Presented by: Charudatta Bhave

Plant/ Site Manager: Rajiv Batra

Location: CIL- ABO, Learning Center , Plant I,
Kothrud, Pune

Date: 05 April 2010

2
Description of the Incident :
Fire Incidence at CIL Plant I ,in Learning Center Classroom No.1
Describe the fire incidence & how it occurred:
On April 5 , 2010 at 2.30 PM a Training was arranged by one of Managers at Learning Center
Classroom No. 1. The training commenced at @ 2.25 PM. An assistant from Learning Center was
supporting him by putting ON the lights , Air conditioners (AC) , Desktop etc. as routine
procedure.

Few participants arrived & occupied the chairs in the room. Suddenly crackling noise was heard &
some smoke was observed from one of the split A.C. As fire was observed from the A.C., the manager
immediately asked the participants to vacate the room & the assistant opened one of fire
extinguishers available nearby. Another assistant from the Learning Center switched off electric
supply.
The fire alarm siren was actuated and classroom participants were also asked to leave the room.
Security was informed about that & the security team attended the fire. Security informed to local
fire tender . They also came and supported for extinguishing the fire. Within 15 minutes fire was
brought under control.

Note : All people inside the building were moved to safe area & nobody was injured.

Describe equipment / plant involved and any related damage: Annexure 1
Describe the product / goods involved and any related damage: Annexure 1

1.Identify Problem
STEP 1 : Identify The Problem
WHERE - The physical
location of the symptom.
Where it occurs
At learning center, Classroom No. 1, Kothrud Plant,
Pune
WHEN - The hour, time of
day, day of week, month,
time of year of the
symptom
14:30 Hrs, Monday, 5th Apr 2010.
HOW MUCH - The extent,
degree, dimension or
duration of the occurance.
Items and area damaged has been detailed in Annexure
1. The fire lasted for 20 minutes. No physical injury to
any person.
WHO - To whom, by
whom, near whom, does
this occur ?
8 Employees were at the location attending a training
program
DESCRIBE THE
SYMPTOMS
Where, When, to what extent
does this symptom NOT occur,
though it might have ?
Where, When, to what extent does this symptom occur
?
Step 1: Identify The Problem
View of Class room before Fire Incidence
The Split A/C
Near which the
short circuit
occurred
Class room with
Projector
Air Conditioners


Fire at
Learning Centre
Class Room-1
Combustible Material
Present ( Hay )
Heat Generation
Continuous Oxygen
Available
Used for side wall
Acoustic Treatment

1992 Construction.
No design FMEA
done
Class room both
the doors open
At the time of fire
Sparking from
one Air Conditioner
Blower Motor
Burnt ?
Cable Insulation
Damaged
Old wiring
(installed 18 yrs back)

No SOP to check
Old Damaged wiring
Concealed wiring not
Visible for inspection
AC circuit malfunction
Component failure
Voltage fluctuation
End of useful life
approaching
Not possible as
regulated Gen-set
supply provided
Dry grass exposed
To spark
Laminated acoustic
Sheet punctured
For passing drain pipe
And cable

Cause Tree Analysis
No-Preventive
Maint Records
ACCIDENTS INVESTIGATION :
THE CAUSES TREE ANALYSIS METHOD
Major findings from the accident investigation

The root causes (latent failures) consisted of :

Room was having wooden partition made of sound skulpt ( Dry Grass )
within which thermo acoustic material had been packed. This is highly
combustible material
18 years old Concealed wiring.
Opening (doors, window) are not of self closing nor fire retardant.


Cause Tree Analysis
Step 2: Determine Possible Causes
& Rank their importance

ISHIKAWA DIAGRAM Analysis

STEP 2 Determine Possible Causes & Rank
their importance.
Step 3. Take short term action
Does problem still affect other employees' safety?
Yes.
Describe potential short term action :
Removal of all Partition mounted Air Conditioners from Learning Center.- Completed
Communication of incidence and the root cause to all employees.- Completed


Statement of Mr. Pramod Sadistap .The eyewitness Manager.
Attached.
Statement of Mr. Charudatta Bhave ,DGM Learning Center.
Attached.
Accident site photographs. Attached.

STEP 4 : Gather Data to Determine Cause
Statement of Mr. Pramod Sadistap
The eyewitness Manager
Statement of Mr. Charudatta Bhave ,DGM
Learning Center
Photographs of Training Class room
The Split A/C
Near which the short
circuit occurred
Before Incidence After Incidence
Highly combustible material
made of hay was used as for
acoustic partitioning
Photos of Class room after Fire incidence
Step6: Plan and implement permanent solution;
Fail-safe where possible

Annexure 1 -Classroom No. 1 Burnt Material List.
Cont.
Sr
No
Description Of Item Qty
1 Roof Sheets, Structures , Gutters , Downtake pipes , NLG Window 1
2 Wooden Panelling 66
3 Chairs 45
4
Partition made from jindal make Aluminium anodised frame with 12
mm thk Pre laminated partical board from both sides.
50
5 Split uint AC with M.S stand 5
6 2x36 Wipro Light Fitting 35
7 Plastic Writing & Copying Board 1
8 Fire & Smoke Detection System 1
9 600x600 mm Mineral fiber Ceiling 100
10 Conference ModularTable 1
11 Doors 4
12 LCD Projector with screen 1
Annexure 1 Contd.
13 2mm thk Vinyl Carpet 90
14 Sound System with Hand Mic & Collar Mic 1
15 Broken Glass for Alu. Doors & Partition 9
16 Light Points 45
17 Desktop Comuter 1
18 Sliding Windows 2
19 Painting 100
20 Manager Table with ledge 1
21
Copper Piping with suction lines insulated with Nitrile rubber Tubular
Installation for 1.5 Tr Split AC
20
22 Vertical Blinds 12
23 Cupboard 1
24 DB 3
25 Training Stationary Material , files , books etc 200
26 MCB 36
27 VCR 1
28 Flip Chart Board , stand & Sheets 4
29 Pin-up Boards 2
30 Training Posters 10
End