bokaro

Report on Fatal Accident that occurred on 04/11/2012 at

Bokaro Steel Plant

1. General Information:

Plant : Bokaro Steel Plant

Department : Hot Strip Mill

Location : (-) 11 mtr. level, Motor Room # 5, Feeder – 45 L

Nature of Accident : Reportable (Fatal)

Date, Shift & Time of Accident : 04/11/2012, 3.30 PM, “G” Shift

Date & Time of Death 04/11/2012, 3.30 PM

2. Employee Information:

Name : Late S.K. Irfan

Category : Contractor’s Employee

Name of the Contractor : M/s Deepak Enterprises, Chas, Jharkhand

Designation : Electrician

Age : 29 years

3. Background Information:

As per Purchase Order No. P35/024/4510016704, Dated 19/01/2012, M/s Deepak Enterprises, Chas, Jharkhand was awarded the work of supply and complete retrofitting of General Electric (GE) make 2000 Amp Circuit Breakers (04 nos.) in 03T π 11, 415 Volts Sub-Station at (–) 11 mtr. level, in Motor Room # 5 of Hot Strip Mill. This Electrical Sub-station, though installed in Hot Strip Mill but supplies power to some areas of Slabbing Mill which is situated by the side of Hot Strip Mill. 4. Circumstances prior and up to the fatality:

a) Capital Repair of Hot Strip Mill was planned from 30th Oct. ’12 to 9th Nov. ‘12. Accordingly the Mill was under shutdown since 30th Oct. ’12 from 3.00 PM onwards.

b) During capital repair many jobs were undertaken in the Mill.

c) Replacement (Retrofitting) of circuit breakers was also planned in 03T π 11, 415 Volts Sub-Station at (–) 11 mtr. level, in Motor Room # 5 of Hot Strip Mill.

d) As per Purchase Order No. P35/024/4510016704, Dated 19th Jan. ‘12, M/s Deepak Enterprises, Chas, Jharkhand was awarded the work of supply and complete retrofitting of General Electric (GE) make circuit breakers. M/s Deepak Enterprises had deputed a group of six (06) persons to execute the job.

e) On 29th Oct. ‘12, visitor’s gate pass was made and the crew members were allowed to visit the site to take measurement. After taking the measurement of the panels, the crew members returned back.

f) On 3rd Nov. ‘12, the crew members again entered the plant on visitor’s gate pass and started the job. On that day, 1 no. circuit breaker was successfully replaced by the crew. (Fig. 1)

g) On 4th Nov. ‘12 (Sunday), it was decided to replace another circuit breaker at (-) 11 mtr. in 45-L panel of Hot Strip Mill also and the job was started at 12 pm. Before start of the job, job briefing was given to the crew members by the area in charge wherein it was explained that Section-I was without power and Section-II (i.e. adjacent panel) was live. Because from live panel (Section – II) was feeding power to EOT Cranes of Slabbing Mill. Accordingly front and backside doors of live panel were kept in closed and locked condition.

h) It was reported that, at 3.30 PM, a flashover had occurred in the backside of live (Section-II) panel during the job and Late Irfan got electrocuted. Other crew members informed the concerned officials about the incidence. Late Irfan was unconscious and his body was lying half inside the live panel. (Fig. 2 & 3)

i) Immediately electrical shut-down was given for Section-II and the victim was removed from the panel. The victim succumbed to his injury at site.

5. Observations:

Based on interactions at site and discussions held with concerned officials, the following circumstantial facts were gathered:

a) Proper Safety Protocol was not prepared keeping the sequence of activities and job wise responsibility in view.

b) On 25th Oct. ’12, a letter was given by the representative of agency to the executing deptt. for seeking permission for retrofitting of circuit breakers. He had given a list of six expert/ trained persons who were deputed to execute the job.

c) Accordingly, visitors’ gate pass was issued and all six persons were allowed to work in the site.

d) Process for issue of gate pass for six persons was not routed through Safety Engineering Department.

e) There is no system to impart Safety Induction training to the persons engaged for the job on turnkey basis (material supply and installation), before issue of gate pass.

f) It was informed that the same persons had already executed similar type of jobs in other departments.

g) Required Safety information was not shared with the crew members during job briefing before start of job.

h) Locking arrangement of the live panel was not foolproof, because the crew members opened the lock of live panel to execute the job conveniently.

i) It was informed that it was not possible to give shut down to live panel, because it was feeding power to Slabbing Mill and there was no alternate power supply arrangement to Slabbing Mill EOT Cranes.

j) Proper insulation barriers were not provided between live and dead panels.

k) Proper supervision was not provided by the contractor as well as executing department.

6. Causal tree analysis:

7. Cause of Incidence: i) Immediate Cause of incidence: Electrocution due to contact with live bus-bar

in substation section-II.

ii) Root Cause of incidence:

a) Section-II was live while job was being carried out in Section-I.

b) Physical barriers were not provided to isolate the live bus-bar.

c) Job supervision was inadequate.

8. Safety aspects involved / violation of safety norms:

(a) Protocol for the capital repair jobs during the shutdown period was available but job wise responsibility was not mentioned in the protocol.

No physical barriers between live and dead panels.

Victim was electrocuted.

Injury

The victim working by the side of live panel.

Inadequate supervision till completion of job.

(b) Process for issue of gate pass for six persons was not routed through Safety Engineering Department.

(c) There is no system to impart Safety Induction training to the persons engaged for the job on turnkey basis (material supply and installation), before issue of gate pass.

(d) Victim was not wearing insulated hand gloves while carrying out electrical job though he had carried out similar jobs in other departments.

(e) Job briefing was given to the crew members by the concerned officials before start of job.

(f) Locking arrangement of the live panel was not foolproof, because the crew members opened the lock of live panel to execute the job conveniently.

(g) Proper insulated barriers were not provided between live and dead panels.

(h) Proper supervision was not provided by the contractor as well as executing department.

9. Recommendations to prevent recurrences:

Accident factors established Possible preventive measures a) Protocol for the capital repair

jobs during the shutdown period was available but job wise responsibility was not mentioned in the protocol.

• Proper Safety Protocol should be prepared for the capital repair jobs during shut down period and job wise responsibility should be mentioned.

b) Process for issue of gate

pass for six persons was not routed through Safety Engineering Department.

• Process for issue of gate pass for the jobs by turnkey basis (material supply and installation) should be routed through Safety Engineering Department and proper Safety Induction training should be imparted to the persons before issue of gate pass.

• On-the-job training w.r.t. existing hazards and preventive measures to be imparted to the persons before putting them on the job.

c) Locking arrangement of the live panel was not foolproof.

d) Proper insulated barriers were not provided between live and dead panels.

• If it was not possible to isolate the live panel, proper insulated physical barriers should have been provided.

e) No supervision till completion of job.

• Strict Supervision should be ensured till completion of such type of jobs where jobs are undertaken on turnkey basis (material supply & installation).

• Proper inspection of work site by the concerned officials to be done and hazards prevailing at the sites to be highlighted and people should be cautioned accordingly.

• Use of proper PPEs by the contractor workers should be ensured.

10. Details of enquiry committee:

(a) An internal committee was constituted to enquire the fatal accident. The members of the committee are as under:-

• M Ravi Varma, General Manager, CRM

• N Mohapatra, AGM (safety), SED

• C R K Sudhanshu, Manager, Pers-Works

11. Details of next of kin:

Name : Smt. Shakila Khatoon

Wife

Relationship with deceased : Islam Nagar

Jugsalai P.O. – Jugsalai

East Singhbhum Jharkhand

Permanent Address : Islam Nagar

Jugsalai P.O. – Jugsalai

East Singhbhum Jharkhand

Enclosed: Fig - 1, 2, 3 showing view of the accident site.

(Suresh Kumar)

AGM (Safety)

SAIL Safety Organisation, Ranchi

Fig. 1 – Showing view of 3T π – 11 Substation, Front Side

Fig. 2 – Showing view of 3T π – 11 Sub station, Back Side

Section – II (Live)

Section – I (Under Shutdown)

Section-II (Live panel) Victim was standing

here for circuit breaker replacement

job & got electrocuted.

Job was going on in this cubicle on

04-11-2012

This Circuit Breaker was replaced successfully on

03-11-2012

Section-I (Under shutdown)

Circuit breaker replacement was being done here

Fig. 3 – Showing view of Bus-bars in 3T π – 11 Sub station, back Side

Flashover marks

Section – II (Live)

Section – I (Under

Shutdown)