1

Case Study | V.Ramachandran & Dr.Janetius (2014)

CASE STUDY
ZERO ACCIDENT A GOAL OR A MEANS

Introduction: Management education today highly depends upon its teaching methodology. Case Method
(case study) plays a vital role in effective learning process in management education (Banning, 2003). As
the famous Chinese proverb goes, If you tell me, I will listen. If you show me, I will see. But if you let me
the feel the experience, I will learn, tells a lot about case method being an effective mode of learning from
time memorial. Today highly ranked management institutions around the world, IIMs and IITs in India steal
the show utilizing this method of teaching. The distinctness of Case Study is attributed for its learning curve,
which does not confine only to a particular know-how but a wide-ranging knowledge.
Employee safety and prevention, occupational hazards have been engaging greater attention of the
psychologists, sociologists, human resource specialists and industrial engineers in India recently. Indian
industry took rapid growth in the past fifty years, more so in the last two decades, when it hesitantly opened
the highly secured gates of global market under globalization. The working conditions at various industries
are full of risks and hazards, whether it could be chemical, electrical, mechanical etc. Unlike the developed
countries, the sudden surge in Indian industry, especially after the globalization, has exposed several
lacunas in maintaining working conditions, in terms of industrial safety, employee welfare and health. Every
year millions of employees are injured fatally in factories, mines, railways ports and docks globally. The
International Labour Organization (ILO) estimates that around 4,03,000 people in India die every year due
to work-related problems and more than 1,000 workers die every day due to work related diseases (Pandita,
2009). A majority of the accidents happen because of unsafe activities or unsafe work conditions that prevail
in the shop floor.
Accidents are enormously costly making direct and indirect loss to the company and to the family
concerned. Human loss is immeasurable and cannot be valued in monetary terms. Todays technology tends
to be accident-proof as most of the machines are equipped with self-acting techniques. This reduces and
avoids the risks of accidents largely when the person who operates is mentally inclined, strongly equipped,
personality destined and continually involved in the operation. However, human negligence and mechanical
failures can cause accidents. Generally, workers at shop floor are more prone to accidents and they get
involved how much hard they try to evade them. The identified causes are muscular weakness, mal-
supervision, stress and strains, family conditions, drug/alcohol addiction, emotional instability, visual
disability, recklessness, hostility, job insecurity, indifference etc. (Bell & Healey, 2006). Besides these, proper
selection and placement of employees, safety training to new employees, safe work practices, warning of
potential hazards, persuasion and propaganda too play vital roles (Srivastava, 2002).
2

Case Study | V.Ramachandran & Dr.Janetius (2014)

With this context, the following case highlights the Industrial Safety how carelessness and negligence can
cause accidents and responsible employees rise to the occasion to manage the crisis tactfully without further
damages to the organization.
Case Narration: A large-scale composite textile mill was having a 100 KL HSD vertical, above ground
storage tank within its premises besides having two above ground horizontal storage tanks of 45 KL each.
The 100 KL vertical AG storage tank was not used for about 3 years since the power supply from the grid
was almost consistent and uninterrupted. Owing to power cut declared by the state government, the unit
was pushed to use its standby generators to run the machines. This situation warranted them to keep the
100 KL storage tank ready for further storage. Since this tank was not utilized for few years, formation of
HSD sludge was noticed which was estimated at about five feet level from the bottom of the tank. In order
to keep the tank fit-enough for storage of HSD afresh, their initial task was to flush away the HSD sludge.
It was the responsibility of the engineering department to take up this activity. A Senior Engineer instructed
the next level subordinate (Deputy Engineer) to complete the work as early as possible. Accordingly, four
engineering staff (two foremen and two contract labourers) started to work on it. There were two manholes
attached to the tank, one at the side bottom and the other at the roof-top of the tank. Since both the
manholes were not opened for years together, the fasteners (bolts and nuts) attached to the manhole at the
bottom of the tank were very hard to come by. Hence, three of them climbed up and reached the top of the
tank to open the other manhole. After a long battle, they were able to open the manhole. As they opened
the manhole, they noticed that the float, which is used to check the storage level, was mislaid. The foreman
entered the tank to set right the strings of the float. For maintenance purpose, a ladder like arrangement
was there inside the tank to step down to the bottom of the tank. As he peeped into the tank, he slipped
from the ladder and plunged into the sludge. Without noticing this mishap, the contract worker also stepped
into the tank and submerged into the sludge. Another contract worker also followed and met with the same
fate. Now all the three were caught in the sludge and were fighting for life. There was nobody to supervise
the whole activity. A foreman, who was supposed to accompany the team, came to the spot casually and
noticed that there is no one in the work area. He panicked and called the names of the workers one after
another. There was no response from either of them. Suspecting a possible mishap, he immediately
reported the matter to his boss, a Deputy Engineer. The emergency alarm was switched on and the entire
technical team rushed towards the fatal tank. A team of employees broke the manhole at the bottom and
pulled out the drowned employees. They looked for conveyance to hospital to save their lives. To make
things worse, there was no company vehicle available at that time. A vehicle owned by a staff was pushed
into operation. As the vehicle was heading towards the hospital, the railway level crossing intercepted their
transit, as that was the time of a regular train to cross. The railway gatekeeper was reluctant to oblige and
help the emergency vehicle out of the way, as there was no cordial relationship between the company
3

Case Study | V.Ramachandran & Dr.Janetius (2014)

management and the railway workers on the gate. By the time, they reached the hospital all the three were
declared brought dead.
On the other side of this disaster, the HR department of the company was unable to trace out and produce
the related HSD Storage License issued by Department of Explosives, Govt. of India. The local police officials
who were having some ill feeling against the company, for their part, availed this opportunity to settle their
scores.
Identified flaws in managing safety: Though the top management was very meticulous and serious in
abiding all acts and rules, unfortunately the employees involved in this assignment did not look into certain
mandatory prerequisites properly. While analysing this case, one can identify the following flaw:
(1) Ensuring availability of proper First Aid, Ambulance, Conveyance facilities
(2) Deployment of skilled and trained employees for specific assignments
(3) Usage of proper Personal Safety Equipment (PSE)
(4) Proper supervision by competent authorities
(5) Prior discussion in the routine Safety Committee Meeting for arriving proper strategy
(6) Acquainting prior knowledge on safety preparedness from other agencies
(7) Evolving a combined Action Plan for proper execution
(8) To have a first-hand training with IOC, HPCL, HP etc., as to how safe this can be done
(9) Decision on outsourcing the assignment to some other agency
Conclusion: Safety is not the responsibility of HR department alone but it is teamwork. It is also essential
to gain support from the society by establishing a good rapport with them. Strict adherence to all statutory
safety provisions tooth and nail, imparting safety education to employees, formulation of safety regulations,
periodical safety audits, observing National Safety Day to create awareness, safety contests, proper accident
analysis for prevention are some methods that could be utilized to combat the risks of accidents.
References
Banning. K. (2003). The effect of the case method on tolerance for ambiguity, Journal of Management Education, 27(5)
556-568.
Bell, J., Healey, N. (2006). The causes of major hazard incidents and how to improve risk control and health and safety
management: a review of the existing literature, Health and Safety Laboratory, UK

Pandita. S. (2009) Status of Occupational Safety and Health in India, Retrieved on January8, 2014 from
http://infochangeindia.org/agenda/occupational-safety-and-health/status-of-occupational-safety-and-health-in-india.html

Srivastava, (2002). Occupational health of workers in India law & practice, The Banaras law journal, vol.31, 11-42
________________________________________________________________________________________

V. Ramachandran, Assistant Professor, Dept. of MBA, Sree Saraswathi Thyagaraja College, Pollachi. (Worked as
HR in a Textile Industry for more than a decade)

Dr. Janetius, Director, Centre for Counseling & Guidance, Sree Saraswathi Thyagaraja College, Pollachi. (Psychology
Trainer for Textile Industry for the last five years)