneumatically clutch operated 150 T Power Press Machine. The machine had main parts like ram, bottom table, power transmission system, electro pneumatic friction clutch and brake unit, pneumatic control system, electric control panel etc. The clutch was air operated and mechanically interlocked brake unit. When clutch was engaged, the brake disengaged and when clutch was disengaged, the brake got applied automatically. The construction of the electro pneumatic friction clutch and brake unit was as follows. The clutch assembly was mounted on the shaft and consisted a cylinder, piston, inner disc, outer disc, brake facing plate, clutch facing plate and brake holding plate etc. The inner disc along with hub was mounted on the shaft close to the flywheel. The inner disc was provided with 18 no. of guides located in circular position. High tension springs were placed on each guide. The piston and cylinder were mounted on the shaft and fitted to a hub by using 8 no. of allen bolts, such that the springs got compressed between the back of piston and inner disc. The clutch facing plate was mounted close to the inner disc and brake facing plate was mounted close to the outer disc. When stroke of the machine was operated, the piston moves forward by air pressure against the spring tension causing brake to release and clutch to engage. At the end of stroke the air pressure releases and the piston comes back to its original position due to spring tension. Thus, under normal condition, when the clutch was disengaged, the springs remain in compressed state. A brake holding plate was fitted after the clutch and brake unit. The check nuts are provided outside the brake holding plate at the end of the shaft.
ABOUT THE ACCIDENT:
WORKER HIT BY CLUTCH ASSEMBLY POWER PRESS M/C CLUTCH ASSEMBLY 8 incidence taking place, a problem of stroke slipping on the said Power Press Machine was reported. On examination, the Maintenance contractor found that the gap between the clutch facing plates increased due to wear and tear of liners (brake, clutch facing segments). As per his instructions, the brake/clutch facing plate were removed and sent for replacing the liners. On the day of incidence, it was decided to carry out maintenance of the clutch assembly of the 150 T Power Press Machine so as to keep the clutch assembly ready, before the brake/clutch facing plate was received back. The Maintenance Supervisor told the deceased worker to help him in carrying out the maintenance work. He initially removed air supply line, rotor seal and solenoid valve. He brought a table near the machine and removed the check nuts of the clutch assembly by standing on the table. Then he removed one allen bolt out of 8 no. of allen bolts of the clutch assembly. Before he opened the second bolt, he went to the maintenance office for attending the phone call. By that time, the deceased worker climbed up the table for removing the allen bolts.
While opening the allen bolt, the clutch assembly got dissembled and the cylinder, piston came out speedily and hit against his chest and he fell down from the table. He was seriously injured and died on the spot.
OBSERVATIONS: The clutch assembly included a cylinder, piston, inner disc, outer disc, brake facing
plate, clutch facing plate and brake holding plate etc. The cylinder and piston were of cast iron and weight about 40 Kg each. Out of 8 no. of allen bolts (size M16 x 66.6 mm length), 6 no. of bolts are found in broken condition. Out of 18 no. of high tension springs (size 42.9 mm O.D. x 29 mm I.D. x 96.8 mm length), 4 no. of springs are found broken and one spring damaged. The cylinder, piston, springs, allen bolts are found lying on the floor. Under normal condition, when the clutch is disengaged, the springs remain in compressed state and hold the cylinder and piston close together by spring tension.
WHAT WENT WRONG?
The brake and clutch facing segments (liners) got worn out and the gap between the clutch facing plate increased due to excessive use of the machine. As the machine was continued to use with the excessive gap, out of 8 no. of allen bolts, 6 no. of the allen bolts broke, which remained inside the assembly. After removing one allen bolt, the deceased worker was removing the coincidently the remaining allen bolt. As soon as he removed the allen bolt, the spring tension released suddenly. With this, the clutch assembly got dissembled and the cylinder, piston of the clutch assembly came out speedily and hit against the chest of the said worker. As a result he was seriously injured and succumbed to injuries.
It is revealed that- i)Before opening the clutch assembly, tension of the H.T. springs was not released by using a puller or any other tension releasing
BROKEN ALLEN BOLTS BROKEN SPRINGS
CYLINDER PISTON
arrangement and it was not ensured that tension of the spring was released. ii)At the time of accident the clutch assembly was being dismantled on the machine itself without removing it from the shaft. iii)The machine was not maintained by timely replacing the clutch, brake facing, without allowing the gap between facings and discs to increase excessively. The machine was continued to use with the excessive gap, causing 6 no. of the allen bolts to break. Thus the systems of work were not safe. iv)The precautionary notice showing information and instructions in respect of 9 dismantling of the clutch were not displayed near the machine. Also training about safe system of dismantling the clutch was not given to the workers to ensure safety.
REMEDIAL MEASURES SUGGESTED:
i) While carrying out dismantling of the clutch, tension of the springs shall be released by using puller and it shall be ensured that the springs are in normal state. ii)Only trained workers shall be required and allowed to carry out such type of work.
A Case Study On 10 5. SERIOUS ACCIDENT WHILE WORKING ON PRESSURE DIE CASTING MACHINE By R.D.Kichambare Former Joint Director Industrial Safety & Health
Accident Type: Caught Between Type of Industry: Engineering Size of work Crew: 4/600 Work Site Inspection Conducted: Yes Designated competent Person on Site: No Employer Safety and Health Programme: No Training and Education for Employees: No Craft/Type of Deceased Employee: Unskilled Age and Sex: 19, Male Time on the Job: A month Time on the Task: 6 Hrs
Description of the Accident: In a factory involved in manufacturing Aluminum castings for automobile industry, a worker working on one of the several Pressure Die Casting Machines (PDCM), was crushed to death. In the said factory there were several PCDMs. One of them was of 800 MT capacity. The cylinder heads were manufactured on this machine. The machine had two large platens of size about one square meter, carrying molds on it. One on them was mounted on the tail stock, a reciprocating die carrier of the machine and the other was mounted on head stock of the machine, a stationary die holder of the machine. There was an interlocked guard on the machine consisting of two cages made out of wire mesh. One of the cages was a fixed one fencing the moving parts of the tailstock of the machine. The other was a reciprocating telescopic type.
The process involved, inserting loose cores in to the die on the tail stock, spray the dies with a special kind of oils for easy removal of the castings, insert a loose sleeve on the die mounted on the headstock of the machine, pouring a molten aluminum metal into the hopper of the injection cylinder of the machine, pull the reciprocating telescopic guard to cover the open space into which the die holding reciprocating tailstock would move to close the dies, and set the machine ready for injection, operate two interlock switches ( push buttons )on the body of the machine, and actuate the injection operation,
11 The operation of two switches would actuate the tail stock of the machine to move forward to close the dies and the molten metal would then get injected automatically in the die cavities. After the injection of the molten was complete, following was the sequence of the operation of the machine. The reciprocating tailstock of the machine would automatically traverse back into its earlier position, Open the reciprocating guard on the machine manually, Remove the castings from the machine, remove the loose cores from the castings, and keep them into trolley for further machining operations, set the machine for the next cycle, The cycle for the described sequence of operations was of about 3 minutes. The closing of dies would take hardly 5 seconds, after the guard was set in its place. Four workers were involved into the manufacturing of the Aluminum Castings in the manner prescribed above. Three of them were on one side of the machine on which a control panel was installed, on the pillar of the headstock of the machine and another worker, a forth one was required to work on the opposite side of the machine. One of the three workers was the main machine operator. His job was to spray the oil mist on the dies when they were ready for closing and injection, pour the molten metal into the injection cylinder of the machine, operated two interlock switches on the machine, to actuate the closing of the molds, followed by injection. The second would put the loose cores into the die cavities, and the third worker would help transfer the casting into the trolley, after it was taken out. The job of worker on the opposite side of the machine was to keep the loose sleeve on the die, mounted on the headstock of the machine. On the fateful day, the sliding portion of the interlocking guard (front gate) was not functional, and the machine was being operated
without using the front gate of the guard. It resulted in dies closing even before the sliding portion of the interlocking guard was pulled over to cover the opening into which the tailstock-die would move. The activity of manufacture had been going on this fashion for over two hours, with proper coordination amongst all four workers. At one stage, when the main machine operator was about to actuate the two interlock switches on the control panel, the forth worker on the other side of the machine noticed that the loose sleeve he had kept on the die mounted on the head stock had moved little away from its position. He therefore, leaned into the opening between the dies, and tried to set it right into its position. However meantime, unaware of what the worker on the side of the machine was doing, the main machine operator pushed the two switches on the control panel of the machine, for closing dies for injection. As the tailstock moved forward to close the dies for injection, the worker on the other side of the machine, who was leaning into the opening between the dies to set the loose sleeve right into its position, was caught with his upper portion of his body between the moving tailstock and the headstock, of the Pressure Die Casting Machine, and was crushed to death on the spot.
Accident Prevention Measures: An electrical interlock arrangement shall be provided so that the molds cannot be closed unless front safety gate is fully closed and on opening the front safety gate, the molds would stop automatically, A hydraulic safety shall be incorporated with the front safety gate such that it will prevent the tailstock mold plate forward, on opening of the front safety gate, The interlock arrangement so provided shall be maintained in effective working condition.
12 A Case Study On 6. SERIOUS ACCIDENT WHILE WORKING ON A ROTARY VACUUM DRIER. Compiled By J.B.Kumbhar Deputy Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ Serious accident took place in bulk drug manufacturing factory. One of the supervisor having qualification B.Sc. & Diploma in Industrial Safety, and employed as Production Officer met with an serious accident while he was working on Rotary Vacuum Drier (here after called as drier). ABOUT THE ACCIDENT: -- On the date of accident, the work of draining out Sodium Salicylate slurry from the drier was in progress and two workers were working in this area. At about 6.30 pm, it was noticed by two workers working on drier that Sodium Salicylate slurry in the drier had become thick and due to this drain valve was choked up. They tried to dilute slurry by circulating steam through drain valve jacket but it was of no use. So, these two workers requested IP to remove this choke up by showering water in side the drier. So, IP went on the drier platform and started showering water in side the drier through its top opening with the help of inch plastic pipe. At that time, his right hand thumb came in contact with the rotating blades (plates) of the stirrer and it was caught & pulled in the gap between the blades and the inner surface of the drier body. This resulted in the on the spot amputation of his right hand palm up to wrist. He immediately rushed down to the ground floor and requested other two workers to call for vehicle. He then ran up to 100 m towards the office. From there he was taken to local hospital. He was given first aid and as per the advice of local Dr., he was shifted to orthopedic specialist for further treatment. His amputed right hand palm was brought to hospital by another vehicle at about 11 pm. It was checked by Doctors and after examining the amputed palm, it was concluded by doctors that it was not possible to in plant the amputed part of his right hand. This accident has resulted in to amputation of right hand palm up to wrist.
OBSERVATIONS:- The said drier on which the IP met with an accident is located in Sodium Salicylate department. This drier is on the platform and there is one centrifuge on the ground floor adjacent to the platform. There is 1005 x 195 mm opening provided on the top of this drier. Height of this top surface of this opening from the working platform floor is 940 mm. There is one stirrer (shaft) fitted in side this drier and it is connected to 10 HP,(1440 rpm ) electric motor through reduction gear box. On this stirrer, blades (metallic plates) are fitted alternatively. The minimum gap between the inner surface of the drier body and the outer diameter of stirrer plates is 5 mm. These stirrer plates rotate in clockwise direction and its rpm is 7. Depth of the rotating stirrer blades from the top surface of the top opening is 150 mm. Body of this drier is a jacketed vessel for circulation of steam. On the bottom side of this drier, there is one 4 inch drain valve. This drain valve is also provided with arrangement for circulating steam around it. One hose pipe is connected to this drain valve and the other end of this hose pipe is connected to centrifuge. This drier is used to remove excess water from the Sodium Salicylate solution. For this, Sodium Salicylate solution is charged in to this drier by pipe line and it is heated by circulating steam through the
jackets and simultaneously stirring/blending is done. Then the slurry of the Sodium Salicylate is drained out in to centrifuge through drain valve by gravity. WHAT WENT WRONG:- On this stirrer, blades (metallic plates) are fitted alternatively inside the drier body.. The minimum gap between the inner surface of the drier body and the outer diameter of stirrer plates is 5 mm. These stirrer plates rotate in clockwise direction with 7 rpm. Depth of the rotating stirrer blades from the top surface of the top opening is 150 mm. It was essential to provide suitable inter
13 locking arrangement to the top lid of the drier so that the drier will not start when the lid is open. However, during inquiry with the IP, it was revealed that there was no lid provided to the top opening of the drier, when he met with an accident. REMEDIAL MEASURES: In order to avoid such type of accidents in future, it was recommended to provide suitable interlocking arrangement to the top lid of the drier so that the drier will not start when the top lid is open and it will stop automatically if the top lid is opened when stirrer is in motion.
A Case Study On 14 7. A Worker Gets Ripped to Death
By R.D.Kichambare Former Joint Director Industrial Safety & Health ------------------------------------------------------------------------------------------------------------------------------ In a Sugar Factory, a worker got ripped to death while working on Bagasse Bale Breaking Machine.
Background: A bagasse is, a left over sugar cane body, after juice is totally extracted from it, in the process of Manufacture of Sugar. The bagasse, is thus a by-product of Sugar Factories. Every year, several tonnes of bagasse is generated in Sugar Factories. The storage of bagasse in loose form is a great problem for the factories. It is therefore, compacted into bales, on Bagasse Baling Machines, while it is still moist. Normally, the bales are of 1'x1'x1' ( one cubic feet )size. After the bails are compacted on Baling Machines, they are bound by steel cross wires, in order that the bales do not easily open. These bales are stacked in pyramid form, in open in the Sugar factory compound, to be used as a Boiler fuel, for the next Sugar Cane crushing season of the factory. For using the bagasse from these bales as a fuel for boiler, it becomes necessary to remove the steel wires on the bales and break the bales into loose bagasse, in order to ensure the efficient combustion of the bagasse. This is done on Bagasse Bale Breaking Machines. The Bagasse Bale Breaking Machine consist of two closely held spiked rollers, revolving in opposite direction, housed in a open hopper. The rollers are driven by a electric motor. The rotary motion from motor is transmitted to the spiked rollers by the pulleys and belt drives. The bale breaking operation is carried out by feeding wire bound bales on to the spiked rollers, in the hopper of the Bagasse Bale Breaking Machine. The spiked rollers, revolving in opposite direction, hold back the entangled steel wires, bound around the bagasse bales. It further tears the bound bagasse bales into loose bagasse. The loose bagasse falls on to the running conveyer at the bottom of the Bagasse
Bale Breaking Machine, and the loose bagasse is carried to the boiler, to be used as a fuel. The steel wires which are held back, get entangled on the revolving spiked rollers. These wires need to be removed frequently to allow the Bagasse Bale Breaking Machine, to work efficiently for breaking the bagasse bales into loose bagasse. The operators of the Bagasse Bale Breaking Machine, were required to remove the steel wires removed from the bales and entangled in the spiked rollers. The operators were allowed to remove it by sitting over the accumulated heap of the bagasse to the level of the hopper, around the Bagasse Bale Breaking Machine, by using their legs to remove the entangled wires.
Brief Description of the Accident: On the day of the accident, as the operator was sitting on the edge of the hopper, and was busy in removing the steel wires of the bagasse bales entangled on the spiked rollers, by his legs, his legs was caught in the gathering in spiked rollers, and the operators was pulled into the hopper. With the result, both of his legs were entangled in the spiked rollers, and his legs got ripped into pieces. As the alarm was raised by the injured operator, the workers working around, immediately cut off the electric supply to the Bagasse Bale Breaking Machine, and tried to rescue the injured worker. The body of the worker had to be removed by dismantling the spiked rollers of the Bagasse Bale Breaking Machine. However, by the time the injured worker was rescued, he had bled profusely through the rip injuries on his legs, and succumbed to them.
Accident Prevention Recommendations:
i) The steel wires used for binding the Bagasse Bales, should be removed, before the bales are fed for being broken into the Bagasse Bale Breaking Machine, ii) A long chute, preventing the access of the workers to the spiked rollers, with a closed but 15
interlocked hopper, should be provided on the Bagasse Bale Breaking Machine, in order to ensure that the access of the worker is prevented to the dangerous revolving gathering in spiked rollers, while they are breaking and opening the bagasse bales.
A Case Study On 16 8 .SEROUS ACCIDENT ON A LATHE M/C DUE TO UNSAFE SYSTEM OF WORK Compiled By R.P.Khadamkar Deputy Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ The serious accident to a female worker occurred, while working on the lathe machine in the factory premises.
ABOUT THE ACCIDENT:
The factory is involved in the machining of the components required for the manufacturing of the automobile components like gears, cross bars etc. The raw material is received in the form of forged jobs of gears, cross bars from the forging factories. The machining process on the cross bars involved operations like facing of cross bars on the lathe machines and making holes of required size in the cross bars by using drill machines. The injured worker was working as a helper. On the day of incidence, the injured worker was entrusted with the work of facing operation of the job-cross bars on the lathe machine. Accordingly, she started the lathe machine. The lathe machine was an electrical power driven machine and having parts like head stock fitted with chuck, tail stock, tool post, lead screw, power transmission system and an electric motor. The operation on the lathe machine was as follows. The job is held in the chuck and a tool is fitted to the tool post. When the machine was started, the power from the electrical motor is transmitted to the chuck and also to the carriage through the transmission system. The lead screw was having square threads and provided at a height about 600 mm from the floor. When the machine was started the job along with the chuck started rotating and the facing operation was carried out by using the tool fitted in the tool post. The lead screw also got rotated by a power transmission system, while the machine was in motion. She carried out the facing operation of about 30 jobs-cross bars on the lathe machine. While she was carrying out the facing operation for the next job on the lathe machine, the loose end of her sari i.e. padar got entangled with the rotating lead screw. As a result she fell and hairs of her head also got entangled with the rotating lead screw. The supervisor rushed to the lathe machine and stopped the machine and removed her. She was seriously injured. The hairs along with the skin of her head got detached from the skull. The accident has resulted in the serious head injury to her. Also part of the lobe of her left ear got amputated.
OBSERVATIONS:
The lathe machine was of 3-phase, 415 V, 1440 R.P.M., 3.0 H.P. an electrical power driven machine. The overall size of the machine was about 2400 mm L x 500 mm B x 1200 mm H. LATHE M/C LEAD SCREW TO WHICH HAIRS OF WORKER GOT ENTANGLED
The lead screw was of 40 mm dia x 2400 mm length and was having square thread on its throughout its length. It was located at the operator side at a height about 600 mm from the floor. The power from the motor was transmitted to the lead screw through the belt, pulley, gear train. The lead screw rotated at a speed about 30 R.P.M.
WHAT WENT WORNG: It is revealed that- The lathe machine was having moving parts like-chuck, lead screw, carriage and parts of transmission system. The serious accident to the worker had occurred, as the loose end of her clothing i.e. padar of sari got entangled with the lead screw of the lathe machine, which was in motion. As a result, she fell down and hairs of her head got entangled with the moving parts i.e. lead screw. She was seriously injured. i)The injured worker ought to have been provided with the apron or tight fitting clothing to prevent loose clothing getting entangled with the any moving parts of the lathe machine. 17 ii)Also, the injured worker ought to have been provided with cap/ helmet on her head (with hairs tied in a bun) to prevent the hairs of her head getting entangled with the any moving parts of the lathe machine. But she was not provided with such or any other type of the personnel protective equipments, when she was required to work on the lathe machine. Thus the systems of work in the factory were not safe and involved risk to the health and safety of the injured worker working on the lathe machine.
REMEDIAL MEASURES SUGGESTED: i)No female workers shall be required / allowed on such type of machine, unless she has been provided with the apron/ tight fitting clothing and its use is ensured. ii) No female workers shall be required / allowed on such type of machine, unless the hairs of her head are tied in a bun and she has been provided with the cap to prevent hairs coming out.
A Case Study On 18 9. SERIOUS ACCIDENT ON LATHE M/C DUE TO UNSAFE SYSTEM OF WORK. Compiled By S.G.Giri Assistant Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ A serious accident occurred to a worker, while working on the lathe machine in the factory premises.
HISTORY: The factory was involved in the manufacturing of domestic pressure cookers. The process involved cutting, pressing, turning operations by using the machines like power press machines, lathe machine. The lathe machine was electrical power driven machine. The power from the main motor was transmitted to the chuck through the V- belt pulleys. A Forward/Reverse switch having lever was provided at the front side of the machine for starting the lathe machine. For adjustment and setting of the machine, V-belts were required to be removed. After carrying out of the alignment of slider and setting of the machine, the belts were fixed again on the pulleys.
ABOUT THE ACCIDENT: The injured worker was working as Lathe Machine Operators. On the day of incidence, the injured worker along with other worker was entrusted with the work of the trimming of pressure cooker lids on the lathe machines. After the lunch, the operation for small lid was to be carried out. Hence it was necessary to carry out slider alignment and setting of the
lathe machine. For carrying out the work, the belts from the main pulleys were to be removed. The injured worker called the other worker and asked to help in the setting work. The other worker was working on the front side and the injured worker was working at the rear side of the lathe. At that time, while the injured worker was trying to remove belt from the pulley by rotating the main pulley of the machine by left hand, the switch of the machine got operated by the body of the other worker, unknowingly. As a result, the motor and pulley started rotating in reverse mode and left hand thumb of the worker got caught in and crushed in the intake nip formed between the belt and the third pulley. The accident resulted in the amputation of his left hand thumb.
OBSERVATIONS: The lathe machine was electrical power driven. The overall size of the machine was about 2370 mm L x 1000 mm B x 1100 mm H. The driving pulley of size 100 mm dia was mounted on the motor shaft. The driven pulley of size 400 mm dia was mounted on the shaft, on which six pulleys of different sizes were mounted. The
LATHE M/C BELT PULLEY IN WHICH THUMB CAUGHT
19
power from driving pulley is transmitted to the driven pulley through a V-belt. The 3 rd pulley was of size 180 mm dia, from which power was transmitted to another set of driven pulleys. The extreme right pulley was coupled to the slider driving pulley through a V-belt. A Forward /Reverse switch was provided at the front side of the machine, at a height of about 800 mm from the ground floor. When the lever of the switch was turned to left position, the motor rotated in clockwise direction and when it was turned to right position, the motor rotated in anticlockwise direction. When the motor was started, the power was transmitted to the set of pulleys. The speed of first set of pulleys and hence 3 rd pulley was about 360 R.P.M. The height of the 3 rd pulley was about 1000 mm from the ground floor. When the motor rotated in anticlockwise direction, the portion between the V-belt and the 3 rd pulley formed intake nip. A main ICTP switch was installed on the wall near the machine, from where an electric supply was provided to the Forward / Reverse switch.
WHAT WENT WRONG:
i)Before starting the said work, the electric fuses of the main ICTP switch of the lathe machine No.2 ought to have been removed and kept in the custody of the responsible person to prevent starting of the lathe machine by anyone unknowingly. But fuses were not removed and not kept in possession of responsible person. Thus the systems of work were not safe and involved risk to the health and safety of workers at work. ii)Also, while carrying out the said work, there was no supervision for ensuring that the said work should be carried out safely.
REMEDIAL MEASURES: i)Before starting such type of the work, the electric fuses of the main switch shall be removed and kept in the custody of the responsible person to prevent starting of the machine by anyone unknowingly. ii)Such type of work shall be carried out the under the supervision of the responsible person to ensure that the said work should be carried out safely.
LEAVER OF FORWARD / REVERSE SWITCH OPERATED ICTP SWTICH FROM WHICH FUSES WERE NOT REMOVED A Case Study On 20 10. A FATAL ACCIDENT DUE TO IMPROPER LIFTING MECHANISM Compiled By N.A.Deshmukh Assistant Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ A fatal accident had occurred, while handling a load body for loading it into the truck.
ABOUT ACCIDENT:
The premises was involved in the manufacturing of load bodies required for transport vehicles. The process involves the fabrication of bodies and painting. Then the load bodies were loaded on a truck with the help of a monorail crane at dispatch section in the factory. The deceased was working as a Supervisor. On the day of incidence, the deceased along with four other workers resumed their duties in third shift. On resuming duties, they went to the dispatch section to carry out the work as usual. The work involved was as under. After fabrication and painting the load bodies were brought to the dispatch section. They fitted accessories to the load bodies and carried out the touch up painting of the load bodies. Then the truck was brought to the delivery end of the dispatch section. The deceased with the help of other worker was loading the load body on the truck. The process of loading the load body into the truck was as follows- The load body, which was ready for dispatch was kept on the ground at the delivery end of the section. The truck was parked in reverse direction with its carrier towards the delivery end. The monorail crane was brought at the delivery end in the dispatch section. A lifting tackle having two ends provided with brackets with holes at each end was hanged into the hook of the crane. Then two polyester webbing slings were put into the each hole of the lifting tackle in such way that two loops were formed at each end of the lifting tackle. The load body was provided with J hooks welded to both sides. Two loops of sling were being inserted into two J hooks of one side of the load body and the other two loops of the sling into two J hooks at the opposite side of the load body. Then, the load body was being lifted with the help of the monorail crane. Then the orientation of the load body was made proper by turning it horizontally manually in hanging condition, so that it could be properly fitted to the fixture provided at the carrier of the truck. After fitting a load body on a carrier, the loops of the slings were being removed and the load body was being dispatched. Then the procedure was repeated for the next load body. In this manner they loaded about 7 no. of load bodies till 1.30 A.M. At about 1.30 A.M., there was tea time so all of them, except the deceased went for tea at LOAD BODY LOAD BODY HIT
the open space near delivery end of the dispatch section. But the deceased, a Supervisor waited there for loading the next load body. He hanged the load body to the webbing slings inserted in the lifting tackle in the above said manner and lifted it with the help of the monorail crane to a height about 2.5 metre. He kept the load body in hanging condition with the crane and he was going to call the truck driver to bring the truck at the delivery end for loading. While passing beneath the hanged load body, when he turned the load body by hands for making its orientation proper, the sling slipped from the J hook (driver side) of the load body. As a result, the load body got tilted due to unbalance and swirled clockwise and hit against the head of the deceased. The workers lifted the load body by crane and removed him. He was seriously injured and was immediately shifted to the Hospital, where he was declared dead. OBSERVATIONS: The load body was fabricated by using the m.s. sheet, angles, channels etc. The overall size of the load body was about 5100 mm L x 2150 mm B x 2200 mm H and weight was about 810 Kg. The load body was provided with 8 no. of the J hooks along the lengthwise to its both sides ( Driver and Cleaner). The J hook was made of m.s. rod of 12 mm dia and is of size 18 mm radius x 90 mm length. The J hooks were fixed to the load body by welded joints. The J hook and mud guard at drivers side of the load body were found in damaged condition. The polyester webbing slings were of having capacity 1 T each. Each sling was of size 6000 mm length x 50 mm width x 12 mm thick and 21 was having loop of size 410 mm length at both ends. The lifting tackle was of m.s. and having size 2280 mm length and was provided with bracket with circular hole of dia 60 mm at each end. The monorail crane provided was of capacity 1T. The crane was having electrical power driven hoist and long travel. WHAT WENT WRONG:
It was revealed that-The fatal accident occurred, while handling the load body for loading it to the truck. The deceased was required to turn the load body in hanging condition, so as to make its orientation proper and to fit it on the carrier of the truck. While handling the load body with the crane, the loop of the polyester sling came out of the open end of the J hook. As a result the load body swirled due to unbalance and hit against his head causing fatal accident. The lifting mechanism including the crane, lifting tackle, polyester webbing sling, J hooks on the load body were being used for handling the load bodies and loading it to the truck for further transport of load bodies. The load of the body is transmitted to every parts of the lifting mechanism. The load body ought to have been provided with round hooks and the webbing slings ought to have been provided with the hooks at ends having spring loaded positive locking arrangement to prevent the sling coming out of the hooks of the load body, while lifting or in lifted condition. But the lifting mechanism i.e.J hooks, webbing slings without having J HOOK WITHOUT LOCKING any type of locking arrangement were provided and used for handling the load bodies, which caused the fatal accident to the said worker. 22 Thus the arrangements in the factory in connection with the handling, transport of heavy articles like load bodies were not safe and involved risk to the health and safety of workers at work.
REMEDIAL MEASURES: i) The lifting mechanism having round hooks and webbing slings with hooks having positive locking arrangement shall be provided and used to prevent the sling coming out of the hooks of the load body, while lifting or in lifted condition.
LIFTIN G TACKL E
A Case Study On 23
11.A FATAL ACCIDENT AT A FACTORY MANUFACTURING-ERW AND CEW STEEL TUBES
Compiled By S G Phadtare Deputy Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ A fatal accident that took place at 16:45 pm with worker age 27 years, employed through a contractor
MANUFACTURING PROCESS: Manufacturing of S.S. E R W (electric Resistance welding) tubes is being carried on in this factory. The steel role (coil) received at factory is slit on slitting machine into the coils of required width, depends upon the diameter of tube to be manufactured. Then these slit coils are loaded on trolley and brought to the tube mill section. Then individual coil is lifted by EOT crane and stored near tube mill machine. Single coil is lifted by a local crane and loaded on support of mill machine and locked by locking plates. The operator who brings the slit coils to mill machine ,also load the coil on support of mill machine, with the help of fixed crane near mill machine. Open end of coil is taken to further process of formation of tube by ERW process. Loading of coil on support of mill machine and locking it as per the photographs attached no.1 to 5
ABOUT THE ACCIDENT: On the date of accident, the crane operator joined duties in second shift. According to him his duty was to bring slit coil from trolley to mill machine by EOT crane, then load the coil on slit loader of mill machine by a local crane (2 ton capacity) and lock the coil with locking plates. After joining duties he brought 4 slit coils by EOT crane (7.5 ton) to mill machine no. 1. Out of these 4 coils, he loaded one coil on machine and started the tube formation process. Each coil is weighing appx.1.35ton
At 16.45pm, to load the second coil on machine (position of both coils is shown in photograph no 6), operator removed the locking plates and
was loading coil on slit loader, the coil dashed against the foundation of mill machine .Due to which the chain holding the coil slacken, the coil was unbalanced and one end of chain came out of hook as spring loaded locking mechanism was not working.(photo no.7) The coil fell on one side, on the deceased worker who was doing cleaning work near the machine.(Photo no.8). He was pressed below the coil. Immediately the crane operator, with the help of EOT crane, lifted the slit coil and injured worker was taken out. He was put in ambulance and taken to hospital where he was declared dead.
WHAT WENT WRONG: After verifying the locking system of hook, it was observed that the spring loaded locking system, which prevents the chain coming out of opening of hook, is not working. As such after dashing the coil to the machine foundation, chain was slacken and easily came out of hook and the coil fell on one side on deceased. The said crane was got examined by a competent person declared under Factories Act 1948. He was again asked to carry out the examination of the said crane and give his observations. Accordingly he had given his observations, which supports the cause of accident.
REMEDIAL MEASURES: It shall be confirmed that the spring loaded locking system, which prevents the chain coming out of opening of hook, shall be working.
24
A Case Study On 25 12. SERIOUS ACCIDENT DURING MATERIAL HANDLING DUE TO UNSAFE SYSTEM OF WORK Compiled By R.B.Lakhe Deputy Director Industrial Safety & Health, Pune
In one factory worker met an serious accident, while loading the M. S. Plates on the platform of the truck, sustaining serious head injury which proved fatal. This accident occurred due to adoption of unsafe system of work.
ABOUT ACCIDENT: On the day of accident, the deceased worker, had attended the duty at 8.30 am as usual along with three coworkers And the work of loading the M S plates (size 5m.x 1.25m. x 6mm ) in the truck was being carried on in the stored yard of the factory. In store yard of the factory, there are various types of material such as M S bars, angles, channels, pipes including M S Plates and on the said day the work of loading of m s plates was to be completed, which was started with the help of JCB loader for lifting the plates, employing four workers. The system and arrangement of loading the M S plates in the truck was as follows. The plate which was to be loaded in the truck was being made holes lengthwise at a distance of one meter from both the ends of the plate by gas cutter. Then the wire rope ( 5/ 8 ) with Dshackle was bolted in both the holes and the plate was lifted vertically by JCB ( power-76 hp. ) 6 inch above the height of platform of the truck (4 ft.) and was being dropped on the platform which was falling horizontally with huge sound on the platform with most of the portion outside the platform of the truck in imbalance position Then the four workers were used to push the plate inside, on the platform so as to load it completely on the platform. It is marked that, the JCB which is used specifically for digging purpose was used for lifting and loading the heavy plates resulting into the said fatal accident. On the day of accident, the deceased worker, along with his coworkers started the work of loading at 9 am. and completed the loading of one M S plate till 9.30 am. under the supervision of Supervisor Shri S Y Pansare. As there were total 12 Plates the supervisor, thought that loading may consume more time if plates are loaded one by one and therefore second time two plates were taken at a time, which were made holes by gas cutter and wire rope with Dshackle was bolted to both the plates and was lifted vertically by the hand (bucket) of JCB and dropped on the platform of the truck. The plates fell horizontally on the platform in such a way that most of the portion ( 75 %) was outside the platform. Immediately after falling the plates, the deceased worker who was standing there itself, started loading the plates, along with three coworkers by pushing the said plates inside, on the platform and while doing so, the plates which were in imbalance position due to maximum portion outside, fell on the body of the workers. However the other coworkers escaped miraculously and the plates fell on the back of the deceased sustaining serious head and neck injury. The other workers nearby rush to the spot. However the deceased worker was profusely bleeding. He was immediately taken to Hospital. However Doctor examined and declared him dead.
SPOT ANALYSIS : The spot examination, work system of loading the plates , working of JCB, Position of lifting plates, position of truck platform , working position of the deceased worker etc. revealed the details which are as follows-
1) Machine / Mechanism : JCB Loader 2) Make : BEML Ltd. 3) Bucket Capacity of lifting soil : 1 cu m. 4) Power : 76HP 5) Operating height : 5.8 m. 6) Size of wire rope with D shackle : 5/8 inch
7)Dimension of M S plate : 5m x 1.25m x 6mm 8)Weight of one Plate : 300 kg 9)Size of loading platform of truck: 5.3 x 2.4 m. 10)Distance of loading platform from ground level: 4 ft. 11) Position of plates while lifting : Vertical 12)Position of plates after dropping on platform: Horizontal 13)Portion of plates outside platform after falling : 75 % 14)Plates lifted at a time : 2 No. 15)System of loading plates: Improper and Dangerous 16)Arrangement for handling of plates : Unsafe and Risky
WHAT WENT WRONG: The lifting of heavy M S plates by JCB loader is itself very dangerous act since it is not meant for lifting plates but for the use of digging the soil. Further for loading the plates after falling in imbalance position on the platform of the truck, the workers should not have allowed to push it inside , on the platform of the truck unless stable position of the plates was ensured which was not done and resulted into the said fatal accident.
26 Secondly, the arrangement used in connection with handling that is lifting the plates was done by JCB loader which is at all not meant for the said purpose. The Management should have provided and carried out the said work of lifting and loading by making the arrangement of suitable crane to ensure the health and safety of the workers at work and further by adopting the proper system of work that are safe and without the risk to health, which could have prevented the said accident.
REMEDIAL MEASURES : 1)The suitable crane with adequate lifting capacity shall be provided for lifting / handling the heavy M S plates. 2) The plates shall not be lifted vertically and dropped down from the distance which is dangerous to cause accident. 3) The proper system of lifting and loading shall be adopted to ensure safety and absence of risk to the health of the workers. 4) The workers shall be well acquainted and properly trained to carry out the loading of heavy plates. 5) Protective wears like safety shoes, helmet, hand gloves shall be provided to the workers.
Case Study On 27 13. FALLING THROUGH THE FRAGILE ROOF Compiled By S.G.Giri Assistant Director Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------ An accident to a worker had occurred while walking on the A.C.Sheet roofing of the building in the factory premises.
HISTRORY: The factory was involved in the bottling of foreign liquor. There was an old administrative building having A.C.sheet roofing, inside the factory premises. The cabins inside the building were having false ceiling. The false ceiling was at height of about 3150 mm from floor and above it was the A.C.sheet roofing at height 2500 mm. A staircase is provided for going to the terrace and roof. From terrace, one could reach the A.C. sheet roofing by crossing the parapet wall.
ABOUT THE INCIDENCE:
As it was the beginning of rainy season, it was decided to check and repair the leakages in roof of the administration building. The gaps between the A.C.Sheets, J-hooks, cause the rainwater to leak through the roof of the building. So, the Factory Manager called the injured worker and asked them to assist him in the said work. They climbed up the roof of the administration building by using a staircase provided from outside to check and assess the actual work to be carried out for rectification of the leakages. Then they stepped on the A.C.sheet roof of the administration building and started observing the roof for leakages. On completing the observation of one portion, they were moving forward to check next portion of the roof. In this manner they moved about 12 metre distance on the roof. While moving further, the injured worker slipped. In the attempt of balancing, when he held the A.C.sheet of the roof by hands, it gave a way due to load of his body and he fell through the roof on the ceiling of the cabin, which was about 2500 mm below the roof. As a result, the ceiling of the cabin broke and he further fell through a height about 3150 mm. Thus he fell through a total height of about 5.65 metre and was injured. The accident resulted into the fracture of his spine.
OBSERVATIONS: The administration building was of size of about 25 m length x 15 m breadth. The roofing was of the Asbestos Cement sheet (A.C.sheet). The minimum height of roof (truss level) from floor was about 5.0 m and maximum height of roof (ridge) was about 8.0 m from the floor. The roof structure was consisting of trusses and purlins.
The A.C. sheets were fixed to the purlins of the roof structure by 'J' hooks and nuts. For checking and observing the roofs,worker was required to pass over the A.C. sheet roof to a distance about 12 m. The cabin beneath the broken A.C.sheet is having a metallic grid with panels of heat resistant material like asbestos fixed in it.
WHAT WENT WRONG: The roofing of the administration building was of the Asbestos Cement sheet (A.C.sheet), which was a fragile material. The injured worker was required and allowed to pass over the A.C.sheet roof for carrying out the observation of roof for assessment of work. When, he slipped and held the A.C.sheet, it gave way and he fell through the height of about 5.65 m and the accident occurred. It is further revealed that-The injured worker was required and allowed to stand, pass over the A.C.sheet roof, without providing him any suitable ladders, duck ladders, crawling boards.
REMEDIAL MEASURES: Whenever the person / workers are required to stand, passed over and carry out any work on the A.C.sheet roof, or roof of the fragile material, through which they were liable to fall, i)They shall be provided with suitable and sufficient ladders, duck ladders, crawling boards and
28 ii) A safety net shall be provided beneath the fragile roof, while carrying out the work at roof.
iii)A permit to work on the fragile roof, by a responsible person of the factory.
A Case Study On 29
14. FATAL ACCIDENT WHILE WORKING ON A PAPER MACHINE. Compiled By Y.P.Patange Assistant Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ Fatal accident to one worker took place in paper manufacturing factory, while he was working on paper machine.
ABOUT THE ACCIDENT:- The deceased worker was working in this factory through contractor, since last 5 years. On the date of accident he had reported on duty at 8 am to work in first ship. There was no electric supply from MSEB from 3.30 am to 8.20 am. After the supply was received, the paper machine was started. At about 8.40 am, the deceased worker had climbed on the platform near the MG cylinder to remove the chock up of the water shower pipe. After reaching on the platform, he had requested co- worker to operate the water shower valve located on the ground floor. Accordingly, the co-worker operated the valve and then went to control panel which is located at about 15 feet away from the spot of accident. The deceased then started the work of removing chock up by hammering on the outer surface of the water shower pipe. While doing so, he probably lost his balance and fell on the moving felt and was trapped in 200 mm gap between the felt roll and the suction box. There is no eye witness to this incidence. Co-worker, working nearby, noticed that there is fold on the felt cloth, near the suction box. He suspected that the deceased worker might have fallen on the moving felt. So, he immediately stopped the paper machine and rushed to the platform along with two other workers. On reaching there on the platform, they noticed that the deceased worker was trapped on the felt and injured. He was found lying in unconscious condition, in the 200 mm gap between the felt roll and the suction box. Seeing this, they realized that it was essential to cut the felt for removing him from there. Accordingly, the felt was cut and he was removed from the felt and shifted to hospital where he was declared dead.
OBERVATIONS: The paper machine is used for making paper by recycling waste paper. At the centre of this machine, there is machine glaze cylinder/drier (here after called as MG cylinder). Below this MG cylinder, there is 400 mm X 1980 mm long touch roller. Next to this touch roll, there is felt roll, one guide roll, stretcher roll, felt roll, suction box/vacuum box and two washing rolls. One 1980 mm wide felt (belt) is passing over from these rolls. This felt passes between two washing rolls to touch roll below the MG cylinder. From there, it passes below the felt roll and then from the bottom of the guide roll to the stretcher rolls. It passes to from the bottom of the next felt roll and then to the suction box. From suction box it reaches the washing rolls. In this way it keeps on moving continuously. There are three platforms at 3050 mm height from the ground level, provided on three sides of the machine and are extending from MG cylinder to washing cylinders. Pipe railings are provided on the outer side of these three platforms. On the inner side of these platforms, there are moving parts of the machine, like rotating washing rolls, felt roll, stretcher roll, moving felt, etc. However, there is no railings/fencing provided on inner side of these three platforms, so as to avoid access of the worker to these moving parts of the paper machine. There is 200 mm gap between the felt roll and the suction box and height of the felt roll and suction box from the platform level is about 300 mm. Adjacent to this felt roll there is one 25 mm pipe water shower which extends from the ground level to the top of felt roll vertically. From there, it passes horizontally over the felt and extends up to the other end of the felt.
30 Height of this shower pipe from the platform level is 500 mm. Workers are required to go to these platforms for adjusting the felt rolls, removing chock up of water shower, changing felts, greasing of bearings etc. They do this work by standing on these platforms. This machine is power operated machine fitted with two 50 HP electric motors. Power of these motors is transmitted to rolls through belt pulleys fitted on common shaft, then to gear box and from gear box to MG cylinder through sprocket and bevel gears. It was revealed that normally speed of the felt is about 30 m/min.
WHAT WENT WRONG:-
There are three platforms at 3050 mm height from the ground level, provided on three sides of the paper machine. Two platforms are extending from MG cylinder to washing cylinders and are on either sides of the moving felt. There is 200 mm gap between the felt roll and the suction box and height of the felt roll and suction box from the platform level is 300 mm.
Adjacent to this felt roll there is one 25 mm m.s. pipe water shower which extends from the ground level to the top of felt roll vertically. From there, it passes horizontally over the felt and extends up to the other end of the felt. Height of this shower pipe from the platform level is 500 mm. Workers are required to go to these platforms for adjusting the felt rolls, removing chock up of water shower, changing felts, applying grease to bearings etc. There are pipe railings provided on the outer side of these three platforms. On the inner side of these platforms, there are moving parts of the machine, like rotating washing rolls, felt roll, stretcher roll, moving felt, etc. All these moving parts of the paper machine are dangerous parts of this machine by virtue of its position and construction and they are accessible from the platform level. It was essential to fence these dangerous parts by safeguards of substantial construction while the parts of machinery they are fencing are in motion or in use. However, it was revealed that on the date of accident, there were no fencing (railings) provided on inner side of these three platforms, so as to avoid access of the worker to these dangerous (moving) parts of the paper machine. This has resulted in to fatal accident.
REMEDIAL MEASURES:- In order to avoid such type of accidents in future, following remedial measures are recommended:- i) Suitable railings/ fencing shall be provided on all the three platforms from the inner sides, so as to avoid access of the workers working on the platform. ii) Wooden planks of the platform shall be replaced by metallic checker plates so as to avoid slipping of the worker standing on the platform. iii) Railings on the platform from the passage side which is weak, shall be got suitably repaired.
A Case Study On 31 15. A FATAL ACCIDENT WHILE WORKING IN CONFINED SPACE IN A CHEMICAL FACTORY. Compiled By J.B.Kumbhar Deputy Director Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------ A fatal accident had occurred while working in a confined space in a chemical factory.
HISTORY: The factory was engaged in the manufacturing of various types of resins using raw materials like benzoic acid, soya fatty acid, pentaery thritol, glycerol, phthalic anhydride, toluene diisocynate and solvents like xylene / toluene/acetone etc. The manufacturing process was as under: The above mentioned raw materials except solvents were taken in 10 metric cube kettle & stirred together at 200 to 230 degree centigrade temperature by heating with the help of thermic fluid heater. Water of reaction was removed to get polymer. At required time (about 6-8 hours), after getting right polymer, reaction mass was cooled to 80 100 0 C. At this temperature, solvent was added to get required solid content of either 70 % or 55 % as per customers requirement.
ABOUT ACCIDENT: On the day of incidence, it was decided to charge 10 m3 vessel with old prepared alkyd resin (having solid content 90 %) and subsequently dilute it with solvent. Accordingly 3 no. of workers started charging vessel/ kettle with the help of 50 kg drums. The kettle was charged with about 350 kg of material. As the material was viscous, it was taking time to charge. After emptying few drums of resin in to the vessel, while they were charging the resin with next drum in the vessel through its man hole, the plastic drum slipped from their hands and fell down in the vessel. In order to remove the drum, those workers placed one bamboo ladder in the vessel. Bottom of this ladder was rested on one of the blades of the stirrer in the vessel. One worker entered in the vessel with the help VESSEL IN WHICH WORKER FELL
entered into the vessel, he felt uneasy. Therefore, he immediately came out from the vessel. Then other worker entered in to the vessel using the ladder. However, while climbing down on ladder, he fell in to the vessel. When the first worker saw it, he entered in the vessel to rescue him from the vessel. But he also fell down in the vessel. In the mean time, the Occupier along with other workers rushed to the vessel. By the time they reached the vessel, the third worker was trying to enter in the vessel. But he was stopped from doing so.
RESCUE OPERATION: Immediately, the intimation regarding the incidence was given to the nearby hospital so that they could arrange for respirator and ambulance and also to the Police & Fire Brigade. Meanwhile, the DISH Officers, when came to know about the incidence, contacted the concerned fire brigade personnel and took the feedback of the incidence and immediately directed the members of the MARG from the concern Industrial Area for rescue operation. After reaching the spot, a person from the medical team of the hospital tried to enter the vessel, however, as soon as he entered, he felt uneasy and therefore he came out from the vessel. By the time police and fire brigade people arrived at the spot, most of the material was removed from the vessel / kettle by the other workers. The material in the vessel was sticky and it was necessary to enter the vessel and remove both the workers. The fire brigade person was unable to enter in the vessel after wearing breathing apparatus, as the size of the man hole was only 17.5 inches diameter. Fire brigade personnel wanted to cut vessel, but could not use the gas cutter as there was risk of fire/explosion due to xylene vapours present in the vessel and it would have created problem to both the workers, who were trapped in the vessel. Then, it was decided to make hole at the bottom side by using grinder. Accordingly a hole of size about 22 inches X 24 inches was cut at the bottom of the vessel by fire brigade persons. The worker who had fallen on his
32
back, was in unconscious condition and shifted to Hospital. He survived and recovered after treatment. Other worker, who had fallen on face into the vessel got lot of resin stuck to his face that made breathing difficult for him. He died due to suffocation caused by vapors of xylene in the vessel.
WHAT WENT WRONG:- The size of the vessel in which these two workers had entered was 4.5 m high X 3 m diameter and was having man hole of size about 17.5 inches at the top side. All the openings provided for various types of pipe lines were closed. Portion inside the vessel was a confined space. This vessel was containing vapors of xylene mixed in the alkyd resin which was charged in it. Xylene was toxic substance and having 100 ppm TLV. (i)The vessel was not checked for contents of vapours before the two workers entered in it. (ii)A certificate from the competent person, based on the test carried out by him that the space was reasonably free from dangerous gas, fume, vapour or dust was not obtained before those two persons were required/allowed to enter the confined space in the vessel. (iii)Belt securely attached to a rope and breathing apparatus were not provided to these two persons before entering confined space.
VESSEL CUT OPEN FOR RESCUE OF WORKER A Case Study On 33 16. SERIOUS ACCIDENT WHILE WORKING IN CONFINED SPACE Compiled By R.P.Khadamkar Deputy Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ A serious accident causing burn injuries had occurred while working in a tank, a confined space.
HISTORY: The factory was involved in the manufacturing of the equipments like s.s. tanks required for brewery, pharmaceutical and chemical industries. The manufacturing process for tanks was as follows. The raw material was in the form of s.s. coils, pipes etc. The s.s coils were uncoiled on a de-coiling machine and coated with a thin PVC film for protecting the surface. The sheets were cut to required sizes and shapes on plasma cutting machines. The blanks were formed by carrying out TIG welding operation. These blanks were used to form dish ends & cones. The shells were formed on plate bending machines. These components were then assembled together by welding to form a tank. The tanks were provided with manhole, drain pipe, nozzles as per design. The tanks were polished and cleaned from both inside and outside. After testing and inspection the tanks were packed and dispatched. The polishing and cleaning process was as under. The tank was kept in horizontal position on the rotator stand. One worker carries out polishing of the welded joints by a portable electric grinding machine and removes the thin film from the outer surface of the tank. Other worker enters the tank through the manhole provided on one dish end. He takes electrical light inside the tank so as to view inner surface of the tank. Then polishing was carried out of welded joints at inner surface and the film coated on inner surface was removed. It was necessary to remove stains formed on the inner surface by the film. The stains are removed by applying a cleaning solvent with the help of cotton cloth. Thus the cleaning process was completed.
ABOUT THE ACCIDENT:
The injured worker was employed through the contractor and was working as a trainee. On the day of incidence, the injured worker along with a fitter was entrusted with the work of polishing & cleaning of the tank. Accordingly they started carrying out the said work. The tank was kept in horizontal position on the rotator stand. The fitter was working on outer surface and the injured worker was working on inner surface. The injured worker connected supply cables of halogen lamp (500W) and portable electric grinding machine to the extension board and S.S.TANK MANHOLE THROUGH WHICH WORKER ENTERED
34 switched on its electric supply. Then he took the halogen lamp, the grinding machine and entered into the tank through its manhole. He kept the glowing lamp in the tank and started polishing of the inner surface. He removed the film from the inner surface of the tank. After finishing this work, he came out of the tank. Then he took a can containing about 1.5 litre of the cleaning solvent, cotton cloth and again entered the tank. He poured the cleaning solvent on the cloth and started wiping the inner surface for removing stains. Due to the halogen lamp (500W), the inner surface and inside air became hot. The vapours of the cleaning solvent, which was volatile chemical, were formed and got accumulated inside the tank. While the injured worker was carrying out further cleaning work inside the tank, the vapours of the cleaning solvent inside the tank caught fire and caused a flash of fire. Due to this, he received burn injuries to his hands, legs. He came out of the tank through the manhole. In this accident, he received about 20-25% burn injuries. After the treatment at the hospital, the worker recovered from the injuries. OBSERVATIONS: The tank was of stainless steel (SS-316) and cylindrical in shape. It was mounted horizontally on a rotator stand. The size of the tank was about 1600 mm dia x 4300 mm height. One dish end was provided with a manhole of size 450 mm dia, inlet of 125 mm dia, a nozzle 90 mm dia and a nozzle of 85 mm dia. The other dish end was provided with a drain of 50 mm dia, an overflow pipe of 150 mm dia. The height of the rotator stand was about 800 mm. The halogen lamp used for lighting was of rating 240 V, 500 W. It was not of flameproof construction. The material safety data sheet indicated that the cleaning solvent was composed of ketones having flash point less than 18 0 C, which was volatile and highly flammable solvent. The capacity of the plastic can used for handling the cleaning solvent was of 5 litre. A piece of cotton cloth was found in burnt condition inside the tank.
WHAT WENT WRONG:
The incidence of flash of fire occurred, when the worker was working inside the tank, which was a confined space. The cleaning solvent composed of ketones having flash point less than 18 0 C, which was volatile and highly flammable solvent. The temperature of the inner surface of the tank and inside air got raised due to heat generated by the halogen lamp of rating 240 V, 500 W. As a result the vapours of the cleaning solvent were formed and got accumulated inside the tank. The vapours of highly flammable solvent formed flammable mixture with the air. The halogen lamp of non flameproof construction was a source of ignition. It caused flash fire of the flammable mixture formed by vapours of the highly flammable cleaning solvent with the air. It is revealed that the solvent- The said worker was required and allowed to enter the tank, in which the vapours of the cleaning solvent were formed and got accumulated during the process. (i)The control measures were not taken for the prevention of accumulation of the vapours of cleaning solvent inside the tank. (ii) No test were carried out for ensuring the space inside the tank free from dangerous vapours and no certificate of fitness was obtained from the competent person. (iii)The said worker was not provided with a self contained breathing apparatus and was not wore with belt securely attached to a rope, the INSIDE TANK BURNT COTTON CLOTH CLEANIN G SOLVENT NONFLAMEPROO F LAMP
free end of which to be held by a person outside the tank. (iv)The highly flammable vapours of the cleaning solvent were formed and got accumulated inside the tank. No lamp or light other than of flameproof construction ought to have been permitted to use inside the tank. But the said worker was not provided with a lamp of flameproof construction. He was required and allowed to use a halogen lamp of 240 V, 500 W, which was of ordinary construction. REMEDIAL MEASURES SUGGESTED: i)The workers shall be provided with a self contained breathing apparatus of adequate oxygen supply capacity. 35 ii)The lamp/light of flameproof construction shall be provided and used while carrying out such type of work. iii)The space inside the tank shall be got tested and certified by the competent person to ensure that it is free from the dangerous vapours/gases. iv)The worker shall be provided with a belt securely attached to a rope, the free end of which is held by a person outside the tank. v)The tank shall be continuously purged with a suitable inert gas. The arrangement shall be done so that vapours are not accumulated inside that tank or work area.
A Case Study On 36 17. FATAL ACCIDENT DUE TO ASPHYXIATION WHILE WORKING IN CONFINED SPACE By R.D.Kichambare Former Joint Director Industrial Safety & Health
Accident Type: Asphyxiation Type of Industry: Chemical Size of work Crew: 4/150 Work Site Inspection Conducted: Yes Designated competent Person on Site: No Employer Safety and Health Programme: No Training and Education for Employees: No Craft/Type of Deceased Employees: Unskilled Age and Sex: 19 Male, 22 Male, 23 Male, Time on the Job: 5 months Time on the Task: 20 Minutes,
Description of the Accident: In a factory involved in manufacture of Edible Oils, one worker got injured and two other workers died of asphyxiation in a pit, a confined a space, in the effluent treatment plant of the factory. The factory was primarily involved in refining the edible oils manufactured elsewhere, and in its packing on the factory premises. The process comprised of decolourisation and de- odourisation of the edible oils bought out from external sources. Several materials, such as special earth, Caustic Soda, Sulfuric / Hydrochloric Acids, were used in the process. There was a effluent plant in the open premises of the factory, to treat the effluent generated in the process. One of the places where effluent was collected for further treatment, was a collected a pit flush with the land level admeasuring 8 feet long, 2 feet wide, and 6 feet deep. A power driven agitator arm to churn the effluent in the pit was installed on the pit. Also there was a transfer motor driven pump installed on the edge of the pit. There was access ladder constructed, on one of the walls of the pit to facilitate the workers to enter the pit, should there be a need. The pit was covered by a removable wire-mesh cover. On the day of the accident, the Supervisor from the maintenance department of the factory instructed a worker to enter the pit to clean the foot-valve of the pump installed on the pit, as it was not pumping out the effluent properly, for transferring into another tank for further treatment. One of the workers therefore removed the wire-mesh cover on the pit and entered the pit by the access ladder provided on the pit. After entering in the pit, as he started walking towards the foot-valve of the pump which was in one corner of the pit, he fainted, became unconsciousand fell into the slurry in the pit. Noticing him fall, another worker near the pit entered the pit. He started rescuing the unconscious worker by lifting him bodily and tried to push him out of the pit.He succeeded in pushing the unconscious worker outside the pit. However, in the process, he too became unconscious and fell into the slurry in the pit.
37 However, in the process, he too became unconscious and fell into the slurry in the pit. This prompted another worker outside pit to enter the pit to rescue the unconscious worker. He entered the pit by the access ladder. He tried to lift him bodily and push him out of the pit. However, while doing so, he too became conscious and fell into the slurry into the pit. A group of several workers then attempted to remove the two unconscious workers with the help of ropes. They were successful in removing them. However they had succumbed to the injuries sustained by inhaling the foul gas in the effluent in the pit and one to fall conscious first had survived. The inquiries revealed the pit contained about one and a half feet deep content of the effluent. The effluent was viscous and appeared slurry like. The effluent had remained in the pit for quite some time. A Hydrogen Sulphide gas had generated into it because of the anaerobic decomposition of the unused reactants, from the process. The gas had remained trapped into the slurry. When the workers entered the pit the slurry got vitiated and the trapped Hydrogen Sulphide gas bubbled out, from the slurry. It was inhaled by the workers who had entered the pit and they were overcome by it. The worker to enter the tank first, survived as his exposure to Hydrogen Sulphide gas was probably less than those who entered the pit later.
Accident Prevention Measures: No person shall be required or allowed to enter any confined space such as any pit, in which any gas, fume, or vapour is likely to be present to such an extent as to involve a risk to persons being overcome thereby, until all practicable measures have been taken to remove any gas, fume, or vapour, which may be present, so as to bring its level within the permissible limits and unless- (a) a certificate in writing has been given by a competent person, based on a test carried out by himself that the space is reasonably free from dangerous gas, fume, or vapour, or (b) such person is wearing suitable breathing apparatus and a belt securely attached to a rope the free end of which is held by a person outside the confined space.
A Case Study On 38 18. A FATAL ACCIDENT DUE TO FALLING IN A QUENCHING TANK CONTAINING HOT WATER Compiled By T.M.Kambale Assistant Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ A fatal accident occurred while working at the quenching tank of the heat treatment furnace in the factory premises.
HISTORY: The factory is involved in the manufacturing of the Aluminium castings components. The process was as follows. The raw material in the form of Aluminium ingots are melted in furnace oil fired furnaces. The molten metal was transferred to the LPDC machines (Low Pressure Die Casting Machines), where Aluminium castings were formed. These castings were subjected to fettling operation for removal of burrs, risers. Then these jobs were sent to heat treatment section. The heat treatment operation involved two processes- Heat Treatment-Solution and Heat Treatment- Aging. After heat treatment, the jobs are checked and dispatched. The Heat Treatment-Solution plant was having a platform at a height about 3.0 metre with three openings in it. Electrical resistive furnaces were installed in each opening. Each furnace was provided with a separate underground quenching tank with its top open, which was right below the furnace. The quenching tank contained full of water in it. A gate was provided to the furnace at its bottom. Two manually operated loading trolleys were provided beneath the platform. Rails were provided along the tanks, on which trolleys moved. Two cylindrical baskets mounted one above the other were provided to each furnace in which jobs were charged, which was further loaded to the furnace. A hydraulic mechanism was provided for the movement of the gate and basket. The Heat Treatment-Solution process was as follows. The baskets containing the jobs i.e. Aluminium castings were kept on the loading trolley. The gate of the furnace was opened and the baskets were loaded into furnace from its bottom. After closing the gate Operator started the heating cycle. The temperature of the Aluminium castings reaches to 480 0 C. The furnace was kept on hold at this temperature for another 2 hours & the heating cycle was stopped. The workers pushed the loading trolley forward and the quenching tank became open. Then operator opened the gate of the furnace and lowered the baskets to dip it into the quenching tank containing water, with the help of hydraulic mechanism. After holding the baskets into the quenching water for 5 minutes, the baskets were again lifted up. The loading trolley was now again moved on the quenching tank and the baskets were kept on it. The trolley along with the baskets wais then moved forward and another loading trolley along with baskets containing next batch of jobs was taken below the furnace. When the hot jobs were quenched into water, its temperature rises. Part of the water got evaporated. The water was added into the tank to make up the water lost. The temperature of the water in the quenching tank remained about 75 0 C. The process was TROLLEY QUENCHING TANK BENEATH IT
39 repeated for next batch. ABOUT THE ACCIDENT: The injured worker was through the contractor and was working as helper in the factory. On the day of incidence, the injured worker along with the other worker was entrusted with the work at the quenching tanks of the Heat Treatment- Solution section. The work involved was as under. When the jobs were ready for quenching, they were pushing the trolley forward by legs. After quenching the trolley was brought back on the tank by them and the basket containing jobs was kept on trolley. Then they were moving trolley out and sending it for next process. Then again they were keeping next batch, on another trolley for the heat treatment process. The heating cycle of the furnaces of the Heat Treatment-Solution was started and continued. At the time of accident, the jobs in furnace were ready for quenching, so the operator asked the injured and other worker to move the trolley forward, so as to quench the jobs in the tank. So, the other worker from left side and the injured worker from right side of the trolley, started pushing the trolley forward by legs. While pushing the trolley, the injured worker lost balance and fell into the quenching tank through its top, which became open as the trolley moved forward. As the tank contained the hot water having temperature about 75 0 C, he received 84- 85 % burn injuries. He succumbed to burn injuries, while under the treatment in the hospital.
OBSERVATIONS: The plant was having a platform of size about 5200 mm L x 11500 mm B x 3000 mm H. supported by pillars formed by m.s. channels. There are 3 No. of circular openings in which cylindrical shaped electrical resistive furnaces No.1,2,3 were installed. The furnace was installed vertically in such a way that 2000 mm of its length above the platform and 600mm of length below the platform. A hydraulically operated gate was provided at the bottom portion of the furnace. A hydraulically operated mechanism is provided for the vertical movement of the baskets. Two baskets one mounted above the other were provided for charging the jobs and have total capacity of 500 Kg. Beneath the furnace, there was an underground quenching tank having its top open. The size of the tank was about 2400 mm length x 2400 mm breadth x 3000 mm depth, which contained water as a quenching medium. There was a pair of rails, which was laid along the tank. The front side of the compartment was open through which there was an access to the tank. The rear side was provided with a removable m.s.bar (pipe) at a height about 900 mm. The left and right sides of the compartment were provided with the m.s. bar at a height of about 1050 mm. There was access to the tank from lower portion of the bar provided at left, right and rear sides. A water feeding arrangement was provided to each tank. The temperature of the quenching water remained 75 0 C. The loading trolley is manually operated. It was formed by welding m.s. plate on the frame of m.s. channels and is provided with 4 no. of wheels. The size of the trolley is about 2450 mm L x 2450 mm B x 150 mm H.
WHAT WENT WRONG:
The injured and other worker was required to push the trolley forward & reverse over the quenching tank of the furnace. When the trolley was moved, the top of the quenching tank became open. The temperature of hot water in the quenching tank remains about 75 0 C during the operation. Thus the underground quenching tanks in the Heat Treatment-Solution Plant by reason of its depth, situation, and contents were a source of danger. The fatal accident to the worker occurred while pushing the trolley over the quenching tank of the furnace. The quenching tank ought to have been securely fenced by providing adequate guards for preventing access to the quenching tank. But there was an access to the quenching tank from NO FENCING TO TANK NO RAILING TO TROLLEY all sides.
REMEDIAL MEASURES SUGGESTED: i) The portion below the platform shall be provided with adequate fencing by using strong metallic guards from both sides and remaining portion of the front and rear portion shall be securely fenced. The height of guard rail shall not be less than 1 metre.
40 ii) The loading trolley shall be provided with railings guard from all sides. iii)There shall not be any access to any person to the quenching tank, while in operations. iv) Precautionary notices shall be displayed in the language understood by the workers. v) The temperature of the quenching water shall be monitored by providing fixed temperature metre near the respective tanks.
A Case Study On 41 19. BURSTING OF HEAT EXCHANGER DURING PNEUMATIC TESTING Compiled By R.P.Khadamkar Deputy Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ A fatal accident had occurred, while carrying out pneumatic test on the core assembly of the plate type heat exchanger in the factory.
HISTORY: The factory was involved in the manufacturing of welded Plate type heat exchangers. The heat exchanger had main parts like core assembly, shell, end covers. The manufacturing process for plate type heat exchanger was as follows. The s.s. plate were cut to a circular shape with holes in it for inlet/outlet on the automated press machine. These chevron type plates welded to form a cassette. Depending upon the capacity of the heat exchanger, number of cassettes stacked to obtain a plate pack and perimeter welded together to form a cylindrical shape core. A circular plate with hole was welded at upper end of the core, on which a flange (top cover) was welded. The top cover was provided with two nozzles welded with a flanges-one for inlet and other for outlet. The cylindrical shell was welded with a bottom cover. The core assembly was fitted in the shell. During the manufacturing process, the core assembly was being tested for leakage at welded joints. The testing was being carried out in three stages. Initially the core assembly was pneumatically tested to locate and the leakages were rectified. Then the assembly was immersed into water and pressurized air was passed through the assembly to find further leakages if any and these leakages were rectified. Finally, hydro test was carried out. The pneumatic test was being carried out as follows. The core assembly was being clamped between the top and bottom flanges. Out of the two nozzles provided to the top flange, one was closed by fitting a blank flange and other was fitted with a flange having nipple. Then pressurized air from a compressor was being passed into the core assembly by a hose connected to the nipple through a valve. With this the core assembly got pressurized and air came out from the portion where, welding was not proper. Then air was being released and leakage was being rectified by welding and again procedure was being repeated for finding further leakage if any.
ABOUT ACCIDENT: The deceased was working as a helper. On the day of incidence, the deceased and other two workers were entrusted with the work of testing of the core assembly required for the Heat Exchanger. Accordingly, for carrying out the said work, they kept the circular shape bottom flange on a cylindrical shell. The bottom flange was already provided with 8 no. of clits at its periphery. The clits were in the form of pieces of m.s. pipe of size 35 mm I.D. x 45 mm O.D. x 40 mm height. They provided 5 no. of clits to the top flange at its periphery. For that purpose they used pieces of m.s. pipe each of size about 35 mm I.D. x 50 mm O.D. x 40 mm height and welded it to the periphery of the top flange. The core assembly with the top flange was placed vertically on the bottom flange kept on the shell. They inserted 5 no. of CORE ASSEMBLY AFTER ACCIDENT
42 studs, each of size M 27 X 1000 mm length through the clits provided to the top and bottom flanges and put washer, nuts from both ends. The core assembly was clamped by tightening the nuts from both ends of the studs. One of the nozzles provided on the top flange was closed by providing a blank flange fitted with nuts and bolts. The other nozzle was fitted with a flange having a nipple by using nuts and bolts. A rubber hose of dia was attached to the pressurized air pipe line and its other end was connected to the nipple on the flange fitted on the top end cover (flange) through a ball valve. One worker opened the ball valve and passed pressurized air into the core assembly. The deceased and the other worker observed the core assembly and checked for the leakages. They rectified two leakages. Then, the ball valve was opened again and pressurized air was passed into the core assembly for checking further leakage, if any. The deceased reported about the leakage in the core assembly. It was necessary to stop the air supply and release the air from the core assembly for rectifying the leakage. So, one worker went at the valve for closing it, while the deceased along with the other worker were observing the leakage spot at the core assembly from opposite side. When he was about to close the valve, 3 no. of the clits of the bottom flange and 3 no. of studs gave a way and the core assembly burst open. The top flange along with few cassettes turned rapidly in vertical plane. With this the projecting portion of the bolt, fitted to the blank flange on the nozzle at the top flange hit and pierced in the head of the deceased worker. He was seriously injured and died on the spot. The other worker fell unconscious due to impact of bursting of the core assembly. He received minor injury.
OBSERVATIONS: The core assembly of the Heat Exchanger included the parts like-Plate pack, top flange (end cover) and bottom flange. The plate pack was of cylindrical shape formed by 132 no. of s.s. circular plates welded together, each of size about 800 mm dia x 0.8 mm thick. There were two circular openings each of size 150 mm dia in each plate provided for inlet / outlet. The plate pack was found burst open
and found expanded. The bottom flange was of m.s. and of circular shape having size of about 960 mm dia x 40 mm thick. It was found provided with 8 no. of clits welded equidistance at periphery of the bottom flange. The clit is prepared from m.s. pipe and was of size about 45 mm O.D. x 35 mm I.D. x 40 mm height. The distance between the consecutive clits was about 380 mm. Out of these 8 number of clits, 3 number of clits were found gave a way. The top flange was of m.s. and of circular shape having size of about 920 mm dia x 90 mm thick. It was found provided with 5 no. of clits welded at periphery of the top flange. The clit was prepared from m.s. pipe and was of size about 50 mm O.D. x 35 mm I.D. x 40 mm height. The distance between the consecutive clits was not equal and it was about 700 mm, 420 mm, 420 mm, 720 mm, 800 mm. Total 5 number of studs each of size M 27 x 1000 mm length were used for clamping the plate pack between the top and bottom flanges. Out of these 3 numbers of studs were found broken. The weight of then core assembly was about 1200 Kg. Air at
BROKEN CLITS BROKEN STUDS NATURE OF STUD FAILURE pressure 6 Kg/cm 2 was supplied to the core assembly by using rubber hose x 12 metre length through a ball valve. There was no pressure reducing valve provided in the air pipe line.
WHAT WENT WRONG? i)The centres of clits were not aligned due to unequal diameters of the top and bottom flanges and also due to location of clits at unequal distances. Hence studs did not remain in vertical position, causing unbalanced force on the clits exerted by pressurized air in the core assembly and bending stress on studs. Out of 8 numbers of clits 3 no. of clits of bottom flange gave a way and 3 no. of studs broke. ii)Total 5 numbers of studs were used for clamping the plate pack between the flanges. Out of these, 4 numbers of studs were fitted diagonally opposite and no stud was provided opposite to the 5 th stud. The unequal tightening of the nuts caused bending stress to act on the studs, which led to failure of 3 numbers of clits and studs. Thus equidistant holes in the flanges or clits of adequate strength ought to have been provided for fitting studs. Also diagonally opposite studs i.e. even numbers of studs ought to have been used for clamping. Thus the clamping arrangement for the plate pack of the heat exchanger was not of sound engineering design and construction. iii) The core assembly was kept on a cylindrical shell having size about 585 mm dia x 360 mm height x 12 mm wall thickness. The bottom flange was of 960 mm diameter. Thus the core assembly was projecting outside the shell and was not well supported. A stand of sound construction ought to have been provided for mounting the core assembly. The pneumatic test of the core assembly of the heat exchanger ought to have been carried out with the core assembly properly mounted and fitted on the stand, so as to prevent random 43 movement of the core assembly, in case it burst open. Thus the mounting arrangement for the core assembly of the heat exchanger was not safe. iv)For carrying out pneumatic test air at pressure of about 6 Kg/cm 2 was supplied from the air compressor through a ball valve. There was no pressure reducing valve provided in the air pipe line for reducing the pressure to safe value for preventing the bursting of the core assembly of the heat exchanger. The safety valve, pressure gauge, pressure switch ought to have been provided in pressurized air supply system. Thus the arrangement for the pneumatic testing of the core assembly of the heat exchanger was not safe. v) The Safe Operating Procedure (SOP) for pneumatic testing of the core assembly of the Heat exchanger was not found displayed near the test area.
REMEDIAL MEASURES SUGGESTED: i)The clamping arrangement for the plate pack of the heat exchanger shall be of sound engineering design and construction. ii) The pneumatic test of the core assembly of the heat exchanger shall be carried out with the core assembly properly mounted and fitted on the stand / fixture, so as to prevent random movement of the core assembly, in case it burst open. iii) The pressurized air supply system consisting a safety valve, pressure gauge, pressure switch shall be provided close to the core assembly subjected to the pneumatic testing. A pressure reducing valve shall be provided in the air supply line before the system. The air pressure for testing shall be maintained to the minimum required safe value for preventing the bursting of the core assembly of the heat exchanger. iv) A Safe Operating Procedure (SOP) for pneumatic testing of the core assembly of the Heat exchanger shall be displayed and followed invariably.
NATURE OF STUD FAILURE PNEUMATIC TESTING OF CORE ASSEMBLY OF THE SUPERMAX PLATE TYPE HEAT EXCHANGER 44
CLITS (8 NO) ON THE BOTTOM FLANGE
320 MM DIA
CLITS (5 NO) ON TOP FLANGE
FORCE ON CLIT
TOP VEIW
CORE ASSEMBLY TURNED IN VERTICAL PLANE
CORE ASSEMBLY PLATE TORN
NIPPLE INLET OUTLET BOLT PIERCED STUDS M27 (5 NO) IN HEAD OF WORKER NOZZLES TOP FLANGE 920 MM DIA
PLATE PACK
BOTTOM FLANGE 960 MM DIA
SHELL
NIPPLE BLANK FLANGE FLANGE
BROKEN CLITS & STUDS A Case Study On 45
20. SERIOUS ACCIDENT WHILE HANDLING THE HIGHLY FLAMMABLE SOLVENT
Compiled By A.B.Pawar Deputy Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ A fatal accident had occurred while carrying out the manufacturing process for rubber hose, in which use of a highly flammable solvent was involved.
HISTORY: The factory was involved in the manufacturing of rubber hoses required for automobiles. The manufacturing process was as follows. The raw rubber and chemicals were mixed in a rubber mill to obtain sheets of rubber compound. The rubber compound sheets were sent to the extrusion machine, where inner tube of the rubber hose was prepared. Then braiding of polyester yarn was formed on the inner tube on the braiding machine. After carrying out surface treatment by using toluene, the reinforced inner tube was subjected to co-extrusion process for outer formation. The rubber hose so obtained was then cut and mounted on the mandrel. Then vulcanization is carried out and hose was extracted from the mandrel. The hose was then packed and dispatched. The extrusion machine used in the said process included extrusion barrel provided with a screw inside it. The screw was driven by the electric motor through a gearbox. The barrel of the machine was provided with a straight head and the cross head at its outlet called die head block. The braided inner tube passes initially through a toluene trough and through the straight head, while the rubber strip was fed to the screw conveyor, which passes it to the cross head to form outer over the braided inner tube. The die head block was required to be heated initially to maintain a rubber flow. In the factory, heating of head block was carried out with the help of a portable kerosene burner. Once, it was heated initially, further heating took place due to friction of screw and a rubber. A trough (tank) of capacity 15 L containing toluene was mounted on the stand. The stand was portable
and was kept adjacent to the die head block of the extrusion machine, while carrying out the outer formation. The water cooling arrangement was provided for the cooling of the extruded rubber hose. Then the hose was applied with a powder to prevent sticking.
ABOUT ACCIDENT: The deceased worker was working as an operator. On the day of incidence, the deceased worker along with four workers working as helpers were entrusted with the work of co extrusion process on Extrusion
EXTRUSION M/C TROUGH CONTAING TOLUENE DIE BLOCK
46 machine for the formation of different sizes of rubber hoses. Accordingly, they started carrying out the said work. The work involved was as follows. The deceased worker fitted the die head block for the job and carried out setting. One worker ignited the kerosene burner and started heating of the die head block by a kerosene burner. Then the deceased worker asked another worker to pour toluene into the trough. While the worker was carrying out heating of the die head block with the help of kerosene burner, the other worker was pouring toluene into the trough with the help of a 20 L capacity drum manually. At that time, the flame of the kerosene burner reached to the toluene in the trough and toluene in the trough and a drum caught fire. Due to this the drum flew up and the burning toluene splashed over all of them and they received burn injuries. The fire was extinguished immediately within 5 minutes with the help of extinguishers. They were shifted to the Hospital, for the treatment. The deceased worker received about 50% burn injuries and he succumbed to burn injuries while under the treatment in the Hospital. The other workers received about 30%, 40%, 4%, 15% burn injuries and were discharged from the hospital after the treatment.
OBSERVATIONS: A rectangular m.s. trough (tank) of capacity 15 litres and having size about 1200 mm length x 150 mm width x 175 mm depth was kept on the m.s.stand of height 800 mm. The trough is not found fastened with the stand. The sludge of rubber solution is found accumulated at the bottom of the trough. The top of the trough was found open and the cover provided is not found fixable. The kerosene fired burner was found used for heating the die head block.
WHAT WENT WRONG? The trough containing toluene was having its top open. The vapours of highly flammable solvent-toluene formed flammable mixture with the air. The flammable mixture received a source of ignition from the open flame of the kerosene burner. As a result, flammable mixture formed by toluene with air caught fire
The fire reached to the drum, which flew up from the hands of the worker. The burning toluene splashed over all of them and their clothes caught fire and they received burn injuries. It is revealed that- i)The precautions were not taken to prevent initiation of ignition from sources such as open flames from kerosene burner. The highly flammable solvent toluene ought not to have been handled unless the kerosene burner is stopped or taken away from the work place to prevent the initiation of ignition from the open flame from the kerosene burner. ii)The precautionary notice showing information and instructions in respect of toluene, was not displayed near the machine to ensure safety of workers at work. iii)Also, while carrying out the said work, supervision was not provided on the work to ensure safety of workers at work.
REMEDIAL MEASURES SUGGESTED: i) The open flame kerosene burner shall not be used, where highly flammable solvents like toluene are being used. ii)Precautionary notice showing information, instruction in respect of toluene shall be displayed near the machine. Such work shall be carried out under supervision of a qualified supervisor.
KEROSENE BURNER A Case Study On 47 21. EXPLOSION OF CONDENSER COIL Compiled By P.V. Adkar Former Joint Director Industrial Safety & Health
An explosion occurred in the ice manufacturing factory in which 5 workers and the occupier got severe burn injuries. One worker later succumbed due to his burn injuries in the hospital. The factory was existing since 5 years and there was hardly any accident except minor ammonia gas leakage. ABOUT INCIDENCE: In this factory, for the refrigeration cycle with use of Ammonia as a refrigerant, there were two sets of condensers out the factory building. One set of the condensers was located close to factory building where the air flow was poor. The occupier decided to shift this condenser to a new place to get better cooling effect. There were 3 coils (10 U bends, 20 Pipes) for this condenser. It was decided to convert existing 3 condenser coils to 6 coils by cutting in between to have (5U bends, 10pipes in each). This work of shifting and installation was allotted to a contractor. The total job was fabrication work involving various valves, fittings liquid & gas line header fitting etc. The fabrication work was completed in open area & then the condenser tubes were tested for leakage by using compressed Nitrogen gas. Then, the condenser was mounted at the new location. Both the headers & valves were fitted. It was again necessary to check for leakage after new assembly. Then contractor asked one of the workers to bring either Nitrogen or Carbon-di- oxide cylinder from supplier. Without testing the content gas of the cylinder, it was connected to one of the condenser pipe in series. Only the inlet valve of this condenser was open & all the other valves including the outlet valve of this
condenser were closed. The gas was released from the cylinder at14 kgs/cm 2 . There was immediate explosion of the condenser tubes which resulted into burn injuries to 6 persons. They were immediately admitted in the hospital. One of them, later succumbed, to his injuries on the same day, WHAT WENT WRONG: During inquiry it was revealed that the gas cylinder used was of oxygen instead of Nitrogen, and also ample quantity of compressor oil was noticed inside the condenser tubes. Hence, when the oxygen came in contact with the oil, there was an explosion. The contractor could not identify the Oxygen cylinder hence caused this incidence. REMEDIAL MEASURES: 1.Before the use of any gas from the cylinder, its properties, hazards, suitability shall be carefully studied by responsible person supervising the job. 2.The pressure vessels, with its fittings (including Pipes) shall be tested, hydraulically only for leakage. 3.Oxygen cylinder should not be used for pressure testing work.
A Case Study On 48 22. Fatal Accident due to Splashing of DMDS (Di Methyl Di Sulfide)
Compiled By V.M. Yadav Deputy Director Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------ An fatal accident that took place in a factory to a worker while working in DHDS ( Diesel Hydro De Sulfurisation ) complex at HGU (Hydrogen Generation Unit) plant in a Refinery due to splashing of a chemical named Di methyl di sulfide on his body.
Incident :-. On that particular day, the worker,a maintenance technician, alongwith his colleagues from maintenance dept. went to HGU( Hydrogen generation Plant) in DHDS (Diesel Hydro De Sulfurisation) complex to connect a metal drum containing @225 litre (240Kg) of chemical named DI Methyl Di Sulfide (DMDS) to the drum unloading manifold already provided on the first floor in HGU section . This drum was placed on this floor for connecting with the help of a crane. This chemical was required to be decanted under nitrogen atmosphere. For this purpose one manifold was provided on the first floor with a arrangement of provision of connecting two hose pipes , one for nitrogen line and another hosepipe for liquid decantation. The nitrogen inlet pipe was connected to the nitrogen header having pressure of 5 kg/cm through a rotameter and a valve to control it. This worker and his colleague put the barrel on the stand in vertical position, opened the threaded caps (corks) from the two openings( one od & another of ) of the drum and connected the nipples with valve and hose pipe to these two openings. They tilted the barrel and kept the stand & barrel in horizontal position. Then they connected the other free ends of the hosepipes to the respective pipelines. While these connections were going in, all the four valves on these two lines were closed. Then the said worker opened the valve near the near the drum on N2 line and after that opened the second valve on the manifold of N2 line. As both the valves on the N2 line were opened, N2 gas with a pressure of about 2 kg/cm entered the drum and the drum got pressurized.
At that moment the other workers who were nearby, heard some sound from the barrel so they told the said worker to get away from the barrel, but because of this excess pressure , the drum got opened up at the seam of the top dish (cover) and the inside DMDS chemical splashed on the body of the worker who was in front of the barrel. Some of this chemical also splashed on the body of other worker who was nearby.. The said workers clothes got soaked in DMDS and he inhaled the vapours of DMDs. He himself immediately rushed to the bathroom on the ground floor , opened the water showers and stood below the showers.
He was feeling drowsiness and within 5 to 10 minutes, he became unconscious and fell down. Other workers took him to factory medical centre .Doctors examined him, gave first aid and then he & other worker both were shifted to nearby hospital. But the said worker died in the hospital after 2-3 hours. Other worker was in hospital for about 5-6 hours for treatment and then he was discharged.
Manifold
Process requirements in HGU section in brief The DHDS plant was in the stage of start up after a gap of about months because of a shut down taken in the plant. The new catalyst was charged in to the reactor no.73-T- 02.(hydrogenator).The Pre-sulfiding activity was going as new catalyst was loaded in 73-T- 02. A sr. Process Engineer (from Process analysis & design) was monitoring the sulfiding activity. At about 12.05 a.m.on 30/5/08 first recycle gas sample of PDS (pre desulfurisation) was collected and sent to the lab. As per this Process Engineer, in this sample the H2S content was NIL whereas it should have been @ 2000 ppm. Also meanwhile in the DMDS storage tank(73-D-O8), the drum (DMDS) level was dropping fast. So he advised to unload one DMDS barrel in DMDS storage tank(73-D-O8) .The storage capacity of this tank no. 73-D-08 is 500 litres. Accordingly Incharge of Maintenance Dept , as per request from process dept. issued hot work permit for shifting the DMDS barrel on the first deck (floor) in HGU section to the crane operator & cold permit to his assistants make the nipple and hosepipe connection with the manifold. After getting the information from the maintenance dept. about the connections being made to the manifold , the process department operators starts unloading DMDS as per the process requirement. The procedure followed by process dept. for unloading DMDS from the barrel to the DMDS storage tank (73-D-O8 ) located on the ground floor is as follows i)Stop the DMDS transfer pump(This pump transfers DMDS from the TANK 73-D-O8 to the reactor.) ii) Reduce the blanketing nitrogen flow to 2 Nm3/Hr by watching the rotameter reading. When the DMDS pumps are on , the N2 flow rate is kept at @ 5 Nm3/Hr. iii).Open N2 blanketing valve on the drum then open audco valve on manifold slowly. iv)Open the DMDS unloading valve on the DMDS drum then open two audco ball valves on the manifold and one on Tank 73-D- 08 v) See the DMDS level in Guage Glass.
49 vi) Slowly unload the DMDS to DMDS storage tank (73-D-O8) vii)Once the entire contents of the drum is emptied , close the loading point valves & drum hose connecting valves. viii)Maintain nitrogen flow for purging to normal 5 Nm3/Hr
Properties of Di Methyl Di Sulfide:- As per the various material safety data sheets of DMDS referred, properties of this chemical are as follows, The M.S.D.S. obtained gives the following relevant information Name of chemical : dimethyl disulfide CAS No. : 624-92-0 UN No. : 2381 Appearance: pale yellow liquid Odour : special foul smell Boiling point: 110 c Flash point: 24 c Relative density : 1.06 (water=1) Data on Routes of exposure: The substance can be absorbed into the body by inhalation and by ingestion Effects of short term exposure: The substance is mildly irritating to the skin and is irritating to the eyes and the respiratory tract. The substance may cause effects on the central nervous system.
Observations at the site of accident and findings:- The accident took place in HGU section at DHDS complex on the first floor. On the first floor , a 1 pipe vertical manifold having connections of two pipes of dia and 1 with audco make ball valves is provided. A line coming from the nitrogen header passing through a rotameter and a valve having
Bulged DMDS barrel a pressure of 5 kg/cm2 is connected to the top of the manifold. The bottom of the manifold is connected to the DMDS storage tank ( 73-D-08) which is located on the ground floor by means of a 1 line. On this site near the manifold at first floor , the drum was lying burst open .The top cover of the drum had opened out from its seam joint alongwith connected nipples and valves and was thrown to some distance towards the manifold. The bottom & shell of the drum was thrown back from the manifold. The bottom of the drum had become bloated or swollen. The N2 valve provided on the top cover was in full open condition, whereas the liquid valve on this cover was in closed condition.
There was not a single pressure guage provided on the N 2 line. The flow of N2 was being controlled by adjusting the flow through a rotameter with the help of a valve. I alongwith two Engineers from the said factory provided a pressure guage on the N2 line after the rotameter to find out the correlation between flow rate and pressure. It was found that when the flow is 3 nm3/ hr , the pressure is @ 2 Kg/cm2. The markings on the rotameter were also not visible. The maximum N2 pressure requirement for this HGU section was 1.5 to 2 Kg/cm2. The nitrogen which was being received from the N2 header was having pressure of 5 Kg/cm2. No pressure reducing valve was provided on this incoming n2 line from the header before it enters the HGU plant to reduce the pressure from 5 kg/cm2 to required 1.5 kg/cm2. It was also found that , no personal protective wears such as rubber apron, hand gloves, goggles, face mask etc. were
50 provided to the maintain ace persons who were carrying out the job of connecting DMDS barrel to the manifold. Considering the toxic properties of DMDS mentioned above, these personal protective wears were required to be given to the workers.
What Went Wrong:-- i) A pressure reducing valve on the nitrogen line before it enters the HGU section to restrict the nitrogen pressure below a safe value to avoid overpressurising of the barrel was not found provided. ii)A pressure guage after the manifold audco valve on nitrogen line to know at what pressure, the nitrogen is being allowed to enter into the barrel was not found provided. iii)Suitable personal protective wears to the maintenance workers while carrying out the DMDS barrel connection considering the hazardous nature of this chemical were not found provided. Remedial Measures: Following remedial measures are suggested to avoid recurrence of such type, i)A pressure reducing valve to reduce the pressure of incoming N2 gas to a safe minimum value , sufficient for maintaining inert atmosphere inside the plant shall be provided. ii)Fittings such as pressure gauge, safety valve shall be provided on the nitrogen line. iii)Suitable personal protective wears shall be provided to the maintenance workers while carrying out the DMDS barrel connection. iv)Proper supervision , instructions and training shall be given to the workers involved in handling of hazardous chemicals.
Top cover of barrel A Case Study On 51 23. AN EXPLOSION OF REACTION VESSEL USED WITHOUT EXAMINATION By P.V. Adkar Former Joint Director Industrial Safety & Health
A big explosion was caused as no care was taken to examine equipments on shifting at new place.
HISTORY: An explosion of reaction vessel took place in the chemical factory causing burn injuries due to spurting of chemical on the bodies of six workers ,and proved fatal in case of one worker. The factory manufacturing Hydroxyl Ethyledene Di Phosphoric acid (HEDP) was shifted from its old place to new place in the chemical zone area. The reaction vessels, glass condensers, and all other accessories were required to be transported to new place located about 50 Kms from previous place. Hazardous chemicals like acetic acid, Phosphorous tri chloride, Butanol were used in the process.
ABOUT INCIDENCE: On the day of accident, 275 kgs of acetic acid was taken into the jacketed reaction vessel from overhead tank and was heated by steam in the jacket. Afterworlds 215 kgs of Acetic acid and 230 Liters of Phosphorous tri chloride, was transferred by air pressure into two different overhead tanks. When the temp had reached 65 0 C Acetic acid and Phosphorous tri Chloride were passed into the reactor slowly through two different pipes lines. The reaction being exothermic the temperature reached to 75 0 C at that points, vapours of acetyl chloride were passed to glass condenser to liquefy and the condensate was passed into another reaction vessel containing Butanol. The condenser outer body tubes and tubes inside it, used for the water circulation were of glass. The both reaction vessels were installed on first floor. The feeding of Phosphorous tri chloride was stopped after 8 hrs. Afterwards when condensate Acetyl chloride was stopped passing into the reaction vessel of Butanol, rubber piece was introduced
in the flange joint and workers were operating the reflex valve to take condensate in the Reaction vessel at that moment worker saw vapours in the condenser joining U shape glass tube for reflex arrangement. Within no time the reaction vessel exploded and the stirrer along with its lid was thrown upward upto 15 meters and entangled in the structured ( lid downwards ,weighing about 750 kgs.) the hot chemical spurted on the body of 6 workers working nearby causing serious burn injuries. One worker expired in the hospital. Complete roof and equipments were damaged.
WHAT WENT WRONG? 1. Before actual operation of the condenser glass tubes and water tube inside it were not tested for leakage of water at elevated temperature.( Water was circulated at normal temperature to test the leakage; when leakage was not detected.) however , the leakage caused at elevated temperature. 2. Inspite of the fact that if vapours of Acetyl chloride come in contact with water there is a violent chemical reaction causing evolution of HCL fumes with large amount of heat, glass was used for condenser body and inner water circulating tubes. 3. It was found that the condenser was not tested at different temperature circulating water of leakage. During transport, crack was remained undetected. At raised temperature, the water leaked and came in contact with Acetyl chloride fumes causing violent reaction emitting very high heat. It caused more leakage and as reflex valve was opened water went directly inside the reaction vessel causing violent reaction with 90
kgs of Acetyl chloride causing tremendous heat and hence the explosion. During design proper material for condenser would have averted the said accident. (The author personally visited the National Chemical Laboratory Pune, where small experiment was requested & arranged to be carried out in Lab, by adding drop by drop 5 cc
52 of water by pipette in 10cc of Acetyl chloride taken in test tube , when temp of 15 0 C raised in 10 sec. and lab was filled with HCL gas. This will give idea to the readers about the amount of heat and violent reaction.) REMEDIAL MEASURES: Graphite condensers were used afterwards instead of Glass which was more fragile.
A Case Study On 53 24. MINOR FIRE CAUSING TRAGEDY By P.V. Adkar Former Joint Director Industrial Safety & Health
A major accident occurred in a factory in Maharashtra which Involved hospitalization of about 65 workers and as well as loss of lives of two employees. The hospitalisation period varied from 4 days to one week. The accident involved a minor fire and at the time, when attempts were being made to extinguish the fire it was not realized that the consequences would be so terrible. In fact there was hardly any property damage because of the fire and not a single person received burn injury. Yet two persons lost their lives and sixty five persons had to be admitted to hospital. ABOUT INCIDENT: It was a chemical factory manufacturing dyes and intermediates. It was situated in a remote village. There was a horizontal blender mixer with a motor driven stirrer. In this factory, in the morning the mixer was charged with raw materials through the small opening provided on the top for the purpose. The operator who was working on this mixer switched on the motor and the Z-arm stirrer started rotating. The operator was satisfied that mixing of the material, which was in the powder form, was going on smoothly. There was some time to complete this batch. After some time however he noticed some smoke coming out through the loosely closed top opening. This was unusual. He immediately stopped the motor and opened the cover of the opening. To his horror, he found that the material inside had caught fire. In fact, it was not exactly fire where flames are jumping but it was only a smouldering fire. Some material had started slowly burning. The operator shouted for the chemist who in turn called the fire brigade officer of the company. The Fire Brigade officer had recently joined the company. He had just retired after a long meritorious service from the fire brigade of a big city. After joining the company, he had immediately ensured that the factory is well equipped with necessary fire fighting equipments. As soon as he got the message, he immediately rushed to the spot. He surveyed the scene. It was a minor fire. No cause for panic.
He asked others to stand aside and with a dry chemical powder extinguisher started covering the smouldering material with the dry chemical powder. He was bending over the mixer opening and, with the extinguisher in hand was fighting the fire. Within no time, the extinguisher was exhausted but the fire had not been extinguished. The material was still burning. Smoke, dust, fumes were still coming out. The fire brigade officer took the second extinguisher and continued to fight the fire. The machine operator and the chemist were on the platform giving him all the help they could. Obviously this was not a usual scene and there was some commotion attracting attention of everybody who was in the factory. Almost everybody came to the hall and gathered in the small place. To them it was an interesting sight. Three persons were busy in fighting smouldering fire and the fire refusing to get extinguished. Smoke continuing to come out. Anxiety writes large on the faces of the three who were fighting the fire. There was no reason for the workers, who had gathered there, to run away. After all, there were no flames, no danger of a major fire breaking out. Apparently everybody was enjoying the scene. The fire was really refusing to die. The second extinguisher was exhausted, the third one, the fourth one. The perspiring fire brigade officer bravely continued his fight and the onlookers in the hall the continue enjoying to watch the fun. This went on till all the extinguishers were
exhausted. The material in the mixer continued to burn. But after some time there was no more material in the mixer to burn. All the material in the mixer had been burnt in the fire. The fire thus automatically died down. All the three persons busy on the platform heaved a sigh of relief. They were completely exhausted by their efforts. There was nothing more to watch, so the workers went back to their work. Everybody was happy and relaxed. There was no reason to imagine that a big tragedy was about to strike. AFTER EFFECTS:
After three or four hours the fire brigade officer was the first to report to the doctor that he was not feeling well. The doctor examined him and realized that he needs to be admitted to the hospital. The nearest hospital was the civil hospital about 20 kilometers away. By the time, a vehicle could be arranged the operator had also taken ill. The chemist also was showing same symptoms. All three were put in the same vehicle. On way to hospital, the fire brigade officer died. Another died in the hospital. When these three serious patients were being taken to hospital the workers who had, by then, gone home started reporting to the doctor. When workers, one by one started reporting to the doctor, it was realized that there was a major emergency. Arrangements were immediately made to shift them to the civil hospital at the district headquarters. About 65 persons were required to be hospitalised and treated. They were in the hospital for varying period from 4 days to a week.
54 WHAT WENT WRONG? First: When the fire brigade man decided to use the dry chemical powder extinguisher on the burning material, he was trying to starve it of oxygen by covering it with powder from the extinguisher. He was not aware that there was already highly oxidising chemical in the burning material and hence it did not require any oxygen from air. Thus the sophisticated extinguishers were of no use to fight this fire and the material continued to burn. Secondly, when the material was burning it was giving out toxic gases viz. oxides of nitrogen. Unknowingly the three persons fighting fire were inhaling the toxic fames. Those workers who were watching the fun were, of course, blissfully unaware about the toxic fumes they were inhaling. The fumes were of oxides Nitrogen which do not have irritating effect like chlorine. Otherwise everybody would have remained away. Moreover oxides of nitrogen have delayed effect and hence the delay in the symptoms of sickness.
COULD THIS BE AVERTED? Instead of using a sophisticated DCP Extinguisher a bucketful of water or two could have extinguished smouldering fire within no time Moreover question of any toxic exposures (and the tragedy) would not have arisen. In spite precautions taken for prevention of accidents, major emergency can occur and one should prepare to tackle the emergency to keep the damage to the property and to life to the minimum The above accident, illustrates the need for the proper on-site emergency plan studying all hazards and contingencies in details.
A Case Study On 55 25. EXPLOSION IN THE CURING OVEN By P.V. Adkar Former Joint Director Industrial Safety & Health
A fatal accident took place in grinding wheel manufacturing factory, due to an explosion of the curing oven. The moulded grinding wheels kept on trolley rack were loaded in the oven. Initially the only electric heating system was provided as the heating media. But two years before the accident, LPG gas heating system was fitted as an option to electrical heating system due to power shortage. The accident took place while switching over the system from electrical heating to gas heating. The oven was not provided with the explosion flaps. ABOUT INCIDENCE: On the day previous to the day of accident at about 11p.m., the loaded oven was started on gas heating system. An automatic arrangement by solenoid valve was provided to cut off the heating after reaching the set temperature. It was observed by the supervisor that after about 4 hours of heating and even after attaining the set temperature the heating was on, due to some defects in gas system. On the day of accident, at about 8.30 a.m. the first shift supervisor switch over the system to gas heating. He also found same defect hence continued heating by switching over to electrical heating. At about 11 a.m., the Assistant Manager tried to detect the defect in the system. To check the defect in the system it was put on to gas heating from electrical. He tried to the set value of set temp to 145 0 C from 140 0 C, when suddenly, the oven exploded and Assistant Manager and the supervisor were thrown away. They received serious injuries but in case of supervisor it proved fatal. WHAT WENT WRONG? Investigation revealed that after switching the system to electrical from gas and in case failure of solenoid valve, gas can leak inside the oven
causing explosive mixture. In such situation gas detection and alarm system was not provided to give warning. The leakage of gas was caused between 8.30a.m.to 11.00a.m.when gas system was turned off. When Asst. Manager started the gas system the spark at burner exploded the air fuel mixture. In the process of curing of grinding wheels no flammable vapours were evolved. The main cause of accident was not maintaining the solenoid valve in order. REMEDIAL MEASURES: 1.Leak detector and alarm appliance arrangement may be fitted to detect the leakage of gas in the chamber on switching over system to electrical 2.Solenoid valve shall be inspected and well maintained. 3.Arrangement to trip electrical heating system in case of leakage of gas. 4.Explosion flaps arrangement shall be provided on the oven.
A Case Study On 56
26. Fatal Accident due to collapse of a Cement silo in a Readymix concrete Plant
Compiled By V.M. Yadav Deputy Director Industrial Safety & Health, Pune -----------------------------------------------------------------------------------------------------------------------------------------
The accident that took place in a factory due to the collapse of a silo used for storing cement, on a cement bulker which was parked near the silo. Three persons who were inside the bulker died in this accident.
About the Incidence
In this factory the manufacturing of ready mix concrete is being carried out by mixing cement, fly ash, sand, khadi and water in proper required proportions, The production of concrete was stopped since @ 9.00 pm previous night. The plant was in closed condition as there was no production going on. One bulker came at the entrance of factory at @ 1.30.a.m. to unload loose cement which it was carrying in to the silos. Stores Incharge, asked them to bring the bulker inside and to park it near the silo no.2 in reverse direction. Accordingly the Driver parked the truck in reverse direction keeping a distance of @ 8-10 ft from the silo. Stores Incharge then went near the silo and asked the cleaner of the truck to make the necessary hose pipe connections. After making the connections the unloading of cement from bulker to silo no. 2 was started. Normally unloading of one full bulker (capacity 15-19 tonnes) takes @ one hour. Stores Incharge stopped the unloading after 10 minutes as the production was not going on. He wanted to check the level of cement in silo no. 2 in the morning after any helper joins duty and then restart the unloading. Stores Incharge asked the cleaner to disconnect the pipe and asked the driver of the bulker to shift his vehicle little bit as one more fly ash bulker was expected to come for unloading. This fly ash bulker came at @ 3.15 a.m. It was parked near to this earlier cement bulker, was unloaded in fly ash silo no.3 as per the instructions and supervision of Stores Incharge. This fly ash bulker left the plant at @ 4.35 a.m. Then at about 7.30 a.m. Stores Incharge and other workers in the factory heard a loud sound in the factory. He came out of his cabin and saw that the silo no. 2 has fallen on the bulker which was parked near the silo in the night. After going closer to the bulker he saw that the silo had fallen mainly on the cabin of the bulker and the cabin was almost became flat. Then police and fire brigade was called. As the silo was full with cement, it was cut from the side and some cement was removed from it and then with the help of a crane the silo was lifted and three bodies were removed from the driver cabin.
Observations:
1.A huge silo had fallen on the cabin of a truck (bulker) which was parked near to it.
2.Some front portion of the cement tank on the tanker had plunged in the ground because of which the tail portion had got lifted in the air 3)A small pit was created because of the collapse of the silo in the soil below the silo 4) The Silo legs twisted & Shell/cone of the silo has fallen on the Cabin 5)3-persons who were sleeping inside the cabin died as silo had crushed the cabin. 6)3-Nos of silo leg top end to lug base plate fillet weld joint sheared-off from the lug base plate. 7)1-No silo leg top end to lug base plate fillet weld joint remained intact. 8)Some of the foundation bolts sheared off from base plate location. 9)Threads of Some of the Foundation bolts sheared off. 10)Some foundation bolts were seen in broken condition and some were in bent condition. 11)Lugs along with base plate, gussets & pad plates remained intact. 12)The bracings of the legs were also twisted / bent. 13)The bracings of the legs were also twisted / bent.
57
The details of the silo which had collapsed A)Silo Details: a) Service : Cement b) Capacity : 200T c) Shape : Circular d) Dimensions :
I) Diameter : 4000mm II)Shell height : 12000mm III)Bottom cone height :700mm IV)Top Cone Height : 400mm e) Support Type: Legs f) Qty Of Legs: 4-Nos g) Leg Member Size ISMB- 350 h) Leg Height-4500mm i) Foundation Bolt Size- 24 j) No. of Foundation Bolts on each Leg : 4Nos.
Observations /Findings:
a)Activities Happened Before Accident: 1)Silo was filled upto some height / capacity. Exact Capacity not known 2)Cement unloaded for about 10-15Min from this said bulker in the night & stopped 3)Complete Cement bulk tanker was not unloaded. 4)In the absence of the helper to check the exact filling level, the silo filling activity was abandoned. 5)The Bulk tanker was parked near to fatal silo. 6)There was movement of two bulk tankers (cement bulk tanker & fly ash bulk tanker near this said fatal silo in the night) near the silo no. 2 structure.
What went wrong?
(a) Settlement of the Soil & Foundation: i)Since there was a water tank below the Centre Silo & above its foundation, there are more chances of its leakage & additional load created by it on the foundation. ii)The leaked water from the tank might have loosened the soil below the foundation iii)After a period, the soil might have loosened & allowed the settlement of foundation due to cycle of Silo loading & unloading.
(b)Silo Legs & foundation Bolts Not Designed Properly: i) Since the Legs has been twisted & bent, it is quite possible that they were not designed properly to consider wind, seismic loading & moments generated in empty & operating condition. (b)The Connection of the bracings & Legs not done properly, the load was transferred to web in inclined direction & not in Leg Axis plane. (c)Since Gussets were not provided at base plate & cap plate locations, the shearing/uprooting of weld joint due to sudden loading would have been avoided & would not have resulted in the bending of the legs. i) The base plate orientation was not correct with reference to leg web orientation. This has resulted in wrong location/orientation of the foundation bolts. ii)In the present condition, there is only one bolt which is under Tension & one bolt under compression. The other two will act as neutral. iii)This would have resulted in the failure of the Foundation Bolts. 58 iv)Broader Legs base or higher legs PCD would have made the silo more stable & would have avoided its tilting. v)The broad PCD would have broader PCD would have been achieved by welding the Legs Flange on the Shell & not on the Cone. (c) Non Functioning of Silo Pressure Relief Valve: i)Silos are deigned for the static pressure of the connected blower. ii)There is always a +ve pressure during the loading. iii)It might have happened that at the time of Silo loading, if the silo was full & level was not known to the operator, they must have realized that the material is not going inside the silo & must have stopped. iii)The Silo must have been filled more that its capacity. iv)The air which must have come along with material, could not be released due to non functioning of the pressure relief valve (breather valve). v)This would have created some movement inside the silo material & would have added an additional load on one of the side & added on to the moment & would have resulted into falling of Silo. (d) Dashing of the bulk tanker with the silo structure. i) The bulk tankers were parked in the reverse direction near the silo no. 2 ii)They were moved two three times to make the hosepipe connection with silo no.2 and then to shift a little in order to make space available for another flyash bulk tanker. iii) It is possible that during this movement one of this bulk tanker dashed the structure around the conical portion of the silo.And as the silo was full, this might have resulted in shifting the centre of gravity and initiating the bending/ tilting of the silo adding uneven forces on the leg supports.
Conclusion : From the various probable causes for the failure /collapse of the silo mentioned above it can be concluded that there were lapses in providing and maintaining a plant which was properly designed and fabricated and following the
system of work in the factory that were safe and without risk to the health of workers by i) Not preventing the possible seepage of water from the curing tank which he had provided below the middle fly ash silo and thus not preventing the possible settlement of the foundation of silo no. 2 ii) Not providing a barrier metal guard of adequate strength to prevent any direct dashing of vehicle on the silo structure. iii) Allowing to unload the cement from the bulker when the silo level was not surely known iv) Allowing to park a vehicle inside the factory v)Not providing a silo having its legs, base plates, cap plates, foundation bolts properly designed and fabricated
59 vi)Not connecting of the bracings & Legs properly ( the load was transferred to web in inclined direction & not in Leg Axis plane ). vii)not providing Gussets at base plate & cap plate locations,( the shearing/uprooting of weld joint due to sudden loading would have been avoided & would not have resulted in the bending of the legs). viii)not providing the correct base plate orientation with reference to leg web orientation. (This has resulted in wrong location/orientation of the foundation bolts.)
A Case Study On 60 27. A FATAL ACCIDENT DUE TO COLLAPSE OF DOOR Compiled By R.P.Khadamkar Deputy Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ A fatal accident to a Security Watchman occurred, while closing the sliding gate of the factory shed.
ABOUT THE FACTORY: The factory was involved in the manufacturing of the various components required for automobile industries. The plant included a factory shed and different machines installed in it. The factory shed was provided with a manually operated sliding gate at the front side, which was made up of m.s. having weight about 700 Kg. A guide roller support bracket having 4 No. of rollers was welded at left end of the opening and a stopper in the form of a piece of channel was fixed at the right end. The gate was provided with wheels at its lower end. The gate slides between the rollers such that a front pair of rollers supports gate from front side and a rear pair of rollers supported gate from back side. The gate wheels moved on the rail provided at the ground.
ABOUT THE INCIDENCE:
The deceased was working as Security Watchmen through the Contractor. The nature of their work was to guard the plant and keep watch on the gate of the factory. On the day of incidence, the deceased and other watchman resumed duties at about 8.00 P.M. The plant was in operation in a General Shift. After end of the shift, workers and staff left the factory. Both the watchmen switched off the light and closed the internal doors. The sliding gate of the factory shed was to be closed and was to be locked as usual. As the gate was heavy, it was required to be operated by both watchmen. The front pair of guide rollers and right side roller of the rear rollers of the bracket were broken and hence the gate was required to be pushed towards wall and then required to slide towards right side. At about 9.30 P.M., the gate was being closed by sliding it towards the right side. The deceased was pushing the left side and other watchman at right side of the gate. At that time, while pushing the gate from left to right side for closing, the welding joint of the guide roller support bracket at the pillar broke. As a result, the gate fell down on the bodies of both the workers and they were seriously injured. One watchman succumbed to injuries, while under the treatment in the Hospital. The other watchman received fracture injuries to femur of his left leg.
OBSERVATIONS: The sliding gate of the factory shed was manually operated. The overall size is about 5000 mm L x 3000 mm H and having weight about 700 Kg. It was fabricated by using m.s. channels each of size 75 mm x 40 mm x 5 mm, m.s.sheets of 14 guage. A guide roller support bracket was having a plate of size 500 mm L x 250 mm B x 10 mm thick and fixed with 4 no. of guide rollers on lower side. The size of each guide roller was about 75 mm dia x 25 mm SLIDING GATE FALLEN ON WORKER 61
width. The gate along with the guide roller support bracket was found lying on the ground. The front pair of guide rollers and right side roller of the rear rollers of the bracket was found broken. The bracket was found detached from the pillar at the welding joint. The welding joint of length about 300 mm was found broken and was in rusted condition. A piece of channel having size about 100 mm x 50 mm and is fixed at the right pillar as a stopper.
WHAT WENT WRONG:
i)The front pair of guide rollers and right side roller of the rear rollers of the bracket were
broken and hence the gate was required to be pushed towards wall and then required to slide towards right side. Both the workers were required to operate the gate, which was heavy. There was support from only one of the rear the guide rollers and load of the gate was transferred to the welding joint of the support bracket with the pillar. As a result, the welding joint gave a way, while both the watchmen were operating the gate. The broken guide rollers ought to have been replaced by new one, immediately for preventing the transfer of load on welding joint and for ensuring the safety of workers at work. But rollers were not replaced, whereas it was reasonably practicable. ii)The welding joint between the guide roller support bracket and the pillar got rusted and hence became weak. It could not withstand the load of the gate and gave a way. The welding joint ought to have been checked for its strength and ought to have been maintained by welding it again to ensure the safety of workers at work, whereas it was reasonably practicable.
REMEDIAL MEASURES SUGGESTED: The sliding gate and its accessories shall be maintained to ensure the safety of workers at work.
GUIDE ROLLER SUPPORT BRACKET ROLLERS BROKEN OPENING WHERE GATE WAS PROVIDED PLANT 62
SLIDING GATE BRACKET GUIDE ROLLERS
WHEEL G.L. G.L.
GATE SLIDING GATE 500 MM X 250 MM X 10 MM THICK BROKEN ROLLERS
3000 MM 75 MM DIA X 25 MM WIDTH WELDING JOINT BROKEN
5000 MM TOP VIEW OPENING SLIDING DOOR SLIDING DOOR A Case Study On 63 28. PREVENTION OF BOILER CHIMNEY Compiled By P.V.Adkar Former Joint Director Industrial Safety & Health,
A very big tragedy has been averted due to excellent co - ordination and timely implementation of on site plan. Incident of bending of Boiler Exhaust (Chimney) of Factory and its possibility of likely to fall on Ammonia Tank installed in open area any time before it was safely removed. Had it fall down then min 3 Kms area would have been badly affected!
ABOUT INCIDENCE:
The factory was engaged in manufacturing of fruit syrup/crush like Mango, Orange Grapes etc. All utilities for the plant were located at one place like Refrigeration Plant using Ammonia stored in the tank of 3 ton capacity. Steam Boiler was installed nearby with huge exhaust chimney, Compressors and electrical sub- station. Due to change of fuel the effect on chimney pipe wall and joints was unnoticed for along time. Boiler Exhaust (Chimney) at factory was observed to be bending on one side at 7.30 PM on that day. The chimney made of Mild Steel, consisting of five sections had a total length of 30.5 meters. The bend was around 25 degrees. The bend was erupted near the joint of 3 rd and 4 th section from ground. This was due to corrosion defect which was earlier detected in section 3 of the chimney. Immediately after noticing the bend, factory operations were stopped, as a precautionary measure to avoid any safety hazard. The boiler was de-pressurised. All the workmen were present in factory were called at emergency assembly point, after reconciling the headcount, only utility operators were retained in factory and all other workmen were released. All the person present at site was provided with Personal Protective Equipment ( PPEs) such as CHIMNEY BENT BY 25 DEGREES
safety shoes and helmets. Fire Brigade and Police were communicated to arrive at site to meet any possible safety risk. Directorate of Industrial Safety & Health , took lead as a Member Secretary of the District Crisis Group. Directorate of Boilers, Pollution Control Department, Local Administration was also informed about the situation of the incident. An ambulance and doctors were arranged to be present at site. Ammonia tank was covered with sandbags and PUF panels to minimize any
possible damage to the same. Two empty ammonia tankers were arranged to carry out transfer of ammonia from system to tankers, as a contingency plan. To carry out repair of Chimney, required height of crane was of minimum 95 feet. The cranes available in town were of maximum 75 feet height, and hence a crane of required height was mobilized urgently from nearby city. Crane wheel punctured two times in journey .Once on the way to city and second in the entry door of the factory. Before starting the actual activities,
64 Crane crew was briefed about safety requirements. All safety equipment viz safety shoes, helmets, safety belt etc were provided. The joint between 2 nd and 3 rd section from ground was opened, by removing the bolts between the flanges to bring down the top 3 sections. All top 3 sections were tied up with crane before removing the bolts. The defective 3 rd section of chimney was removed and Section 4 was joined with section 2 to re-erect the chimney. Stability certification
was obtained from competent authority, after inspection and ultrasonic testing of the chimney sections. While doing the above activity there is 5.5 mtrs reduction in the height of the chimney and this has been communicated to all concerned Govt. Authorities It is decided to fabricate this 5.5 mtrs portion and reinstall during the annual shutdown of the boiler. The Photographs shows i) Bended Chimney for 25 0 .ii) Crane Boom fall short iii) Crane of adequate height. iv) All Agencies ready to handle possible tragedy v) Covered Ammonia tank.
Lesson learned:- The Chimneys shall be critically inspected periodically and shall be timely maintained.
AMMONIA RECEIVER COVERED BY WOODEN PLANK TIEING OF PART OF CHIMNEY DEFECTIVE SECTION OF CHIMNEY REMOVED A Case Study On 65
29.FATAL ACCIDENT WHILE DRIVING A FORKLIFT Compiled By N.A.Deshmukh Assistant Director Industrial Safety & Health, Pune ------------------------------------------------------------------------------------------------------------------------------ Fatal accident took place in one of the factory which is engaged in manufacturing of soft drinks. One fork lift driver met with a serious accident while he was taking his fork lift in the reverse direction.
ABOUT THE ACCIDENT: Forklifts are used in this factory for shifting soft drink bottle crates from one place to other or for loading/ un-loading of crates. The above said fork lift along with the driver was hired outside agency on contract basis. The renovation work of dispatch ramp by constructing it with RCC was completed recently. On the date of accident, at about 3.50 pm, the deceased worker was taking his fork lift in reverse direction on the dispatch ramp. At that time, one of the wheels of his fork lift slipped from the edge of the dispatch ramp and fork lift toppled down from the 4 feet height on the road leading to the empty bottle yard. Portion of his body below chest was trapped under the fork lift. Workers working nearby rushed for his help. It was difficult to lift the fork lift and remove him from there. So, another fork lift was brought to the spot of accident and the deceased worker was rescued by lifting the fork lift below which he was trapped. He was immediately shifted to Hospital, by ambulance of the factory in unconscious condition .He expired on the same day while he was under treatment in the Hospital.
OBSERVATIONS: On visiting the spot of accident, it was observed that in this factory, there is one dispatch ramp which is located outside the unloading bay. The road of this dispatch ramp is straight road up to certain distance and then there is taper portion on this road. On the north side of this dispatch ramp, there is another parallel road which is leading empty bottle yard. There is level difference on both these roads. The road leading to the empty bottle yard is at lower level and maximum height of dispatch ramp from this road is 5 feet. One fork lift is seen lying near this wall. One seat belt is found provided for the driver on this fork lift. However, it was revealed that the deceased worker was not wearing seat belt when he met with an accident. Damage marks are seen on the corner of the ramp at about 4 feet from the road leading to empty bottle yard.
WHAT WENT WRONG: During inquiry, it was revealed that the deceased worker was holding valid licence. It was revealed that there was level difference of about 5 feet on the ramp and the road leading to empty bottle yard. Both these roads were adjacent and parallel to each other. There was no barrier wall or fencing provided along the road edges connecting ramp and adjacent road which was at 5 feet depth from the ramp. The portion of the ramp was tapered and there was possibility of increasing the speed of the fork lift while descending from the ramp. On that day, while the driver was taking his fork lift in the reverse direction from the ramp and when he had reached the tapered portion of ramp, he lost control on the fork lift. As there was no fencing provided in the edge of the road, his fork lift toppled down from ramp to 5 feet deep adjacent road.
REMEDIAL MEASURES: In order to avoid such type of accidents in future, it was recommended to construct one barrier wall/ or suitable fencing all along the edge of the two roads which were at two different levels.
A Case Study On 66 30.EXPLOSION DUE TO AMMONIA GAS LEAKAGE IN A COLD ROOM
Compiled By V.M. Yadav Deputy Director Industrial Safety & Health, Pune ----------------------------------------------------------------------------------------------------------------------------------------- An explosion took place in a factory due to ammonia gas leakage in the cold room, while carrying out the draining of oil from the accumulator, which was located inside the cold room. HISTORY: In this factory the activities like receiving milk from outside, pasteurizing it, packing it in , 1 litre plastic bags and storing it in cold rooms is being carried out. The packed milk was being stored in the cold rooms and to maintain the temperature inside the cold rooms at @ 1-4 degree centigrade, a ammonia based cooling system (refrigeration) was installed in the plant.
Details of Ammonia Refrigeration System: The ammonia refrigeration/ cooling system consists of i)An ammonia receiver in which about 400 to 500 kg of ammonia is stored at pressure of @ 10-12 kg/cm2. ii)An oil separator: separates the oil carried over with the compressed ammonia which comes from the compressor iii)Cooling coil: cools down the ammonia gas which becomes hot after compression and converts in to liquid ammonia. iv)Compressor: Receives ammonia at @ 2-3 Kg/cm2 in gaseous form , compress it to a pressure of @ 10-12 kg/cm2. v)Cooling fans: consists of a oil accumulator which first separates the oil coming from the pipelines , then a throttle/ expansion valve which receives ammonia at a pressure of 10- 12 kg/cm2 and expands the ammonia suddenly, so as to get a sudden pressure drop and because of this effect, temperature of ammonia drops to -4 C to 0 C. Then the circulating fans consist of network of ammonia tubes through which chilled ammonia flows. The fan circulates chilled ammonia in the cold rooms to maintain the temperature at @ -1 to 2 C. The oil accumulator was provided with a drain pipe at its bottom ( length @1 ft and dia of ) ABOUT THE ACCIDENT Since last 3-4 days before the occurrence of the incidence, the cold room temperature was not going down to the required temperature of 1-4 0 C.
So on the day of incidence, after resuming his regular duty, the ammonia plant operator informed maintenance department, that he wanted to drain out the oil from the oil accumulator which was located inside the cold room. Maintenance supervisor asked one worker to help the operator in his work. They collected the necessary tools like spanner, screw driver and hammer and went inside the cold room. The Operator opened the drain valve of the oil accumulator but as the drain line was choked, oil did not come down. He then removed the drain valve and put it aside. Then the co-worker pierced a screw driver inside the drain pipe from the bottom. As soon as he did this, as the system was under pressure, ammonia gas from the system started leaking from the pipe. As there was no valve on the drain pipe, it was impossible for them to stop the ammonia flow. So, they opened the doors of cold room and came out of the cold room. Meantime the workers in the factory were told to evacuate the factory because of the leakage. Accordingly the workers went outside the factory gate. COLD ROOM
At @ 9.20 a.m., there occurred an explosion inside the cold room and a momentary flash of fire came out of the door. The walls of the cold room were shattered. Because of the pressure wave, some plastic crates were thrown away. Five workers were slightly affected due to ammonia gas and were admitted to hospital. Three workers received minor injuries. The Operator received minor burn injury on his face and hand. OBSERVATIONS: The explosion had taken place in the cold rooms. There were two adjacent cold rooms of the size 30L X 20 B X 10H. and 27 L X 12 B X 10 H, which were damaged due to the heavy impact of the explosion .The walls of the cold room on the east side, south side and north side had collapsed, cracks got developed on the walls and two to three columns of the cold room were damaged. There were cracks on the ceiling of the cold room also. The wall on the west side between cold room and the adjacent laboratory was shattered. A m.s. ladder which was located near the cold room was dislocated and had moved about 15 away from its original position. The milk packing machine which was located on the east side of the cold room was damaged. The tube lights inside the cold room were shattered. Some electrical wires, cables were burnt.
67 Properties of Ammonia: Ammonia is a colorless, corrosive gas with a sharp, pungent odor which can be detected by smell at low concentrations. The flammable or explosive concentration of ammonia in air is 15-28%. If the ammonia concentration is in the flammable range, a large and intense energy source can cause ignition and explosion. Material safety data sheet of Ammonia Physical state (gas, liquid, solid): Gas Vapor pressure at 70F : 94 psi Vapor density at 60 0 F (Air = 1): 0.62 Solubility (H20) : Very soluble Stability and Reactivity Unstable, Anhydrous Ammonia is an irritating, flammable, and colorless liquefied compressed gas packaged in cylinders under its own vapor pressure of 114 psig at 70 F. Ammonia can cause severe eye, skin and respiratory tract burns. It poses an immediate fire and explosion hazard when concentrations exceed 15%; therefore, area must be ventilated before entering. Anhydrous ammonia has an expansion ratio of 850 to 1. One litre of liquid will expand 850 times as a gas. Cause of explosion: The spot where the explosion took place were two cold rooms of the size 30 x 20 x 10 ht and 27 x 12 x 10 ht totally closed from all the sides.
Ammonia gas started leaking in these closed cold rooms as the worker pierced rod inside the drain pipe of the oil accumulator which was centrally located between two cooler COOLING UNIT COLD ROOM DRAIN VALVE
units. Ammonia gas kept on accumulating inside the cold room and slowly pressurizing the cold rooms.
This ammonia leak occurred and the lower explosive limit of 15% was reached in the confined space. When the doors of cold room
were opened, the air-gas mixture was then ignited explosively by an ignition source such as an unprotected hot tungsten filament of the fluorescent tube (provided in the cold rooms) which were broken because of ammonia gas accumulation and the thermal stress because of the sudden temperature difference.
WHAT WENT WRONG: It was found that, i)The oil accumulator was frequently required to be drained to remove oil to maintain the efficiency of cooling inside the cold room. It was found that the occupier had provided the oil accumulator inside the cold room. And 68
there was only one valve was provided on the drain line. Minimum two valves ought to have been provided on this line so as to reduce the risk of ammonia leakage in case of failure of one valve. ii) Ammonia plant operator in order to drain the oil from the accumulator removed the drain valve completely and pierced the rod inside the pipe subjecting the ammonia system to a hazardous situation of ammonia leakage in a confined space. The operator ought to have checked whether the accumulator contains ammonia and its pressure and he ought to have removed the drain valve only after ensuring that there is no ammonia in the accumulator. The operator and other workers were not trained to follow a system of work that were safe and without risk to the health of the workers by the occupier. iii)The factory was not equipped with necessary equipments like self contained breathing apparatus to use them in a hazardous situation like ammonia leakage. iv)This work of draining the oil from the accumulator and removing the drain valve of accumulator which was a part of a ammonia pressurized system was not supervised by a trained and responsible person. v) It was found that no safety instructions were displayed in the workroom about precautions to be taken related to ammonia and other hazards.
ACCUMULATOR A Case Study On 69 31. CHLORINE GAS LEAKAGE- SUCCESSFUL DISASTER MANAGEMENT
By V.A. More Former Joint Director Industrial Safety & Health ----------------------------------------------------------------------------------------------------------------------------------------- It was 11 pm and I was about to go to bed ., all of a sudden phone rang, I lifted the phone. Is Mr.More is there! This is S.D.O. speaking ..voice was very disturbing .. I am Sdo, speaking she reveled again. At present I am near Chlorination near Highway and I am along with the leaking chlorine tonners loaded in the truck which are brought for neutralizing purpose in the BMC chlorination plant. All tonners were brought for unloading in Chlorination plant. Plant people refused to accept it hence they are standing in middle of the road. Chlorine is slowly leaking from one of the tonner. I dont understand what to do now? Immediately the thought which came to my mind was the area in which this disaster took place is not under my purview of operation as I am responsible for different Region. But on humanitarian ground and being a member Secretary of District Crisis group I took the initiative to contribute the best of capacity to combat Disaster. So I collected the basic information from S.D.O.& Started thinking of the further action. It was surprising that these five Chlorine tonners were dumped in for last twenty years. Nobody has cared about these rusty filled Chlorine tonners kept in haphazard manner at Maharashtra Jeevan Pradhikarans incomplete sewage treatment plant. In the nearby community thousands of people were living. Many were passing around it for several years. There was huge pile of dirt and garbage got accumulated around these neglected Chlorine tonners. It was rainy morning, white yellow fumes started coming out from the one of the Chlorine tonner. Fumes started spreading with the wind. It created chaos among the nearby community. People started suffering from eye burn, breathing discomfort, coughing. After all it was Chlorine! The monster that was trapped for two decades suddenly escaped from the cage and took horrifying image. Chlorine is much useful but at the same time it is toxic also. Its safe concentration in air is 1 ppm (1 part of 1 lack) If it increases up to 100 ppm then the atmosphere becomes threat to life. Due to this sudden incident local people became panic. Everybody recollected worst memories of Bhopal disaster. Local administration seems to be unaware about what to do. Somehow they came out of this sudden shock and started acting on the situation. Experts from the largest Chlorine manufacturer were called. Also information was given to DISH officer and District Collectorate. Leakage started from 4 am of that day & was not yet under control. At 8 am, expert panel from Chlorine manufacturing Factory was arrived. They connected necessary device to collect leaking Chlorine and its destruction. Till then 30 people got affected due to chlorine. All were admitted in Hospital. As a precautionary measure, around 3500 people were evacuated. Gas destruction work was progressing safely and slowly. Other four non leaky Chlorine tonners were kept under observation.
N.D.R.F., was also called as stand-by. District Collector, Resident District Collector, Team of Experts Inspecting the defective chlorine Tonner
Municipal Commissioner were personally monitoring the situation. After rigorous efforts of 24 hrs., gas was completely taken out from leaky tonner and safely destroyed. Everybody sighed in relief. Due to pressure of local people and also from safety point of view, it was decided to shift the remaining four tonners out of the village. But outside the village means where? Nobody was having its answer. Discussion happened at higher level authority and it was decided to send these tonners to water treatment plant as it is near highway. By the time we could decide on shifting we observed that unfortunately one out of the four remaining chlorine tonners started leaking. We were worried but still all the tonners were loaded in 2 trucks and their journey towards water treatment plant began. This was done under the leadership of SDO Madam. The caravan of Chlorine tonner loaded trucks along with police force, ambulance, and other officers slowly reached to water treatment plant chlorination plant at 8 pm. There was no tension till this period .. But all of a sudden one phone call came from some where giving an order of not to accept these tonners in water treatment plant. Immediately everybody made about turn. But where to go? And what to do? As and when the caravan reached to near by village or community the resident/villagers made strong resistance to this caravan. Due to this SDO was puzzled. All the vehicles were stopped in the mid way near Chlorination plant and highway and she called me. 70
Even though the leakage from one of the tonner was not that much serious the situation was critical. Slight raining started. I organized to send one Safety Manager from region and suggested a temporary measure of placing tarpaulin over the leaky tonner. Keeping it under the surveillance of experts, I suggested S.D.O. Madam to go home. Then I started thinking about what can be done on next day morning. On that night itself, I called MARG coordinators and other selected members of MARG and gave required instructions. I discussed with District Disaster Management Officer and gave information about tomorrow mornings action plan and became relaxed. In the morning I reached to a village situated opposite side of water treatment plant. I took District Disaster Management Officer along with me. Fortunately for the safety reasons, those trucks loaded with Chlorine tonner were shifted in the open space of godown building situated on the right side of highway. Commissioner, Municipal Corporation and Tahsildar were present on the site. A huge crowd of local people and nearby villagers was gathered to watch the situation. Tonners were inspected with the help of experts. Leakage was found from vapour valve of tonner. Valve was not operating. Whole body and valve of tonner was badly corroded. Hence it became necessary to take out Chlorine gas and destruct it as early as possible. Again there was a concern about other three tonners. But there was no Chlorine leakage from it so far. Fortunately management of one of the chemical company in area took initiative to take them to Caustic tanker summoned for neutralizing Chlorine
their factory. Therefore it was decided to shift these three tonners to their desired destination in order to minimize hazard at that place. For that the preparations ware made till 1 pm. These tonners were loaded in two trucks and kept ready along with police force and adequate resources for immediate measures required in case of emergency situation. By shifting other three tonners to our tension and risk at site was going to be reduced. But again suddenly after all these preparations, factory has refused to take the tonners. We felt once again in trouble.
Our situation was just similar to 26/11 where Nobody was ready to accept dead bodies of terrorist attack. We found ourselves in similar situation for these tonners. Then we again decided not to bother about three containers and concentrate on leaking tonners.
It was not an easy task to destruct 900 Kg Chlorine gas from one tonner. For that 30% dilute caustic solution tanker was brought from Chlorine Manufacturing Company. In the mean time Oxygen cylinders became empty. Hence oxygen cylinders from other region were brought. By looking at the condition of valve of leaky tonner, initiation of urgent action became necessary.
71 We discussed together and decided to cut the valve. It was a decision with great risk. Anything could have been happened. As far as my knowledge was concern, it was the first time such a brave decision for destructing Chlorine was taken. Even though it was a risky decision but considering the panic created by this chlorine during last 3 days in the area, it became necessary to take some immediate steps to destroy this Chlorine. Then we started our off site disaster management plan. Cutter was required to cut the valve. Fire brigade was having pneumatic cutter. One separate device was created to remove both liquid and vapour valves. That means it was decided to create separate arrangement and Chlorine to be released in caustic solution through metallic pipes. Capping was required to be done immediately without any further delay, after cutting the valves. But this work was so risky and requires people having courage and strength. It was decided to give this job to a nearby group of expert. Finally it was decided. . Everybodys places were fixed. Who will cut valve? Who will put cap? How to close cutter? Who will stand where? etc. was decided. Flag was posted near the vicinity to get an idea about wind direction. As a precaution, all the people were taken on highway. Highway systems were also alerted. Leaky tonner was in the truck and behind that tonner caustic tanker was parked. All the people in the nearby communities and villages were alerted and instructed to close their doors and windows. Ambulances were kept ready in all the villages in the 4 5 Km range in the down wind direction. Announcements were continuously made on loud speaker. Everybody has taken their respective positions. Limited people like us were standing in the 25 30 feet distance on opposite direction along with necessary PPEs. Actually on the truck, near tonner, there were five persons. One cutting person, other two persons ready for capping and one person doing video shooting. Every boy was equipped with Leakage successfully plugged & neutralization process started
breathing apparatus. One person was doing video shooting with his camera. Two other person was in position ready for capping. Fourth Person of Municipal Corporation was ready with cutting machine. Wind was blowing heavily. Flag was also swirling heavily due to wind. I unnecessarily thought that the flag is also trembling due to fear. Then that moment came. ..Cutter started. Capping people took their positions. Heart beats and curiosity of all increased. Breathes were hold. Cutter has through with his work in few moments and Chlorine trapped inside started coming out with large noise and huge pressure. Everybody missed their heart beat for a while. On that moment, except yellowish smoke, nothing was visible in the truck. Cameraman lost his balance fell down. Two persons who are standing for capping succeeded in placing cap with great efforts. Some part of Chlorine started going in Caustic tanker. Something has gone wrong. Hence to reduce effect of Chlorine in the atmosphere, water spraying was started. One big yellowish / white cloud got created started rising in the sky in the wind direction. Everybody was panic due to happenings on the site. One sudden thought came in mind. What would have been happened if they failed in placing cap? If somebodys breathing suit felled? If wind direction was
72 suddenly changed were the immediate questions in mind Till 6 7 pm in the evening Chlorine transferring from tonner to alkali tanker was continued. Some amount of Chlorine was sure gone in atmosphere. But most of the Chlorine was successfully destroyed. Everybody sighed in relief. Definitely this successful mission completed by this team was not less than that of the military persons fighting on the border. They completed this off site disaster management plan by keeping their lives under danger. They gave relief and confidence to District Administration. On 15 th August, Honorable Guardian Minister and District Collector praised and honored me along with all above mentioned team members in District Collectors office. This is called Team Work and off course successful disaster management.