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Accident case study

Sr.No Narration Damage or Immediate Basic cause Corrective Preventive Action Learning from
of injury cause Action Events
accident
Example Person Fracture on  Slippery  Leakage on  Pipe  Procedure for  All pipe MOC
No-01 walk on a Lag floor pipe changed MOC Selection Should have
floor  Obstruct  MOC not  Floor  Inspection as per
Slip on ion on Suitable Cleaned Schedule of standard
floor walkway  No pipe line Engineering
procedure Practice
for  There should
selection of be Leak
MOC Detection
and repair
system
(LDAR )
Example Person Fracture on  Ladder  Certified &  Certified  Ladder check  Always Use
No-02 Working a leg was approved ladder to list to be Standard
On ladder non- ladder is be used. prepared Items
Standar not Used  Angle if  Improvement Instead of
d be used ladder to be done in Non-
 Angle of  Angle of must be Housekeeping Standard
ladder is Ladder was more SOP. items.
only 15 to acute. than 15  Ladder usage  Certification
degree  Oil Spill degree. guide line to required by
 Surface during  Housekee be published & Safety
is maintenanc ping to be circulated to professional.
Slippery e work done. All employees  Standard
guide line to
be follow.
 Housekeepin
g to be
checked
before
starting the
work.
Example Manual Fracture on  Manual  Unskilled  Need  Improve  Always wear
No-03 Drum a leg Heavy for job training operating safety PPEs
Shifting Lifting  Wrong for this standard. during work.
Work  Safety Shoes to be job  Use hydraulic  Always use
Shoes wear  Safety system mechanical
not  Help not shoes to  PPE buddy device for
wear available be wear program to be heavy lifting
from doing this done in work.
another type of morning
person Work session.
 Instead of
Manual
handling
Hydraulic
equipmen
t to be
used
Example Person Eye  Line  Less work  Use of  Training to be  Always Use
No-04 working Irritation joint knowledge Chemical given for appropriate
on gasket  Use of Splash working on CS PPEs as per
Caustic punctur Spanner on proof Lye line. job
Lye line e joint front Goggles  Line to be  Always drain
 Wrong side.  Spanner drain before line& Keep
Safety to be work to be Safety PPEs
goggles used on started. on during
used opposite work.
side of  Line
working Breaking
part. permit SOP
to be follow
during work.
Example Mixing of Toxic gas  Compati  Not  Prepare  Visible board  Always
No-05 two inhalation bility wearing Fume placed on that follow
chemicals not proper Hood for particular Administrati
Checked PPEs better operation area ve Controls
 Not follow exhaust for  Always wear
Standard of Gas compatibility PPEs
procedure emission chart. according
for mixing  Training  Providing with activity.
of these given to proper PPEs &
chemicals person check list to be
mixing prepared for
these particular
chemicals Operation.
Exaple Pump Finger Cut  Rotating  LOTO not  LOTO to  Checklist  Always check
No-06 Maintena part taken that prepared for for LOTO
nce guard during particular machine before
missing Checking pump Guarding for working on
activity  Guard various area Any
provided  ITPM Schedule machine.
for to be revised
rotating & include this
part check list to it.
Example Floor Leg  Ms Pipe  Person  Removed  All unwanted  Don’t wait
No-7 Sweeping fracture on floor absent all scrap items for excess
at the minded obstacles removed from scrap
back from that site. Excess inventory.
side of area. inventory of Regular
person scrap to be scrap
during removed from disposal to
back site. be done.
word  Check
moveme working area
nt before work
start
Example Bag Postural  Imprope  Unstable  Stacking  Height of bag  Height &
No-8 stacking damage r bags standard stacking to be area of bag
stacking stacking to be marked stacking to
of bags  Height of improved  Stable stacking be marked.
 Bags are stack bags  Marking done.  Bags remain
of the area same sizes
uneven or for each
sizes stacking time.
 Sizes of
bags to be
remain
same for
each time
Example Tank Person fell  Tank top  Not  Top  Tank fitness to  Tank thick
No-9 filling from top surface wearing surface of be checked as ness
tank is safety belt tank to be per frequency schedule to
corrode  No railing changed  Use of safety be checked
d & thin available belt during as per
for tank filling. frequency
protection  Railing  Always wear
provided on safety belt
tank during
working on
height
 Railing
provision to
be done.
Example Vehicle Person get  Reverse  Cleaner not  Reverse  Before  All the part
No-10 reversing struck horn not available horn entering gate of vehicle to
working during provision any vehicle be remain
reversing of done one cleaner working
vehicle. compulsory  Cleaner is
 Walking zone compulsory
defined for for any
other person vehicle.

Example Asbestos Person fell  Weak  Noe  Roof  Height work  Always wear
No-11 roof from top of roof wearing leader is permit should safety belt
changing the roof structur Safety PPEs used. be during
work e  Roof  Safety strengthening. height work
leaders not body  Person  Work
used. harness working with knowledge
 Life line not applied roofing work to be given
used during should be with hazard
work checked assessment
 Lifeline during work in checks.
placed respect of
PPEs
Example Chemical Person  Wrong  Improper  Right  Process  Always
No-12 Charging fainted mask is Knowledge mask knowledge follow
used.  Activity used given to all superior
responsible person instruction.
Supervisor  Training given  Use
not to all working appropriate
available people. PPEs
helper start  RCA done and
work outcome share
before with all person
supervisor
come
Example Bag Hand Hut  Open  Self  Self  Open blade  Do not use
No-13 Cutting Injury blade retracted retracted standard to be open blade.
Work use for knife not Knife is applicable in
bag used used for factory
cutting  Blade bag  Provide handle
without cutting based tool to
handle work each area of
factory.

Example Acidic Person get  Wrong  Hydraulic  Acid proof  New hydraulic  Always use
No-14 chemical chemical type of emptying hand pump proper PPEs
drum burn on hand pump gloves purchased for  Do work
emptying hand gloves damage provided that activity & with proper
work used  Breakdown for work damaged PPEs
is too long pump send for  Breakdown
for this maintenance & preventive
pump maintenance
need to
improves
Example Steaming Person get  Wrong  Clamping  Right  Both end  Do not use
No-15 with hose saviour leg rating was rating flanged with loose Hose
pipe burn injury hose inadequate, pipe Hydraulic on steam
used  Loose hose being pressured application.
is used introduce fitting pipe is
d for that introduced
cleaning.  Manufacturer
Test certificate
made
compulsory for
any hose.
 Hose standard
system with
coding & data
to be displaced
on Hose
storage area
Example Tank Tank get  Vent  Not follow  Vent  SOP followed  SOP always
No-16 Empting vaccumised valve is SOP for valve & SOP display to be
process & dish not Tank removed on all tank followed
aped opened/ emptying. & replace farm for  Preventive
Partly  Preventive with new empting maintenance
opened maintenanc one process schedule to
e not done  Preventive be followed
properly. maintenance stringently.
check list
applied for all
tanks
Example Tractor Hydraulic  Hydrauli  Not proper  Hydraulic  Proper  Preventive
No-17 Unloading system fail c oil maintenanc oil filled maintenance Maintenance
operation & tractor level is e to schedule to be done
get too less  Behaviour hydraulic  Person gets at regular
damaged based system penalised for interval
activity this activity  Fitness
certificate &
maintenance
report to be
compulsory
for vehicle.
Example Explosive Caught fire  Static  One of  Non  All jumpers  After getting
No-18 tank farm in line charge jumpers in Conductiv placed on line. maintenance
area produce line e pipe line  Leakage activity
material d during removed to be attained. done, revert
transferri transfor  Drop wise used  Jumper back all
ng activity ming leakage of checklist to be previous
material chemical provided. activity as
occurs per
dismantling
activity.
 MOC of pipe
to changed
Example Leakage Fire hazard  Non  Housekeepi  Flame  Housekeeping  As per zone
No-20 of occurs Flame ng not proof improved classification
chemical proof proper fitting  Pre checking equipment
in fitting  Pre replace of work provision to
explosive checking with environment be done.
tank farm work previous improved  For critical
environme fitting  Frequency of area
nt not done watch is additional
 Frequency increased. manpower
of watch is  One dedicated or
very less watch person surveillance
appointed for provided.
any misshapes
Example Defective Person fell  Visualisa  Power  New  Do not move  Use clean
No-21 Goggles from floor tion not failure Safety in power PPEs
wearing & get clear occurs in goggles failure  Don’t Get
by colour hospitalise night provided condition. panic on
worker d  One part of Remain stands worsen
railing is still on spot condition.
missing  Immediate  Always check
railing done on for missing
that missing guards.
railing area.
Example Reactor Due to  Pressure  Preventive  Pressure  Preventive  Critical
No-22 get blast one gauge not done to gauge maintenance equipment
pressurise person not pressure replaced. checklist always to be
d died working gauge prepared for checked.
 Additional pressure  Do not add
amount of gauges. extra
chemical  Decided chemical.
added to amount of
reactor. chemical to be
added.
Example Auto Tanks get  Auto LI  One of  Auto  Cable replaced  Other
No-23 Level over flow. not cable of LI Level with new standby
indicator Chemical working signalling indicator cable. protection to
not wastage get break. get  Malfunctionin be provided
working occurs corrected g also to be by not
checked relying on
single
equipment.
Example Push Person get  Earthing  Due to  Earthing  Push button  Double
No-24 button shock not monsoon provided cleaned with earthing
operation availabl water to push dry air provided on
in open e on spread on button  Canopy the push
area push button provided button.
during button  Canopy not  Pre
monsoon available monsoon
for water activity to be
protection done as a
part of
preventive
operation
Example Manually 3 person  H2S gas  Simple  Meter  Air bubble  Use suitable
No-25 aeration get un formatio mask wear placed on hood provided PPEs
tank conscious n  Sludge working  Instead of  All meter &
cleaning movement area manual sensor are
work gets H2s handling calibrated &
generation sludge updated.
to higher pumping done.  If possible
PPM  H2S sensor than manual
 H2s Sensor calibration handling
not done. avoided
working
Example Dust One person  Static  Low  Antistatic  Floor cleaning  Layer of
No-26 Explosion get burn charge Minimum floor done flammable
injury generat Ignition provided  Exhaust dust avoided
ed level system on floor.
powder improved  Antistatic
material  Static charge floor
spread on discharge provision to
floor device be done.
 1 mm provided
dense level
on floor
 Friction
generated
on walking
on floor
Example Treated Person who  H2S Gas  Without  Portable  Person get  Appropriate
No-27 Effluent get inside generati bubble H2s Gas inside with full PPEs must
common of the tank on hood sensor PPEs for this kind
collection died occurs  No pulling meter to  Pulling rope of Work
tank to device be placed provided to  Sensing
cleaning higher attached to inside the person Device
work PPM person tank should
always to be
Placed
Example Bhopal More than  Methyl  Water Line  Mask  Water Link  MSDS always
No-28 Gas 5000 Iso Chocking applied or must be remain trust
tragedy(1 Person died Cyanide  Isolation of One cleaned worthy.
984) & 15000 release Tank Not cotton  Isolation tank  Safety
Person get in Proper cloth in line during personnel
affected atmosph  Surge tank rinse with these work always
ere Also in water  Isolation of needed
maintenanc applied Material tank  Proper
e(Isolated) on face should be Isolation
 No safety no one confirmed required.
Person was died.  Safety officer  Don’t go for
Available in must available excess
company during this amount of
 Poor class activity production
of  Don’t produce
Maintenan excess amount
ce of production
 Excess  Immediate
amount of response of
Production director saved
 Wrong many lives
MSDS
 Director
not
responded
immediatel
y.
Example Chernob 31people  Nuclear  Person  Core  Person get  Cooling
No-29 yl killed and Power Operating outside proper arrangement
Nuclear releasing Plant’s System for cooling training. must be
Accident 100 times Core first time arrangem  Expert strong
(1986) more went in  Not ent done. required enough
to Properly  Graphite during first  Controlling
radiation
meltdo trained wall time of of chain
than the wn  Don’t know applied operation reaction
atombom how to just (Commissionin must be
bs control outside of g) known to
dropped Chain the  Give proper operating
on Japan. reaction nuclear training about person
 One by one chamber Starting &  Do not go for
addition ending one time
uranium procedure Addition, Go
bars  Time between step by Step
two bars manner
insertion to be
maintained.
Example Fukushi Hundreds  Due to  Plant  Core  Right location  Citation of
No-30 ma of people Earth location should be selection for plant is so
nuclear gets Quack & not proper. more the plant. crucial part.
disaster affected Tsunami  Environme protected  Standby
due to Reaction nt worsen from cooling system
(2011)
radioactive chambe condition graphite arrangement
release r core  Cooling walls & should be
from the meltdo System Get plant remain
vent wn Destroyed should be available.
occurs of quake
& tsunami
protectio
n type

Example Gulf of Thousands  Poor  One Bolt  Maintena  New Line  Maintenance
No-31 Mexico of Class of missing In nce class established in of oil rig
Oil Spill animals, Mainten Line. improved 2 weeks time. placed in
including ance  Due to high mid sea area
turtles, pressure remain on
pump Line spot.
crabs, fish,
pressurised
and birds
 Line Burst
fell victim, from that
and the missing
local bolt area
fishing
and
tourism
industries
suffered
badly.
Example In lunch Person gets  Not  Not follow  Hand  Always follow  Always wash
No-32 break hospitalise wash safety washing safety cardinal hand before
person d due to hands officer done rules for taking lunch
eating chemical before instruction before better health.  Always wear
meal poisonous eating  Wear taking  Always wear healthy
effect. lunch damaged lunch healthy PPEs PPEs.
hand gloves
during
work

Example Reaction Reactor get  Wrong  Poor class  Right  Class of  Mirror
No-33 between Burst selectio of rupture maintenance replacement
two n of preventive disc to be to be done
chemical rupture Maintenan placed(Ex improved with critical
in reactor disc(Hig ce act what  If Exact rating equipment
her than  Behaviour required) rupture disc related to
required based not available safety
) safety issue than wait for equipment.
new rupture  Consultation
disc arrived required
rather than with person
placing higher that this will
range. never
happened
again.
Example Distillatio Distillation  Flamma  One of the  Exhaust  Gasket  Appropriate
No-34 n column column get ble gasket in system to changes with fitting
operation fire composi column be appropriate applied as
tion applied is improved gasket per zone
form in not as per  Flame proof classification
area due requiremen fitting changed  Right rating
to t with current & class of
leakage  Non Flame one. gasket to be
of proof used in
solvent Fixture critical areas
generates  MOC not
sparks on change for
operating any material
button.
Example Formulati Get dust  One  Above 1  Restrict  Regular  Avoid Any
No-35 on of fire explosion & person mm Thick Mobile housekeeping spark
sensitive two person taking layer Access in done on Floor. generative
powder get saviour on persists on this area.  Spillage of device in
burns get mobile floor. powder is highly
hospitalise phone  Exhaust avoided. flammable
d system not  Alternative area
working Exhaust  Housekeepin
system g to be
installed. improved
 Prevention
system
remains
healthy at
each time.
Example Bomb More than  Intellige  Proper  Intelligenc  Proper  More Focus
No-36 Explosion 50person nce Checking e failure checking done & be vigilant.
in Shree get died & failure not done to be at all public  Avoid public
Lanka 100 of for reviled gatherings gathering.
people get explosives  Try to avoid
injured  More accumulation
people of crowd.
accumulate
d for Easter
function
Example Formulat Whole go  Forklift  Less  Instead of  Knowledgeabl  Zone
No-37 ed 50Kg down burn is used Knowledge forklift e person according
M.S. Lead fortunately for  In adequate Hydraulic engaged with equipment
type no one get Shifting control Pallet this activity to be used
drum injured of  Tendency truck of  Strict control  More
Shifting drum(Fo of work drum applied on focusing on
work(Zon rklift getting loader is activity Behaviour
e-0) used is completed used  Consult with based safety
for in short operating for that
zone-2 time. person for his particular
Class) behaviour plant.
based un
thoughtful
activity
Example HCL Person get  Safety  Person  New  Never ignore  Always wear
No-38 spillage Saviour shoes ignorance shoes for small good class of
cleaning acid burn in damage about pain given amount of PPEs. If
work bottom from its  More time pain. Report it found
part of feet bottom spent in to FMO. damage in
part. those  Don’t spent PPEs
shoes. long time in immediately
contaminate replace it.
PPEs. Remove
it immediately

Example Soil Person get  Activate  No  First to  If possible  Proper


No-39 Digging shock live Mapping of deactivat then Project project map
work with cable in digging ed live plant available
sped & line of work cable rechecked during
shovel digging available  Always stop on digging work
work &  Under finding of this  Particular
sped estimate type signage region all
insert in brick & active cable
to live send layer line needs to
part During be de
digging energised.
 Never under
estimate civil
masonry
work bellow
ground.
Example Excavatio Soil erosion  Area  Excavation  During  Excavation  Always
No-40 n work occurs on barricad done in Excavatio done on 45 excavation
near to person & ing not Straight n work degree outside done in
main road get done for way on a near road way outside slant
hospitalise vehicle degree of vehicle  So that soil way so that
d moveme 90. movemen erosion not chance of
nt  Land t stopped occurs. soil erosion
stoppag holding for safe  Holding neglected.
e structure work Structure to  Vehicle
not made be made for movement
for safe safe work stopped near
work excavation
area.
Example An The  Employe  Investigatio  Avoid  Increasing  Always wear
No-41 employee employee e had n reveals Over time frequency of safety PPEs
is working falls off the worked the ladder of Worker ladder  Do not use
on a ladder and seven was  Don’t checking defective
ladder breaks arm. 12-hour damaged step on schedule. ladder/Tools
and the shifts in and did not last step  Behaviour during work
ladder a row provide a of ladder based safety  Ladder
seems to  Employe stable because it improve checking
collapse e was working is used for frequency
standing platform in placing increased by
on the any tools & managemen
top step environme tackles t.
of the nt.  Fall  Consulting
ladder  Interview arrester with working
(an with facility system personnel
unsafe manager given for regarding
action) reveals that work behaviour
 No fall he did not  Ladder based
arrest or inspect the inspected mistake.
restraint ladder & tagged
system when it was
was due for
used inspection.
 A ladder He was
inspecti aware that
on ladder
policy is needed to
in place, be
but inspected
there is
no
evidenc
e that
the
ladder
has ever
been
inspecte
d

Example Beam Person fall  Reactor  Anchoring  Reactor  Anchoring  Reactor


No-42 cutting from moveme point of movemen point of safety movement
work building & nt not safety belt t blocked belt is other I stopped
using died blocked is on same by beam Apart of when lay
Railing platform. welding that platform. down side
platform  Anchoring two  Ladder bottom ways.
ladder not done at angles to anchoring  Knowledge
which is the bottom its body done & make given to
not of platform it fix. contract
anchored ladder employee
at regarding
bottom. anchoring &
Wright hazard
beside associated
one
reactor  Ladder
lay down Bottom
& one of remain
it’s nozzle always fix.
in
between
two legs
of
platform
ladder
Example Welding Fire  Welding  Previous  All  
No-43 work at occurred sparks batch combusti
first floor. on Ground fell on contaminat ble
floor to the ion remains material
ground present on removed
floor floor. from the
 Housekeepi radius of
ng not 10.7Mts
done area to
 Non avoid fire
combustibl hazard.
e fire
blanket not
used during
welding
work.
Example Emptying Fire occurs  Transfer  Static  Transferri  Earthing not  Solvent
No-44 of solvent in solvent ring of charge ng of available & transferring
to tank solvent developed solvent also jumper is always
explosive at very at the should be loosing done with
tank farm high surface of of very continuity very less rate
rate tank less rate & Also
 Earth is not & from checking
available at the earthing
bottom of surface
the tank guided
one
Example Person Person get  Leakage  Ignorance  Leakage  Don’t ignore  Always wear
No-45 passing un drop fell of chemical must be anything helmet
under the conscious directly drop fell on repaired which fell during plant
drop wise on the hair. directly on operation
leakage persons  Helmet not head  Wash head
line head wears.  Wear helmet with plenty
 Not during plant of water
washing operation area  Don’t ignore
head  Washing of smallest of
head is thing
required regarding
chemical
handling.

Example     
No-46

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